Even before the recent election, physicians felt perched on a precipice.

Changes sweeping health care have threatened their independence, income, and influence. An epidemic of burnout and depression shadows the profession. And the incoming Trump administration promises still more upheaval.

Who represents doctors in this unsettling environment? Decades ago, the answer would have been clear: the American Medical Association, the nation’s oldest and largest medical organization.

But today, medicine is a house more divided than ever.

The AMA still has more clout — and spends far more on lobbying — than the scores of medical specialty societies and splinter groups that sort doctors by political leanings. But it counts fewer than 25 percent of practicing physicians as members, down from 75 percent in the 1950s.

And the association infuriated many doctors recently with its quick endorsement of President-elect Donald Trump’s choice for secretary of health and human services — Representative Tom Price, an orthopedic surgeon-turned-congressman who’s led the charge to overturn Obamacare. Just two weeks earlier, the AMA’s House of Delegates had reaffirmed the association’s support for coverage expansions under Obamacare.

“That felt like a slap in the face, and many physicians aren’t sure if the organization really stands for us any longer,” said Dr. Christian Pean, an orthopedic surgery resident at NYU Hospital for Joint Diseases and a 2014 recipient of the AMA Foundation’s leadership award for young physicians.

Divisions within doctors’ ranks could make it more difficult for their voices to be clearly heard in the coming clamor to replace the Affordable Care Act with a Republican alternative.

“Doctors are disorganized, and it’s a shame because we seriously need physician leadership to inject some sort of moral authority into [this] debate,” said Dr. Robert Berenson, a senior fellow at the Urban Institute and former high-ranking official with the Centers for Medicare and Medicaid Services.

“This is a real litmus test for the AMA,” Berenson said. “Do they have the will and the fortitude to step up and oppose rolling back all the progress we have made, or will they be accommodating and quiescent?”

A Trump pick roils the ranks

Just hours after Trump named Price as his pick to head HHS, the AMA’s board of trustees put out a strong statement of support.

Controversy erupted immediately. Within days, more than 700 AMA members had signed a letter protesting that endorsement as “divisive.” A separate petition accusing the AMA of disregarding patients’ needs drew 5,500 physician signatures.

Dr. Patrice Harris, board chair of the AMA, found herself in the hot seat.

In a recent phone interview, Harris said the organization’s endorsement of Price doesn’t signal that the AMA has backed off its support for Obamacare. “Our commitment to health insurance coverage hasn’t changed,” she said. “Our commitment to the principles of the Affordable Care Act has not changed.”

A doctor examines a patient. Gerald Herbert/AP Images

Her language puts the association on the record, but it’s hardly the strong, clear public declaration that AMA members had requested at an association meeting last month in Orlando, Fla.

At that meeting, just a few days after the election, physicians passionately debated Obamacare and ended up asking the AMA to publicly reaffirm its dedication to “comprehensive health reform” that “improves access to care for all patients.”

Harris was similarly cautious when asked about the AMA’s support for family planning services, which Republicans have said they want to cut. “We remain committed to preventing intrusions into medical decisions that we strongly believed should be reserved for patients and physicians,” she said.

Asked about turning Medicaid into a block grant program, which Price has backed in the past, Harris said: “We don’t find it productive to deal in hypotheticals.”

Instead, she noted that Price is a longtime AMA member and praised him for having been “accessible to us.” Harris said he “seeks out and listens to physicians’ concerns” and is “attuned, as a physician, to how policies impact delivery” of health care.

Beyond that, Price’s views align with AMA policies in several areas, including the need to fix problems with electronic health records, reduce regulation, and eliminate a deeply disliked method that Medicare has used to control physician spending.

“But there’s also been times when we disagree,” Harris said, adding that the endorsement does not “equate with an agreement on all his prior policy positions.”

‘Followers rather than leaders’

That kind of caution is characteristic of the AMA, which generally prefers to work behind the scenes and press its agenda at the negotiating table, rather than rally the public.

“They end up being followers rather than leaders because they want to be where the action is,” said Dr. Marcia Angell, a former editor of the New England Journal of Medicine and a senior lecturer in the department of global health and social medicine at Harvard Medical School.

