Jeff Susman, MD

“What they’re gonna do is pull the plug on us when we get too old.”
“You won’t be able to see your own doctor anymore.”
“What if I get hurt on the job—what happens then?”

I have taken to asking cab drivers, frequent fliers, and store clerks what they think about health care reform. Their responses (and worries) are enlightening—if a bit scary. The amount of misinformation and downright hogwash that passes for fact is amazing. And the upcoming elections do little to enhance the level of discourse.

In fact, the fiction foisted upon the American public on TV and radio during this season of debate is downright disgusting. So I have taken to the streets, and I’m calling on you to do the same.

No legislation is perfect—certainly not anything as complex as the Patient Protection and Affordable Care Act, aka Health Care Reform, signed into law by President Barack Obama on March 23 of this year. But on balance, the new measure makes important progress in expanding access and coverage, countering egregious business practices (such as dropping enrollees who get sick), helping reduce waste, and enhancing primary care infrastructure.

So it is time we have a debate based on fact, not political rhetoric. It is time we demand accountability from our politicians. It is time we, as physicians, become patient advocates and help set the record straight about what health care reform does—and does not—entail.

I developed some talking points. (If you want to come up with your own, it may help to revisit the key provisions and time frame of health care reform at a site such as http://www.hhs.gov/healthcare/rights/index.html.)

Now, I tell as many people as possible that health care reform will:

• extend coverage to people who are currently underserved (some 32 million additional Americans)
• guarantee that Americans who have preexisting conditions or become seriously ill will have access to health care
• provide coverage for routine preventive services
• enhance end-of-life care.

Don’t allow politicians and others to reduce health care reform to sound bites and catch phrases. Take the time to raise the discourse. Provide patients with the information they need from a source they trust—their family physician.

“What they’re gonna do is pull the plug on us when we get too old.”
“You won’t be able to see your own doctor anymore.”
“What if I get hurt on the job—what happens then?”

I have taken to asking cab drivers, frequent fliers, and store clerks what they think about health care reform. Their responses (and worries) are enlightening—if a bit scary. The amount of misinformation and downright hogwash that passes for fact is amazing. And the upcoming elections do little to enhance the level of discourse.

In fact, the fiction foisted upon the American public on TV and radio during this season of debate is downright disgusting. So I have taken to the streets, and I’m calling on you to do the same.

No legislation is perfect—certainly not anything as complex as the Patient Protection and Affordable Care Act, aka Health Care Reform, signed into law by President Barack Obama on March 23 of this year. But on balance, the new measure makes important progress in expanding access and coverage, countering egregious business practices (such as dropping enrollees who get sick), helping reduce waste, and enhancing primary care infrastructure.

So it is time we have a debate based on fact, not political rhetoric. It is time we demand accountability from our politicians. It is time we, as physicians, become patient advocates and help set the record straight about what health care reform does—and does not—entail.

I developed some talking points. (If you want to come up with your own, it may help to revisit the key provisions and time frame of health care reform at a site such as http://www.hhs.gov/healthcare/rights/index.html.)

Now, I tell as many people as possible that health care reform will:

• extend coverage to people who are currently underserved (some 32 million additional Americans)
• guarantee that Americans who have preexisting conditions or become seriously ill will have access to health care
• provide coverage for routine preventive services
• enhance end-of-life care.

Don’t allow politicians and others to reduce health care reform to sound bites and catch phrases. Take the time to raise the discourse. Provide patients with the information they need from a source they trust—their family physician.

“What they’re gonna do is pull the plug on us when we get too old.”
“You won’t be able to see your own doctor anymore.”
“What if I get hurt on the job—what happens then?”

I have taken to asking cab drivers, frequent fliers, and store clerks what they think about health care reform. Their responses (and worries) are enlightening—if a bit scary. The amount of misinformation and downright hogwash that passes for fact is amazing. And the upcoming elections do little to enhance the level of discourse.

In fact, the fiction foisted upon the American public on TV and radio during this season of debate is downright disgusting. So I have taken to the streets, and I’m calling on you to do the same.

No legislation is perfect—certainly not anything as complex as the Patient Protection and Affordable Care Act, aka Health Care Reform, signed into law by President Barack Obama on March 23 of this year. But on balance, the new measure makes important progress in expanding access and coverage, countering egregious business practices (such as dropping enrollees who get sick), helping reduce waste, and enhancing primary care infrastructure.

So it is time we have a debate based on fact, not political rhetoric. It is time we demand accountability from our politicians. It is time we, as physicians, become patient advocates and help set the record straight about what health care reform does—and does not—entail.

I developed some talking points. (If you want to come up with your own, it may help to revisit the key provisions and time frame of health care reform at a site such as http://www.hhs.gov/healthcare/rights/index.html.)

Now, I tell as many people as possible that health care reform will:

• extend coverage to people who are currently underserved (some 32 million additional Americans)
• guarantee that Americans who have preexisting conditions or become seriously ill will have access to health care
• provide coverage for routine preventive services
• enhance end-of-life care.

Don’t allow politicians and others to reduce health care reform to sound bites and catch phrases. Take the time to raise the discourse. Provide patients with the information they need from a source they trust—their family physician.

“So, which do we want—the health risk appraisal package, the mental health compliance add-on, or the drug benefit data mining option?”

I am sitting in a meeting to consider options for our university’s employee health insurance program. There are a myriad of options, all allegedly poised to reduce the cost of care, optimize drug utilization, and maybe even improve the health of the people they cover.

People at the meeting fire a barrage of questions:

“Who is the pharmacy benefit manager?” our Dean of the College of Pharmacy wants to know.

“Does the package provide access to [fill in the name of one of the largest, most well-known health care systems]?” someone else queries.

“What about coverage for contact lenses?” asks another.

I realize I’m witnessing the brave new world of health care, and it is not a pretty picture.

First, there’s the torrent of marketing hype in the name of customizing employee health options. With glossy brochures extolling the benefits of services ranging from counseling to risk assessment, the process feels more akin to buying a new car (do you want the rust-proofing?) than choosing health insurance coverage.

