Jeff Susman, MD

When I entered residency many years ago, a local physician sparked a fierce controversy when he ran a display ad in the Yellow Pages. Now, physicians use billboards to promote the augmentation of body parts that were once unmentionable in polite company. So I guess it was just a matter of time until consumers began rating physicians—along with plumbers, painters, movers, and more—on Angie’s List.

I don’t deny that consumer views of health care are important. But isn’t there a more robust, valid, and transparent way to collect important information about physician performance? I hope to find out over the next couple of years.

Cincinnati, where I live and practice, is one of 14 communities participating in the Robert Wood Johnson Aligning Forces for Quality initiative. One of our key projects is to develop a community-wide means of publicly reporting quality measures, based on primary (not claims) data. We’re starting with diabetes and cardiovascular care, but will add a host of other measures if we succeed.

Why go to the trouble?

I think physicians need to take the lead in accountability and public reporting—not the Centers for Medicare & Medicaid Services or local insurers, and certainly not Angie’s List. We need to promulgate public reporting principles, ensuring that the information is:

• verifiable, valid, and standardized
• focused on patient-oriented outcomes that matter
• tied to performance improvement
• understandable and able to influence clinician and patient behavior.

I also believe in a little frank and friendly competition. Standardized reporting allows head-to-head comparisons with our peers, and keeps us striving for improvement. What’s more, it arms patients with the information they need to make sound health care decisions. Sure, the public’s experiences—with friendly clinicians, pleasant receptionists, timely appointments, and even the magazines in the waiting room—matter. But our patients deserve more.

Achieving the reporting standards we’re striving for won’t be easy. But isn’t it better to face this challenge ourselves than to be lumped in with dog groomers, mechanics, and chimney sweeps?

When I entered residency many years ago, a local physician sparked a fierce controversy when he ran a display ad in the Yellow Pages. Now, physicians use billboards to promote the augmentation of body parts that were once unmentionable in polite company. So I guess it was just a matter of time until consumers began rating physicians—along with plumbers, painters, movers, and more—on Angie’s List.

I don’t deny that consumer views of health care are important. But isn’t there a more robust, valid, and transparent way to collect important information about physician performance? I hope to find out over the next couple of years.

Cincinnati, where I live and practice, is one of 14 communities participating in the Robert Wood Johnson Aligning Forces for Quality initiative. One of our key projects is to develop a community-wide means of publicly reporting quality measures, based on primary (not claims) data. We’re starting with diabetes and cardiovascular care, but will add a host of other measures if we succeed.

Why go to the trouble?

I think physicians need to take the lead in accountability and public reporting—not the Centers for Medicare & Medicaid Services or local insurers, and certainly not Angie’s List. We need to promulgate public reporting principles, ensuring that the information is:

• verifiable, valid, and standardized
• focused on patient-oriented outcomes that matter
• tied to performance improvement
• understandable and able to influence clinician and patient behavior.

I also believe in a little frank and friendly competition. Standardized reporting allows head-to-head comparisons with our peers, and keeps us striving for improvement. What’s more, it arms patients with the information they need to make sound health care decisions. Sure, the public’s experiences—with friendly clinicians, pleasant receptionists, timely appointments, and even the magazines in the waiting room—matter. But our patients deserve more.

Achieving the reporting standards we’re striving for won’t be easy. But isn’t it better to face this challenge ourselves than to be lumped in with dog groomers, mechanics, and chimney sweeps?

When I entered residency many years ago, a local physician sparked a fierce controversy when he ran a display ad in the Yellow Pages. Now, physicians use billboards to promote the augmentation of body parts that were once unmentionable in polite company. So I guess it was just a matter of time until consumers began rating physicians—along with plumbers, painters, movers, and more—on Angie’s List.

I don’t deny that consumer views of health care are important. But isn’t there a more robust, valid, and transparent way to collect important information about physician performance? I hope to find out over the next couple of years.

Cincinnati, where I live and practice, is one of 14 communities participating in the Robert Wood Johnson Aligning Forces for Quality initiative. One of our key projects is to develop a community-wide means of publicly reporting quality measures, based on primary (not claims) data. We’re starting with diabetes and cardiovascular care, but will add a host of other measures if we succeed.