More than 190 medical organizations with various agendas are represented through the AMA’s House of Delegates, forcing the organization to balance often-competing interests. On top of that, there’s growing political polarization among doctors, now split almost evenly between Republicans and Democrats. And clinicians are further divided by type of practice and employer.

Because the AMA’s tent is so large, “they have difficulty articulating strong policy positions,” said Berenson, the Urban Institute scholar.

Dr. Jeffrey Singer, a general surgeon associated with the libertarian Cato Institute, quit the AMA 15 years ago out of frustration with what he perceived as its timidity. He wanted the group to stand up more forcefully against government meddling in physicians’ practices.

But the AMA leadership “no longer wanted to make waves,” Singer said. “I just didn’t feel they represented me anymore.”

Donald Trump. AP

A top-dollar lobbying force, but declining clout

Wealth has guaranteed the AMA influence in the corridors of power, nationally and in the states. The association has spent $347 million lobbying since 1998 — more than any other company or group except the US Chamber of Commerce and the National Association of Realtors, according to the Center for Responsive Politics.

Still, scholars agree that the association’s clout has declined over the last 30 years as specialty societies rose in prominence, health care costs soared, managed care became more prevalent, and physicians’ allegiance to the organization diminished.

“Their influence over health policy eroded badly,” Jonathan Oberlander, chair of the department of social medicine at the University of North Carolina, Chapel Hill, said by email.

It’s impossible to say how many practicing physicians belong to the AMA because the organization wouldn’t say how many of its 234,360 members were medical students. But it’s clear that just a fraction of 926,000 doctors practicing in the US pay AMA dues.

Nonetheless, Harris said the association represents “90 percent of physicians in this country” through its House of Delegates — where every specialty medical society and state and country medical county casts votes on proposed policies.

But others point to increased splintering within the profession, with left-leaning groups such as Doctors for America and the National Physicians Alliance and right-leaning groups such as Docs4PatientCare and the Benjamin Rush Institute now competing for doctors’ loyalty.

A history of deep conservatism

Throughout most of the 20th century, the AMA fiercely defended physicians’ autonomy and opposed government involvement in health care, earning a reputation for deep conservatism.

It opposed including health insurance in the Social Security Act of 1935.

It fought President Harry Truman’s national health insurance plan in the 1940s.

It fought the creation of Medicare and Medicaid in the mid-1960s.

Dr. David Blumenthal, a former US national coordinator for health information technology, remembers becoming passionate about improving patient access to care during the late 1960s and 1970s.

“I didn’t think, at the time, the AMA was in the vanguard of these issues,” said Blumenthal, 68, who has never joined the association. “To the contrary, it was very visible in its opposition.”

But in recent years, the AMA has been more aggressive about expanding access to health care, reducing the ranks of the uninsured, and addressing other social issues.

Its embrace of the Affordable Care Act in 2009 was unprecedented, and deeply controversial. In 2014, it passed resolutions in support of transgender rights. And earlier this year, the AMA declared gun violence a public health crisis — and began lobbying for gun control measures.

Patient Rose Bush (R) receives treatment from Doctor Leon Yeh in the Emergency Room at OSF Saint Francis Medical Center in Peoria, Illinois. REUTERS/Jim Young

“They’ve softened around the edges,” Blumenthal said.

Such moves have won the AMA points with some socially conscious younger physicians, who have worked hard to advance policies the organization once would have shunned.

“I joined the AMA because I saw the ability to make a difference,” said Dr. Laura Faye Gephart, a Texas obstetrician-gynecologist who has been a member since 2005. “A group of us are pushing hard to make the organization more responsive to issues we see affecting our patients’ health.”

That group was dismayed by the Price endorsement, and Gephart was among the physicians who signed a petition asking the AMA to clearly articulate its support for Obamacare, family planning, gay marriage, and adequate funding for Medicaid.

The association has yet to put out such a statement. And now, many are wondering if its voice will be muted in the public sphere in the coming debates over health care.

That would be “unfortunate,” said Beatrix Hoffman, a history professor at Northern Illinois University who studies the politics of health reform, “because people tend to trust physicians and want to hear from them.”