Second, there is the only slightly veiled implication of—dare I say it?—rationing. Sure, it’s couched in terms like “active health management,” “addressing compliance,” and “adding value.” But the need to transition plan participants to less costly health care options appears, to me at least, to be based not on science, but on Orwellian behind-the-scene deals.

Moreover, I can’t help but wonder what we’re investing in. How useful are support calls from nurses halfway across the country (or maybe even around the world)?

It is really hard to tell the quality of the services we’re buying and the impact they will have; discussions tend to be swayed more by random opinion and less by informed purchasing. While much is made of cost savings and employee satisfaction, little hard data are presented and there is little talk of value.

As we muddle through the discussion of which ornaments to include on the university’s health care tree, I wonder when we are going to provide first-dollar coverage for primary care, encourage the use of a well-established patient-centered medical home, and foster the development of a trusted relationship with a primary care physician-led team.

Now that is a package worth paying for.

“So, which do we want—the health risk appraisal package, the mental health compliance add-on, or the drug benefit data mining option?”

I am sitting in a meeting to consider options for our university’s employee health insurance program. There are a myriad of options, all allegedly poised to reduce the cost of care, optimize drug utilization, and maybe even improve the health of the people they cover.

People at the meeting fire a barrage of questions:

“Who is the pharmacy benefit manager?” our Dean of the College of Pharmacy wants to know.

“Does the package provide access to [fill in the name of one of the largest, most well-known health care systems]?” someone else queries.

“What about coverage for contact lenses?” asks another.

I realize I’m witnessing the brave new world of health care, and it is not a pretty picture.

First, there’s the torrent of marketing hype in the name of customizing employee health options. With glossy brochures extolling the benefits of services ranging from counseling to risk assessment, the process feels more akin to buying a new car (do you want the rust-proofing?) than choosing health insurance coverage.

Second, there is the only slightly veiled implication of—dare I say it?—rationing. Sure, it’s couched in terms like “active health management,” “addressing compliance,” and “adding value.” But the need to transition plan participants to less costly health care options appears, to me at least, to be based not on science, but on Orwellian behind-the-scene deals.

Moreover, I can’t help but wonder what we’re investing in. How useful are support calls from nurses halfway across the country (or maybe even around the world)?

It is really hard to tell the quality of the services we’re buying and the impact they will have; discussions tend to be swayed more by random opinion and less by informed purchasing. While much is made of cost savings and employee satisfaction, little hard data are presented and there is little talk of value.

As we muddle through the discussion of which ornaments to include on the university’s health care tree, I wonder when we are going to provide first-dollar coverage for primary care, encourage the use of a well-established patient-centered medical home, and foster the development of a trusted relationship with a primary care physician-led team.

Now that is a package worth paying for.

“So, which do we want—the health risk appraisal package, the mental health compliance add-on, or the drug benefit data mining option?”

I am sitting in a meeting to consider options for our university’s employee health insurance program. There are a myriad of options, all allegedly poised to reduce the cost of care, optimize drug utilization, and maybe even improve the health of the people they cover.

People at the meeting fire a barrage of questions:

“Who is the pharmacy benefit manager?” our Dean of the College of Pharmacy wants to know.

“Does the package provide access to [fill in the name of one of the largest, most well-known health care systems]?” someone else queries.

“What about coverage for contact lenses?” asks another.

I realize I’m witnessing the brave new world of health care, and it is not a pretty picture.

First, there’s the torrent of marketing hype in the name of customizing employee health options. With glossy brochures extolling the benefits of services ranging from counseling to risk assessment, the process feels more akin to buying a new car (do you want the rust-proofing?) than choosing health insurance coverage.

Second, there is the only slightly veiled implication of—dare I say it?—rationing. Sure, it’s couched in terms like “active health management,” “addressing compliance,” and “adding value.” But the need to transition plan participants to less costly health care options appears, to me at least, to be based not on science, but on Orwellian behind-the-scene deals.

Moreover, I can’t help but wonder what we’re investing in. How useful are support calls from nurses halfway across the country (or maybe even around the world)?

It is really hard to tell the quality of the services we’re buying and the impact they will have; discussions tend to be swayed more by random opinion and less by informed purchasing. While much is made of cost savings and employee satisfaction, little hard data are presented and there is little talk of value.

As we muddle through the discussion of which ornaments to include on the university’s health care tree, I wonder when we are going to provide first-dollar coverage for primary care, encourage the use of a well-established patient-centered medical home, and foster the development of a trusted relationship with a primary care physician-led team.

Now that is a package worth paying for.

As I assume the role of dean at the Northeastern Ohio Universities College of Medicine, I find myself reflecting on the purpose of medical schools.

Ask the woman on the street about the purpose of medical schools, and she’ll probably say, “To train doctors.” And indeed, when all else is stripped away, educating medical students is the cornerstone of our mission. But it seems like an afterthought at many schools. Look at where the money goes, where people are hired, and what consumes the dean’s calendar—at most med schools, it is not medical education.

What should medical schools do?

Medical schools should focus on the health of their community, be it a single part of a large metropolitan area or an entire state. But how many schools devote substantial resources to the needs of the populations they serve?

Medical schools should actively manage the workforce they train. Schools produce specialists-to-be, willy-nilly, but neglect to nurture primary care physicians. While school administrators hide behind the idea of student choice and the broad needs of our nation, I see these as smokescreens. What our country really needs is more family physicians (and other primary care providers), and it is time medical schools stepped up to train them.

Medical schools should train a diverse workforce that reflects today’s society, rather than simply choosing students from middle- and higher-income families. Programs must focus on closing the gap in health disparities, starting with a more representative corps of clinicians.

What else?

Medical schools should shift the focus of clinical care. While many schools have developed outstanding clinical programs, the overwhelming focus on clinical enterprise strikes me as misplaced. More time is spent on engineering lucrative service lines—another transplant or cardiac surgery program—and less on basic education and services.

Medical schools should rethink their approach to research. Sure, many of our “great” institutions have established world-class research. But again, at the risk of sounding like a curmudgeon, I question how much of it really improves the health of populations. Another gene discovered, another esoteric biochemical process unraveled—but what about figuring out ways to improve the care rendered to individuals with diabetes?