Why go to the trouble?

I think physicians need to take the lead in accountability and public reporting—not the Centers for Medicare & Medicaid Services or local insurers, and certainly not Angie’s List. We need to promulgate public reporting principles, ensuring that the information is:

• verifiable, valid, and standardized
• focused on patient-oriented outcomes that matter
• tied to performance improvement
• understandable and able to influence clinician and patient behavior.

I also believe in a little frank and friendly competition. Standardized reporting allows head-to-head comparisons with our peers, and keeps us striving for improvement. What’s more, it arms patients with the information they need to make sound health care decisions. Sure, the public’s experiences—with friendly clinicians, pleasant receptionists, timely appointments, and even the magazines in the waiting room—matter. But our patients deserve more.

Achieving the reporting standards we’re striving for won’t be easy. But isn’t it better to face this challenge ourselves than to be lumped in with dog groomers, mechanics, and chimney sweeps?

As the nation prepares for a new administration, it’s time to rebuild our crumbling health care system. In a statement on the AAFP Web site, President-Elect Barack Obama has pledged to “encourage and provide appropriate payment for providers who implement the medical home model…” Physician-directed inter-disciplinary teams, disease management and care coordination, quality assurance, and health IT systems, he states, “will help to improve care for those with chronic conditions.”¹

There’s much to applaud in that statement. Yet I worry that a critical element is often overlooked in discussions of this concept—namely, our patients, the people for whom we’re building medical homes.

Written standards governing patient access and detailed plans for patient care do not equal a trusting physician-patient relationship, any more than an interactive Web site can substitute for a caring clinician who connects with his or her patients. Amid the multiplicity of measures alleged to judge medical “home-ness,” let’s not settle for attributes that are easy to determine and miss those that are truly important.

A medical home should nurture the spirit, not merely provide refuge from the rain. To do that, we need to see patients as whole individuals, not just a sum of their chronic conditions. Too little attention is paid to mental health as an underlying mediator of wellness; too few dollars are allocated to incentives for integration of physical and mental well-being.

While we certainly need to do a better job treating heart disease and diabetes, a system that values smoking cessation and other lifestyle interventions would diminish the morbidity and mortality of these scourges. It’s time to challenge the old sickness model of medicine and move to a system that rewards health promotion, disease prevention, and population-based care.

Finally, we need to build a medical home for everyone—“black, white, Hispanic, Asian, Native American; Democrat and Republican; young and old; rich and poor; gay and straight; disabled or not.”² As Barack Obama said in a recent speech, shouldn’t everyone have “the same kind of health insurance that members of Congress get for themselves?”²

As the nation prepares for a new administration, it’s time to rebuild our crumbling health care system. In a statement on the AAFP Web site, President-Elect Barack Obama has pledged to “encourage and provide appropriate payment for providers who implement the medical home model…” Physician-directed inter-disciplinary teams, disease management and care coordination, quality assurance, and health IT systems, he states, “will help to improve care for those with chronic conditions.”¹

There’s much to applaud in that statement. Yet I worry that a critical element is often overlooked in discussions of this concept—namely, our patients, the people for whom we’re building medical homes.

Written standards governing patient access and detailed plans for patient care do not equal a trusting physician-patient relationship, any more than an interactive Web site can substitute for a caring clinician who connects with his or her patients. Amid the multiplicity of measures alleged to judge medical “home-ness,” let’s not settle for attributes that are easy to determine and miss those that are truly important.

A medical home should nurture the spirit, not merely provide refuge from the rain. To do that, we need to see patients as whole individuals, not just a sum of their chronic conditions. Too little attention is paid to mental health as an underlying mediator of wellness; too few dollars are allocated to incentives for integration of physical and mental well-being.

While we certainly need to do a better job treating heart disease and diabetes, a system that values smoking cessation and other lifestyle interventions would diminish the morbidity and mortality of these scourges. It’s time to challenge the old sickness model of medicine and move to a system that rewards health promotion, disease prevention, and population-based care.

