Rethinking ASA’s flawed election process

Watching and working in ASA officer election campaigns for the past several years has been a deeply unsettling experience.

The ASA’s officers today are outstanding anesthesiologists, dedicated to their profession and to the organization. But the process of electing them, from my viewpoint, is a dysfunctional endurance test, fraught with barriers to entry and hobbled by tradition.

Imagine a hybrid of ritualized Kabuki theater and a high-school campaign for homecoming queen, and you’d be close. And yet the results have binding effects on a 50,000-member, multimillion-dollar specialty society whose work affects the professional lives of all ASA members.

We need to reevaluate and redesign this system sooner rather than later for the health and long-term future of the organization. Here is a glimpse of some of the fundamental problems.

While in theory offices come open for election every year, in reality it’s taboo to challenge an incumbent officer.

There are no term limits. An incumbent officer can be reelected indefinitely. So anyone thinking about running for office has no certain knowledge of what year an office may become vacant.

People may announce their intention to run for a given office years in advance of when the office is likely to become vacant, with the intentional effect of discouraging anyone else from running in opposition. (Think of dogs marking their territory.)

The campaign process is prohibitively expensive at personal cost to the candidates, often involving travel to multiple state society meetings. The cost alone is a barrier to entry for younger physicians, as is the time away from work and family.

The Caucus System

ASA for decades has divided itself into state and regional caucuses organized by geography:  Mid-Atlantic, Midwest, New England, Southern, and Western. Of these, the Western caucus is the largest, as it includes both California and Texas, and New England is the smallest.

If the caucuses were intended solely to encourage debate of policy issues in smaller groups, that would be fine. However, the caucuses play a powerful, disproportionate role in the chess game of electing officers.

By tradition, a caucus will endorse only one candidate for any given office. If more than one candidate in a caucus wants to run for that office, the caucus is expected to decide internally which candidate to support and which one should gracefully withdraw.

The caucus leadership holds lopsided power in this “kingmaking” process. It is rare and highly controversial for anyone to buck the caucus system and run without caucus endorsement. This poses a significant barrier to entry for any new candidate, no matter how qualified, especially if he or she hasn’t spent years (or decades) cultivating alliances.

Once the caucus has anointed a candidate, the leaders invariably declare that caucus members are free to act according to conscience and vote for the candidate of another caucus in the final secret-ballot election. However, caucus members are strongly discouraged from campaigning in support of an opposing candidate.

If two candidates appear equally qualified, caucus members often feel pressure to be loyal to the home caucus candidate. On occasion, caucuses have struck private deals to throw support to a selected candidate in return for future support of another candidate.

On the day before the final House of Delegates elections, candidates in contested races visit each caucus to answer questions, accompanied by “posses” of friends and allies carefully curated to demonstrate strong nationwide support. I’m not kidding about this; it’s all part of election strategy along with the calculated choice of the person who will deliver the nominating speech.

Every word the candidates say is scrutinized for any weakness or flaw. These caucus rounds have been known to make or break campaigns. Candidates are under tremendous pressure not to make any memorable errors. Remember when Al Gore claimed invention of the Internet, and Hillary Clinton dismissed opposing voters as a “basket of deplorables”? ASA politicos remember what candidates say during caucus rounds long after the elections are over.

What’s the solution?

Working out a better system should be a thoughtful process aimed at reducing barriers to entry for younger physicians and eliminating the “kingmaker” role of the geographic caucuses. At a minimum, changes to be considered should include:

Implementation of term limits (e.g. five or six years) for the offices below First Vice President, to make it clear well in advance when the office-holder will either run for higher office or step down;

Elimination of caucus endorsement;

Creation of a defined, open time period in each election cycle for declaration of intent to run for office, in order to eliminate the advantage of declaring years in advance;

Creation of a primary system to allow for multiple candidates from any state or region to conduct “virtual” campaigns, leading up to a preliminary round of electronic voting by delegates to narrow the race down to two final candidates;

Limits on campaign spending, or financial campaign support from the ASA, to make the cost of campaigning less prohibitive.

If the ASA is truly interested in increasing member engagement and decreasing cynicism, then we need to open the doors and windows and let in some fresh air. The current election atmosphere is toxic. We can do better.


Lisa Saunders

For the record, Al Gore never said he invented the internet. Perhaps a better example would have been Mitt Romney’s claim that 47% of Americans pay no income tax.


Norma Joan

44.4% of Americans did not pay taxes in 2018; I don’t know the number from the year he said it, but it appears he was not so far off.


I applaud the innovating and “out-of-the-box” thinking. Since California and Texas have such a disproportionate number of elected ASA leaders fostered and supported by the caucus system, their apparent “choke hold” on the election process could only be broken with smaller states aligning and collaborating with other voting blocks outside the Western Caucus to promote their own interests and candidates. The California alignment with New York seems to set a new precedent and exonerates those who wish to follow suit. Thank you for your leadership and making public that California feels no obligation to vote with the Western Caucus.



The Frontier Caucus comprising of Washington, Oregon, Idaho, Nevada, Arizona, Colorado, New Mexico and Wyoming was formed several years ago precising for this reason, to promote Frontier interests and candidates.


Neal Koss

Politics is a stinky business at all levels!!



This was a very enlightening article. I’ve grown increasingly disenchanted with the ASA this year and worry that it is moving away from its member-centric roots. It’s interesting that you bring up the financial aspect of campaigning. I think anesthesiologists need organization and advocacy, but the ASA seems increasingly focused on corporate partnerships to bring in more money. Money is great for advocacy, but not if it compromises the organization’s commitment to its members. I can’t help but wonder how much of this is influenced by the senior administrative staff rather than the elected officers.


Dr Jef

Thank you for taking this up Karen. I appreciated your details of a process unknown to any who aren’t or haven’t been direct participants.

I found myself asking not about Al Gore or other trifles, but about the Core Mission of the ASA. What DOES the ASA do in reality for me as the practicing Anesthesiologist? I’ve been both a member and non member. I’ve read the mission statement. I know what issues they talk about taking up. I’ve sat in many caucus meetings. I’ve occasionally brought up a practice standard or guideline. But in my day-to-day practice, those issues that most directly affect me don’t appear influenced by anything the ASA does or doesn’t do. The ASA hasn’t ended CRNA independent practice. Has it kept a lid on the spread? Did it come out against repeating the same process, with the AA? Has it even spoken ABOUT MOC, let alone AGAINST it? The ASA appears complicit with the ABMS debacle we call MOC, from the cheap seats here. Clearly, there will be myriad different opinions, and healthy respectful debate is well and good. I’m not actually looking to incite professional riot, but rather suggest a step back to ask the bigger questions. Do we NEED an ASA? Do we WANT an ASA? Does it need to be the behemouth financial leviathan it is today? Should it have the power it has?



This is why we have a representative government – A republic, as well as an electoral college. Thank you for addressing this. From all caucuses this year, we noticed that still, in 2019, the lack of female promotion was evident. Let’s find a way to facilitate a.better way for all.




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