In my new position, I hope to redirect our school’s priorities to what matters most. With that in mind, I’m interested in learning what you think medical schools should do. Write to me and let me know.

As I assume the role of dean at the Northeastern Ohio Universities College of Medicine, I find myself reflecting on the purpose of medical schools.

Ask the woman on the street about the purpose of medical schools, and she’ll probably say, “To train doctors.” And indeed, when all else is stripped away, educating medical students is the cornerstone of our mission. But it seems like an afterthought at many schools. Look at where the money goes, where people are hired, and what consumes the dean’s calendar—at most med schools, it is not medical education.

What should medical schools do?

Medical schools should focus on the health of their community, be it a single part of a large metropolitan area or an entire state. But how many schools devote substantial resources to the needs of the populations they serve?

Medical schools should actively manage the workforce they train. Schools produce specialists-to-be, willy-nilly, but neglect to nurture primary care physicians. While school administrators hide behind the idea of student choice and the broad needs of our nation, I see these as smokescreens. What our country really needs is more family physicians (and other primary care providers), and it is time medical schools stepped up to train them.

Medical schools should train a diverse workforce that reflects today’s society, rather than simply choosing students from middle- and higher-income families. Programs must focus on closing the gap in health disparities, starting with a more representative corps of clinicians.

What else?

Medical schools should shift the focus of clinical care. While many schools have developed outstanding clinical programs, the overwhelming focus on clinical enterprise strikes me as misplaced. More time is spent on engineering lucrative service lines—another transplant or cardiac surgery program—and less on basic education and services.

Medical schools should rethink their approach to research. Sure, many of our “great” institutions have established world-class research. But again, at the risk of sounding like a curmudgeon, I question how much of it really improves the health of populations. Another gene discovered, another esoteric biochemical process unraveled—but what about figuring out ways to improve the care rendered to individuals with diabetes?

In my new position, I hope to redirect our school’s priorities to what matters most. With that in mind, I’m interested in learning what you think medical schools should do. Write to me and let me know.

As I assume the role of dean at the Northeastern Ohio Universities College of Medicine, I find myself reflecting on the purpose of medical schools.

Ask the woman on the street about the purpose of medical schools, and she’ll probably say, “To train doctors.” And indeed, when all else is stripped away, educating medical students is the cornerstone of our mission. But it seems like an afterthought at many schools. Look at where the money goes, where people are hired, and what consumes the dean’s calendar—at most med schools, it is not medical education.

What should medical schools do?

Medical schools should focus on the health of their community, be it a single part of a large metropolitan area or an entire state. But how many schools devote substantial resources to the needs of the populations they serve?

Medical schools should actively manage the workforce they train. Schools produce specialists-to-be, willy-nilly, but neglect to nurture primary care physicians. While school administrators hide behind the idea of student choice and the broad needs of our nation, I see these as smokescreens. What our country really needs is more family physicians (and other primary care providers), and it is time medical schools stepped up to train them.

Medical schools should train a diverse workforce that reflects today’s society, rather than simply choosing students from middle- and higher-income families. Programs must focus on closing the gap in health disparities, starting with a more representative corps of clinicians.

What else?

Medical schools should shift the focus of clinical care. While many schools have developed outstanding clinical programs, the overwhelming focus on clinical enterprise strikes me as misplaced. More time is spent on engineering lucrative service lines—another transplant or cardiac surgery program—and less on basic education and services.

Medical schools should rethink their approach to research. Sure, many of our “great” institutions have established world-class research. But again, at the risk of sounding like a curmudgeon, I question how much of it really improves the health of populations. Another gene discovered, another esoteric biochemical process unraveled—but what about figuring out ways to improve the care rendered to individuals with diabetes?

In my new position, I hope to redirect our school’s priorities to what matters most. With that in mind, I’m interested in learning what you think medical schools should do. Write to me and let me know.

As some of you know, I recently accepted a new job as dean of Northeastern Ohio Universities College of Medicine, in Rootstown (near Akron). While I will remain editor of The Journal of Family Practice, I am faced with many bittersweet transitions.

One of the most difficult is saying goodbye to “my” patients.

There is Mr. R, who dutifully transported his wife to dialysis in the final years of her life. We would talk about their courtship in Japan, the ups and downs of her care, and most recently, his gradual recovery from losing the love of his life.

And Mr. J, a former baker who graced me with tales of bread making and the occasional loaf of homemade rye. We discussed his accomplished children, his wife’s increasing medical problems, and the intricacies of getting just the right “crumb” in wheat bread.

Ms. P, another long-time patient, has suffered from depression, fibromyalgia, and chronic pain. For many years I have watched her struggle to balance a demanding family, work, and the need for personal space. Each month she trudges on, resigned to a difficult life as a divorced caregiver.

As I sit and reflect on these individuals—and the host of other patients who have persevered through my canceled appointments and office moves—I feel as if I am losing a part of my family. Indeed, like many experienced clinicians, my encounters with established patients follow a ritual more akin to the family dinner table than a doctor’s office.

It is difficult to convey to younger colleagues the connections that are made over a period of years. While I may have strayed from the traditional image of family physician as a cradle-to-grave doctor—having given up maternity care and no longer making routine hospital visits—I remain impressed by the power of the doctor-patient relationship. And not just on the patient.

People lay bare their suffering, fears, and trauma. Even while maintaining that professional façade, we can’t help feeling their pain, their triumphs, their humanity and vulnerability.

I will miss immensely the immediacy and intimacy of patient care, the often hectic pace, the bizarre contrasts from one encounter to another. First, a well child of a first-time mom, then a drug-seeking patient requesting a Percocet refill. All I can do is shake my head and smile. Not many surprises now, but regular delights.

And though I know that transitions are the norm with today’s mobile society and employers’ frequent change of insurers, a sense of loss permeates my soul as I pack up the artifacts of my professional life and prepare to write the next chapter.

As some of you know, I recently accepted a new job as dean of Northeastern Ohio Universities College of Medicine, in Rootstown (near Akron). While I will remain editor of The Journal of Family Practice, I am faced with many bittersweet transitions.

One of the most difficult is saying goodbye to “my” patients.

There is Mr. R, who dutifully transported his wife to dialysis in the final years of her life. We would talk about their courtship in Japan, the ups and downs of her care, and most recently, his gradual recovery from losing the love of his life.

And Mr. J, a former baker who graced me with tales of bread making and the occasional loaf of homemade rye. We discussed his accomplished children, his wife’s increasing medical problems, and the intricacies of getting just the right “crumb” in wheat bread.

Ms. P, another long-time patient, has suffered from depression, fibromyalgia, and chronic pain. For many years I have watched her struggle to balance a demanding family, work, and the need for personal space. Each month she trudges on, resigned to a difficult life as a divorced caregiver.

As I sit and reflect on these individuals—and the host of other patients who have persevered through my canceled appointments and office moves—I feel as if I am losing a part of my family. Indeed, like many experienced clinicians, my encounters with established patients follow a ritual more akin to the family dinner table than a doctor’s office.

It is difficult to convey to younger colleagues the connections that are made over a period of years. While I may have strayed from the traditional image of family physician as a cradle-to-grave doctor—having given up maternity care and no longer making routine hospital visits—I remain impressed by the power of the doctor-patient relationship. And not just on the patient.

People lay bare their suffering, fears, and trauma. Even while maintaining that professional façade, we can’t help feeling their pain, their triumphs, their humanity and vulnerability.

I will miss immensely the immediacy and intimacy of patient care, the often hectic pace, the bizarre contrasts from one encounter to another. First, a well child of a first-time mom, then a drug-seeking patient requesting a Percocet refill. All I can do is shake my head and smile. Not many surprises now, but regular delights.

And though I know that transitions are the norm with today’s mobile society and employers’ frequent change of insurers, a sense of loss permeates my soul as I pack up the artifacts of my professional life and prepare to write the next chapter.

As some of you know, I recently accepted a new job as dean of Northeastern Ohio Universities College of Medicine, in Rootstown (near Akron). While I will remain editor of The Journal of Family Practice, I am faced with many bittersweet transitions.

One of the most difficult is saying goodbye to “my” patients.

There is Mr. R, who dutifully transported his wife to dialysis in the final years of her life. We would talk about their courtship in Japan, the ups and downs of her care, and most recently, his gradual recovery from losing the love of his life.

And Mr. J, a former baker who graced me with tales of bread making and the occasional loaf of homemade rye. We discussed his accomplished children, his wife’s increasing medical problems, and the intricacies of getting just the right “crumb” in wheat bread.

Ms. P, another long-time patient, has suffered from depression, fibromyalgia, and chronic pain. For many years I have watched her struggle to balance a demanding family, work, and the need for personal space. Each month she trudges on, resigned to a difficult life as a divorced caregiver.

As I sit and reflect on these individuals—and the host of other patients who have persevered through my canceled appointments and office moves—I feel as if I am losing a part of my family. Indeed, like many experienced clinicians, my encounters with established patients follow a ritual more akin to the family dinner table than a doctor’s office.

It is difficult to convey to younger colleagues the connections that are made over a period of years. While I may have strayed from the traditional image of family physician as a cradle-to-grave doctor—having given up maternity care and no longer making routine hospital visits—I remain impressed by the power of the doctor-patient relationship. And not just on the patient.

People lay bare their suffering, fears, and trauma. Even while maintaining that professional façade, we can’t help feeling their pain, their triumphs, their humanity and vulnerability.

I will miss immensely the immediacy and intimacy of patient care, the often hectic pace, the bizarre contrasts from one encounter to another. First, a well child of a first-time mom, then a drug-seeking patient requesting a Percocet refill. All I can do is shake my head and smile. Not many surprises now, but regular delights.

And though I know that transitions are the norm with today’s mobile society and employers’ frequent change of insurers, a sense of loss permeates my soul as I pack up the artifacts of my professional life and prepare to write the next chapter.

Interested in implementing an electronic health record (EHR), but haven’t yet made the plunge? Hoping to prepare for “meaningful use” of your current EHR? Ready to collect $44,000?

Last August, $1.2 billion was made available to states to create statewide health information exchanges and regional extension centers (RECs). The resources were allocated under the auspices of the Health Information Technology Act.

The RECs’ mission? To advance adoption of EHRs, enhance implementation of meaningful use (complex specifications still pending), and provide the tools physicians need to qualify for Medicare and Medicaid incentives (this is where that $44K payoff comes in). The RECs will support some 100,000 primary care clinicians, particularly those in smaller practices, those servicing public and critical access hospitals, and those caring for the underserved.

Additional resources will be used to create the Health Information Technology Research Center—a platform for collaboration and a national learning consortium that will offer technical assistance, tools, and training. Preferred vendors will be identified and favorable use terms negotiated.

The goal is to implement EHRs in all primary care offices. But how doable is that, really? PQRI—the Physician Quality Reporting Initiative—hardly conjures up warm and fuzzy feelings. CMS has yet to engender confidence in its use of technology. And the RECs themselves have highly variable track records.

The identification of preferred vendors may sound great, but in reality, this method of vendor selection may interfere with integration and substantial health information exchange within larger referral networks. Take Cincinnati, where a growing number of hospitals and larger health systems have settled on EPIC. The unfortunate result may well be the creation of “islands” of health information, with larger group practices and health systems on one set of systems and other, small providers unable to communicate effectively. Not the way to encourage integrated delivery systems.

It’s important to remember that health IT is not an end unto itself, but a means of enhancing patient care. Reaching meaningful use will require a substantial commitment of time and personnel, and a reassessment of workflows and processes.

My suggestion: Take advantage of the free technical assistance, but tread cautiously when making a significant health IT investment. While $44K sounds like a lot of money, choosing the wrong vendor could be far more costly. Get advice from colleagues who have already implemented EHRs, and carefully assess the effect on referrals.

And good luck.

Interested in implementing an electronic health record (EHR), but haven’t yet made the plunge? Hoping to prepare for “meaningful use” of your current EHR? Ready to collect $44,000?

Last August, $1.2 billion was made available to states to create statewide health information exchanges and regional extension centers (RECs). The resources were allocated under the auspices of the Health Information Technology Act.

The RECs’ mission? To advance adoption of EHRs, enhance implementation of meaningful use (complex specifications still pending), and provide the tools physicians need to qualify for Medicare and Medicaid incentives (this is where that $44K payoff comes in). The RECs will support some 100,000 primary care clinicians, particularly those in smaller practices, those servicing public and critical access hospitals, and those caring for the underserved.

Additional resources will be used to create the Health Information Technology Research Center—a platform for collaboration and a national learning consortium that will offer technical assistance, tools, and training. Preferred vendors will be identified and favorable use terms negotiated.

The goal is to implement EHRs in all primary care offices. But how doable is that, really? PQRI—the Physician Quality Reporting Initiative—hardly conjures up warm and fuzzy feelings. CMS has yet to engender confidence in its use of technology. And the RECs themselves have highly variable track records.

The identification of preferred vendors may sound great, but in reality, this method of vendor selection may interfere with integration and substantial health information exchange within larger referral networks. Take Cincinnati, where a growing number of hospitals and larger health systems have settled on EPIC. The unfortunate result may well be the creation of “islands” of health information, with larger group practices and health systems on one set of systems and other, small providers unable to communicate effectively. Not the way to encourage integrated delivery systems.

It’s important to remember that health IT is not an end unto itself, but a means of enhancing patient care. Reaching meaningful use will require a substantial commitment of time and personnel, and a reassessment of workflows and processes.

My suggestion: Take advantage of the free technical assistance, but tread cautiously when making a significant health IT investment. While $44K sounds like a lot of money, choosing the wrong vendor could be far more costly. Get advice from colleagues who have already implemented EHRs, and carefully assess the effect on referrals.

And good luck.

Interested in implementing an electronic health record (EHR), but haven’t yet made the plunge? Hoping to prepare for “meaningful use” of your current EHR? Ready to collect $44,000?

Last August, $1.2 billion was made available to states to create statewide health information exchanges and regional extension centers (RECs). The resources were allocated under the auspices of the Health Information Technology Act.

The RECs’ mission? To advance adoption of EHRs, enhance implementation of meaningful use (complex specifications still pending), and provide the tools physicians need to qualify for Medicare and Medicaid incentives (this is where that $44K payoff comes in). The RECs will support some 100,000 primary care clinicians, particularly those in smaller practices, those servicing public and critical access hospitals, and those caring for the underserved.

Additional resources will be used to create the Health Information Technology Research Center—a platform for collaboration and a national learning consortium that will offer technical assistance, tools, and training. Preferred vendors will be identified and favorable use terms negotiated.

The goal is to implement EHRs in all primary care offices. But how doable is that, really? PQRI—the Physician Quality Reporting Initiative—hardly conjures up warm and fuzzy feelings. CMS has yet to engender confidence in its use of technology. And the RECs themselves have highly variable track records.

The identification of preferred vendors may sound great, but in reality, this method of vendor selection may interfere with integration and substantial health information exchange within larger referral networks. Take Cincinnati, where a growing number of hospitals and larger health systems have settled on EPIC. The unfortunate result may well be the creation of “islands” of health information, with larger group practices and health systems on one set of systems and other, small providers unable to communicate effectively. Not the way to encourage integrated delivery systems.

It’s important to remember that health IT is not an end unto itself, but a means of enhancing patient care. Reaching meaningful use will require a substantial commitment of time and personnel, and a reassessment of workflows and processes.

My suggestion: Take advantage of the free technical assistance, but tread cautiously when making a significant health IT investment. While $44K sounds like a lot of money, choosing the wrong vendor could be far more costly. Get advice from colleagues who have already implemented EHRs, and carefully assess the effect on referrals.

And good luck.

A 300-lb white man comes in for a physical. His BP is elevated, but he doesn’t have time to get an EKG. The patient returns 1 week later, complaining of a rash. We do an EKG and find upside down T waves in 2, 3, aVL, aVF, and the lateral leads. The patient denies any chest pain or other symptoms, but I send him to the hospital, thinking he has coronary disease and will end up with a stent. At the hospital, he is diagnosed with bilateral pulmonary emboli.

This story, sent to me by a reader, is evidence of a dirty little secret of clinical practice—the importance of luck.

In the lexicon of luck, there are times when a prepared mind puts disparate information together to arrive at a diagnosis. A case in point: While filling in for a colleague, I saw a patient with anasarca. He had a minimally elevated transaminase and, in leafing through his chart, I spotted an ultrasound suggesting intrinsic liver disease. Lo and behold, his hepatitis B and C panels were positive. My suspicion immediately turned to chronic hepatitis. Perhaps this comes under the heading of educated luck.

Consider, too, the dumb luck of the incidental finding—when you order an imaging test for pneumonia and find the treatable (but unrelated) cancer or aneurysm.

But what I’m struck by most is when physicians experience plain old good luck. I had a long-time patient with mental health issues and a long history of arthralgias. After an unrevealing initial work-up, I sent her to a rheumatologist, who quickly diagnosed clubbing and a non-small cell cancer. All of a sudden I was a hero for making a referral for a diagnosis I had missed!

On the flip side are the patients who seem to be dogged by bad luck. The incidental puncture wound that leads to fulminate meningitis; the 22-year-old who has a stroke out of the blue. I see such cases occasionally as a potential expert witness and just shake my head: “What awful luck. No one could have been expected to prevent that!”

I doubt that many of our patients would want to hear their doctors talk about the role of luck in medicine. That’s our dirty little secret.

A 300-lb white man comes in for a physical. His BP is elevated, but he doesn’t have time to get an EKG. The patient returns 1 week later, complaining of a rash. We do an EKG and find upside down T waves in 2, 3, aVL, aVF, and the lateral leads. The patient denies any chest pain or other symptoms, but I send him to the hospital, thinking he has coronary disease and will end up with a stent. At the hospital, he is diagnosed with bilateral pulmonary emboli.

This story, sent to me by a reader, is evidence of a dirty little secret of clinical practice—the importance of luck.

In the lexicon of luck, there are times when a prepared mind puts disparate information together to arrive at a diagnosis. A case in point: While filling in for a colleague, I saw a patient with anasarca. He had a minimally elevated transaminase and, in leafing through his chart, I spotted an ultrasound suggesting intrinsic liver disease. Lo and behold, his hepatitis B and C panels were positive. My suspicion immediately turned to chronic hepatitis. Perhaps this comes under the heading of educated luck.

Consider, too, the dumb luck of the incidental finding—when you order an imaging test for pneumonia and find the treatable (but unrelated) cancer or aneurysm.

But what I’m struck by most is when physicians experience plain old good luck. I had a long-time patient with mental health issues and a long history of arthralgias. After an unrevealing initial work-up, I sent her to a rheumatologist, who quickly diagnosed clubbing and a non-small cell cancer. All of a sudden I was a hero for making a referral for a diagnosis I had missed!

On the flip side are the patients who seem to be dogged by bad luck. The incidental puncture wound that leads to fulminate meningitis; the 22-year-old who has a stroke out of the blue. I see such cases occasionally as a potential expert witness and just shake my head: “What awful luck. No one could have been expected to prevent that!”

I doubt that many of our patients would want to hear their doctors talk about the role of luck in medicine. That’s our dirty little secret.

A 300-lb white man comes in for a physical. His BP is elevated, but he doesn’t have time to get an EKG. The patient returns 1 week later, complaining of a rash. We do an EKG and find upside down T waves in 2, 3, aVL, aVF, and the lateral leads. The patient denies any chest pain or other symptoms, but I send him to the hospital, thinking he has coronary disease and will end up with a stent. At the hospital, he is diagnosed with bilateral pulmonary emboli.

This story, sent to me by a reader, is evidence of a dirty little secret of clinical practice—the importance of luck.

In the lexicon of luck, there are times when a prepared mind puts disparate information together to arrive at a diagnosis. A case in point: While filling in for a colleague, I saw a patient with anasarca. He had a minimally elevated transaminase and, in leafing through his chart, I spotted an ultrasound suggesting intrinsic liver disease. Lo and behold, his hepatitis B and C panels were positive. My suspicion immediately turned to chronic hepatitis. Perhaps this comes under the heading of educated luck.

Consider, too, the dumb luck of the incidental finding—when you order an imaging test for pneumonia and find the treatable (but unrelated) cancer or aneurysm.

But what I’m struck by most is when physicians experience plain old good luck. I had a long-time patient with mental health issues and a long history of arthralgias. After an unrevealing initial work-up, I sent her to a rheumatologist, who quickly diagnosed clubbing and a non-small cell cancer. All of a sudden I was a hero for making a referral for a diagnosis I had missed!

On the flip side are the patients who seem to be dogged by bad luck. The incidental puncture wound that leads to fulminate meningitis; the 22-year-old who has a stroke out of the blue. I see such cases occasionally as a potential expert witness and just shake my head: “What awful luck. No one could have been expected to prevent that!”

I doubt that many of our patients would want to hear their doctors talk about the role of luck in medicine. That’s our dirty little secret.

Recently, I was delighted to receive a run of this journal’s earliest issues (courtesy of Jay Siwek, Editor of American Family Physician). What fun to see the beginning years of our discipline through the eyes of such intellectual giants as John P. Geyman, Gayle Stephens, and Gene Farley. The tenor of the first issue of The Journal of Family Practice, published in May 1974, was guarded optimism, a dash of hubris, and a belief in the future.

Reading about family medicine’s early years evokes mixed emotions. On the one hand, I’m struck by our progress: The discipline has been integrated into medical schools, developed a substantial research agenda, and amassed a burgeoning compilation of literature. No longer are we plagued by a paucity of data about common primary care problems, the absence of competency-based training, or the need to debate the advisability of clinical clerkships in the community.

Articles on computers in family practice (consider the $800,000 to $14 million investment), the problem-oriented medical encounter, and the diagnostic index E-book serve as quaint reminders of an existence before the iPod touch and comprehensive EHRs. All in all, our discipline has grown robustly.

On the other hand, many aspirations remain unmet. The integration of the family, psychosocial, and behavioral health aspects of family practice is still just a promise. We struggle to develop patient-centered medical homes that truly integrate mental health, despite overwhelming evidence of their effectiveness. Community medicine and public health continue to be weak stepchildren. The schism between public health and medicine remains largely ignored. And the concept of a truly multidisciplinary team continues to be just that—a theory with limited implementation.

Even many of our basic tenets of continuity and comprehensive care are regularly assailed, amid the spread of minute clinics and subspecialism. I’ve already seen cardiologists and surgeons who claim to be developing patient-centered medical homes—shades of Clinton–era health care reform. Perhaps the greatest disappointment, though, is the inequity of our health care system, which persists despite our best efforts.

I’d like to end—as I started—with guarded optimism. Disappointments notwithstanding, the words, “Let us with enthusiastic vigor develop family medicine and other programs that relate to societal needs”¹ ring as clear and true today as they did 36 years ago.

Recently, I was delighted to receive a run of this journal’s earliest issues (courtesy of Jay Siwek, Editor of American Family Physician). What fun to see the beginning years of our discipline through the eyes of such intellectual giants as John P. Geyman, Gayle Stephens, and Gene Farley. The tenor of the first issue of The Journal of Family Practice, published in May 1974, was guarded optimism, a dash of hubris, and a belief in the future.

Reading about family medicine’s early years evokes mixed emotions. On the one hand, I’m struck by our progress: The discipline has been integrated into medical schools, developed a substantial research agenda, and amassed a burgeoning compilation of literature. No longer are we plagued by a paucity of data about common primary care problems, the absence of competency-based training, or the need to debate the advisability of clinical clerkships in the community.

Articles on computers in family practice (consider the $800,000 to $14 million investment), the problem-oriented medical encounter, and the diagnostic index E-book serve as quaint reminders of an existence before the iPod touch and comprehensive EHRs. All in all, our discipline has grown robustly.

On the other hand, many aspirations remain unmet. The integration of the family, psychosocial, and behavioral health aspects of family practice is still just a promise. We struggle to develop patient-centered medical homes that truly integrate mental health, despite overwhelming evidence of their effectiveness. Community medicine and public health continue to be weak stepchildren. The schism between public health and medicine remains largely ignored. And the concept of a truly multidisciplinary team continues to be just that—a theory with limited implementation.

Even many of our basic tenets of continuity and comprehensive care are regularly assailed, amid the spread of minute clinics and subspecialism. I’ve already seen cardiologists and surgeons who claim to be developing patient-centered medical homes—shades of Clinton–era health care reform. Perhaps the greatest disappointment, though, is the inequity of our health care system, which persists despite our best efforts.

I’d like to end—as I started—with guarded optimism. Disappointments notwithstanding, the words, “Let us with enthusiastic vigor develop family medicine and other programs that relate to societal needs”¹ ring as clear and true today as they did 36 years ago.

Recently, I was delighted to receive a run of this journal’s earliest issues (courtesy of Jay Siwek, Editor of American Family Physician). What fun to see the beginning years of our discipline through the eyes of such intellectual giants as John P. Geyman, Gayle Stephens, and Gene Farley. The tenor of the first issue of The Journal of Family Practice, published in May 1974, was guarded optimism, a dash of hubris, and a belief in the future.

Reading about family medicine’s early years evokes mixed emotions. On the one hand, I’m struck by our progress: The discipline has been integrated into medical schools, developed a substantial research agenda, and amassed a burgeoning compilation of literature. No longer are we plagued by a paucity of data about common primary care problems, the absence of competency-based training, or the need to debate the advisability of clinical clerkships in the community.

Articles on computers in family practice (consider the $800,000 to $14 million investment), the problem-oriented medical encounter, and the diagnostic index E-book serve as quaint reminders of an existence before the iPod touch and comprehensive EHRs. All in all, our discipline has grown robustly.

On the other hand, many aspirations remain unmet. The integration of the family, psychosocial, and behavioral health aspects of family practice is still just a promise. We struggle to develop patient-centered medical homes that truly integrate mental health, despite overwhelming evidence of their effectiveness. Community medicine and public health continue to be weak stepchildren. The schism between public health and medicine remains largely ignored. And the concept of a truly multidisciplinary team continues to be just that—a theory with limited implementation.

Even many of our basic tenets of continuity and comprehensive care are regularly assailed, amid the spread of minute clinics and subspecialism. I’ve already seen cardiologists and surgeons who claim to be developing patient-centered medical homes—shades of Clinton–era health care reform. Perhaps the greatest disappointment, though, is the inequity of our health care system, which persists despite our best efforts.

I’d like to end—as I started—with guarded optimism. Disappointments notwithstanding, the words, “Let us with enthusiastic vigor develop family medicine and other programs that relate to societal needs”¹ ring as clear and true today as they did 36 years ago.

Mrs. Jones delivered several weeks ago and now presents with brief periods of shortness of breath. Could it be a pulmonary embolism?

Mr. Johnson has had odd paresthesias in all 4 extremities and occasionally feels like his vision is “off.” Hmm. Maybe MS?

Mr. Smith has a history of diabetes, heart failure, and COPD, and now complains that he feels “wobbly” and can’t walk properly. A vascular problem? Stroke?

These are just a few of the patients I have seen over the past several weeks who have given me cause for concern.

Mrs. Jones doesn’t have leg tenderness or swelling; her spells last for just a second or 2. Mr. Johnson is always anxious. Mr. Smith decided to stop all his pills because he thinks he’s overmedicated.

The students and residents want the evidence, the pretest probabilities, the black and the white. Yet all I see are shades of gray.

It’s hard to tell our learners that the decision point is often clinical instinct—part educated hunch, part experience, and part an instantaneous weighing of the evidence. That child with croup can go home safely, this patient with abdominal pain needs an urgent MRI, and another with chest pain needs a cardiac workup.

Most of us in family medicine become comfortable with uncertainty; we’re able to tolerate ambiguity. And while we may worry, we can move on to the next patient with only a modicum of concern. Indeed, the ability to accept uncertainty is often a deal breaker in weighing a career in primary care—as much if not more so than the desire for a controllable lifestyle or the promise of a Porsche in the garage.

We come to recognize that not every patient with angina is on the verge of an MI, and that labels such as “atypical chest pain” are shorthand for “I’m just not sure.”

I still don’t have a diagnosis for the patients whose cases I’ve described. For now, what I can tell you is that Mrs. Jones’ D-dimer is elevated but her CT-PA is normal; Mr. Johnson has decided to talk to his oncologist and defer further evaluation, and Mr. Smith—and I—are expectantly awaiting the results of his MRI.

It’s all in the life of a family physician.

Mrs. Jones delivered several weeks ago and now presents with brief periods of shortness of breath. Could it be a pulmonary embolism?

Mr. Johnson has had odd paresthesias in all 4 extremities and occasionally feels like his vision is “off.” Hmm. Maybe MS?

Mr. Smith has a history of diabetes, heart failure, and COPD, and now complains that he feels “wobbly” and can’t walk properly. A vascular problem? Stroke?

These are just a few of the patients I have seen over the past several weeks who have given me cause for concern.

Mrs. Jones doesn’t have leg tenderness or swelling; her spells last for just a second or 2. Mr. Johnson is always anxious. Mr. Smith decided to stop all his pills because he thinks he’s overmedicated.

The students and residents want the evidence, the pretest probabilities, the black and the white. Yet all I see are shades of gray.

It’s hard to tell our learners that the decision point is often clinical instinct—part educated hunch, part experience, and part an instantaneous weighing of the evidence. That child with croup can go home safely, this patient with abdominal pain needs an urgent MRI, and another with chest pain needs a cardiac workup.

Most of us in family medicine become comfortable with uncertainty; we’re able to tolerate ambiguity. And while we may worry, we can move on to the next patient with only a modicum of concern. Indeed, the ability to accept uncertainty is often a deal breaker in weighing a career in primary care—as much if not more so than the desire for a controllable lifestyle or the promise of a Porsche in the garage.

We come to recognize that not every patient with angina is on the verge of an MI, and that labels such as “atypical chest pain” are shorthand for “I’m just not sure.”

I still don’t have a diagnosis for the patients whose cases I’ve described. For now, what I can tell you is that Mrs. Jones’ D-dimer is elevated but her CT-PA is normal; Mr. Johnson has decided to talk to his oncologist and defer further evaluation, and Mr. Smith—and I—are expectantly awaiting the results of his MRI.

It’s all in the life of a family physician.

Mrs. Jones delivered several weeks ago and now presents with brief periods of shortness of breath. Could it be a pulmonary embolism?

Mr. Johnson has had odd paresthesias in all 4 extremities and occasionally feels like his vision is “off.” Hmm. Maybe MS?

Mr. Smith has a history of diabetes, heart failure, and COPD, and now complains that he feels “wobbly” and can’t walk properly. A vascular problem? Stroke?

These are just a few of the patients I have seen over the past several weeks who have given me cause for concern.

Mrs. Jones doesn’t have leg tenderness or swelling; her spells last for just a second or 2. Mr. Johnson is always anxious. Mr. Smith decided to stop all his pills because he thinks he’s overmedicated.

The students and residents want the evidence, the pretest probabilities, the black and the white. Yet all I see are shades of gray.

It’s hard to tell our learners that the decision point is often clinical instinct—part educated hunch, part experience, and part an instantaneous weighing of the evidence. That child with croup can go home safely, this patient with abdominal pain needs an urgent MRI, and another with chest pain needs a cardiac workup.

Most of us in family medicine become comfortable with uncertainty; we’re able to tolerate ambiguity. And while we may worry, we can move on to the next patient with only a modicum of concern. Indeed, the ability to accept uncertainty is often a deal breaker in weighing a career in primary care—as much if not more so than the desire for a controllable lifestyle or the promise of a Porsche in the garage.

We come to recognize that not every patient with angina is on the verge of an MI, and that labels such as “atypical chest pain” are shorthand for “I’m just not sure.”

I still don’t have a diagnosis for the patients whose cases I’ve described. For now, what I can tell you is that Mrs. Jones’ D-dimer is elevated but her CT-PA is normal; Mr. Johnson has decided to talk to his oncologist and defer further evaluation, and Mr. Smith—and I—are expectantly awaiting the results of his MRI.

It’s all in the life of a family physician.

The call comes at 1:01 AM.

It’s my brother, Steve, calling to tell me that Mom’s blood pressure is 60 palpable. Despite my brother’s pleas that something be done, the staff and attending physician are adamant. “She has a DNR,” they insist. Steve can’t seem to persuade them that our mother’s wishes include the use of transfusions, pressors, and transfer to the ICU 3 floors below.

I phone the charge nurse. “Yes, we hold Mom’s durable power of attorney for health care,” I tell her. “But despite what your records may indicate, she does not belong on the DNR list.”

“Are you sure? We have a DNR.”

Absolutely sure, I respond, explaining that Steve and I are the ones who discussed Mom’s wishes with her before she was intubated and admitted to long-term acute care.

A few days later, as Mom’s septic shock is successfully treated, the intensivist applies pressure again. “This is futile. We should disconnect the ventilator,” he says.

“I am sorry, doctor, but that is not her wish.”

“But this is a waste of an ICU bed,” the intensivist adds—words that no doctor should ever utter to the family of a critically ill patient. We respond by threatening legal action and calls to the state medical board.

As time passes, Mom grows increasingly more lucid. Once again, she has narrowly escaped death. Barring a miracle, she will never see home again. Yet as best as we can tell, she continues to desire aggressive care, short of CPR.

Futile? Perhaps. But who are we to decide her fate?

I am not afraid of death squads. It is doctors playing God who frighten me.

The call comes at 1:01 AM.

It’s my brother, Steve, calling to tell me that Mom’s blood pressure is 60 palpable. Despite my brother’s pleas that something be done, the staff and attending physician are adamant. “She has a DNR,” they insist. Steve can’t seem to persuade them that our mother’s wishes include the use of transfusions, pressors, and transfer to the ICU 3 floors below.

I phone the charge nurse. “Yes, we hold Mom’s durable power of attorney for health care,” I tell her. “But despite what your records may indicate, she does not belong on the DNR list.”

“Are you sure? We have a DNR.”

Absolutely sure, I respond, explaining that Steve and I are the ones who discussed Mom’s wishes with her before she was intubated and admitted to long-term acute care.

A few days later, as Mom’s septic shock is successfully treated, the intensivist applies pressure again. “This is futile. We should disconnect the ventilator,” he says.

“I am sorry, doctor, but that is not her wish.”

“But this is a waste of an ICU bed,” the intensivist adds—words that no doctor should ever utter to the family of a critically ill patient. We respond by threatening legal action and calls to the state medical board.

As time passes, Mom grows increasingly more lucid. Once again, she has narrowly escaped death. Barring a miracle, she will never see home again. Yet as best as we can tell, she continues to desire aggressive care, short of CPR.

Futile? Perhaps. But who are we to decide her fate?

I am not afraid of death squads. It is doctors playing God who frighten me.

The call comes at 1:01 AM.

It’s my brother, Steve, calling to tell me that Mom’s blood pressure is 60 palpable. Despite my brother’s pleas that something be done, the staff and attending physician are adamant. “She has a DNR,” they insist. Steve can’t seem to persuade them that our mother’s wishes include the use of transfusions, pressors, and transfer to the ICU 3 floors below.

I phone the charge nurse. “Yes, we hold Mom’s durable power of attorney for health care,” I tell her. “But despite what your records may indicate, she does not belong on the DNR list.”

“Are you sure? We have a DNR.”

Absolutely sure, I respond, explaining that Steve and I are the ones who discussed Mom’s wishes with her before she was intubated and admitted to long-term acute care.

A few days later, as Mom’s septic shock is successfully treated, the intensivist applies pressure again. “This is futile. We should disconnect the ventilator,” he says.

“I am sorry, doctor, but that is not her wish.”

“But this is a waste of an ICU bed,” the intensivist adds—words that no doctor should ever utter to the family of a critically ill patient. We respond by threatening legal action and calls to the state medical board.

As time passes, Mom grows increasingly more lucid. Once again, she has narrowly escaped death. Barring a miracle, she will never see home again. Yet as best as we can tell, she continues to desire aggressive care, short of CPR.

Futile? Perhaps. But who are we to decide her fate?

I am not afraid of death squads. It is doctors playing God who frighten me.