Finally, we need to build a medical home for everyone—“black, white, Hispanic, Asian, Native American; Democrat and Republican; young and old; rich and poor; gay and straight; disabled or not.”² As Barack Obama said in a recent speech, shouldn’t everyone have “the same kind of health insurance that members of Congress get for themselves?”²

As the nation prepares for a new administration, it’s time to rebuild our crumbling health care system. In a statement on the AAFP Web site, President-Elect Barack Obama has pledged to “encourage and provide appropriate payment for providers who implement the medical home model…” Physician-directed inter-disciplinary teams, disease management and care coordination, quality assurance, and health IT systems, he states, “will help to improve care for those with chronic conditions.”¹

There’s much to applaud in that statement. Yet I worry that a critical element is often overlooked in discussions of this concept—namely, our patients, the people for whom we’re building medical homes.

Written standards governing patient access and detailed plans for patient care do not equal a trusting physician-patient relationship, any more than an interactive Web site can substitute for a caring clinician who connects with his or her patients. Amid the multiplicity of measures alleged to judge medical “home-ness,” let’s not settle for attributes that are easy to determine and miss those that are truly important.

A medical home should nurture the spirit, not merely provide refuge from the rain. To do that, we need to see patients as whole individuals, not just a sum of their chronic conditions. Too little attention is paid to mental health as an underlying mediator of wellness; too few dollars are allocated to incentives for integration of physical and mental well-being.

While we certainly need to do a better job treating heart disease and diabetes, a system that values smoking cessation and other lifestyle interventions would diminish the morbidity and mortality of these scourges. It’s time to challenge the old sickness model of medicine and move to a system that rewards health promotion, disease prevention, and population-based care.

Finally, we need to build a medical home for everyone—“black, white, Hispanic, Asian, Native American; Democrat and Republican; young and old; rich and poor; gay and straight; disabled or not.”² As Barack Obama said in a recent speech, shouldn’t everyone have “the same kind of health insurance that members of Congress get for themselves?”²

Amonth before Election Day, my wife and I were discussing how much fun it is to watch our children wander the globe while we stay home and amuse ourselves with the likes of the vice presidential debate and the government’s multi-billion dollar banking bailout.

I have a hard time getting my head around $1 billion, never mind the $850 billion in the final bailout bill. To put it into perspective, consider these numbers:

$381 billion: Medicare spending in 2006
$314 billion: Health care savings from healthier lifestyles
$162 billion: Savings from “wired” health care (eg, EHRs, e-prescribing)
$125 billion: Annual cost of care for the uninsured
$120 billion: Cost of the Iraq War in 2007
$120 billion: Cost to fully implement a wired health care system

I cite these numbers to illustrate that the cost of fixing our nation’s broken health care system—often viewed as unfathomably expensive—is well within our reach. With the presidential election behind us, it’s time to demand that the new administration do the following:

Wire the health care system; double reimbursement rates of primary care physicians; enact tort reform; mandate flexible health insurance for all Americans; and launch a healthy lifestyle campaign.

Wired health care and tort reform—eliminating frivolous lawsuits and defensive medicine—could provide a net savings of $40 billion and $200 billion, respectively, according to published reports. The other line items are a wash: savings equal costs. Doubling our reimbursement rates would involve paying less for routine procedural care (eg, cataract surgery) and more for cognitive services (eg, smoking cessation counseling).

We can all quibble about the numbers and the means of achieving these goals. But I think we can all agree that it’s time to tackle our health care crisis with the same vigor applied to presidential politics and the search for a fix for our nation’s financial follies.

Amonth before Election Day, my wife and I were discussing how much fun it is to watch our children wander the globe while we stay home and amuse ourselves with the likes of the vice presidential debate and the government’s multi-billion dollar banking bailout.

I have a hard time getting my head around $1 billion, never mind the $850 billion in the final bailout bill. To put it into perspective, consider these numbers:

$381 billion: Medicare spending in 2006
$314 billion: Health care savings from healthier lifestyles
$162 billion: Savings from “wired” health care (eg, EHRs, e-prescribing)
$125 billion: Annual cost of care for the uninsured
$120 billion: Cost of the Iraq War in 2007
$120 billion: Cost to fully implement a wired health care system

I cite these numbers to illustrate that the cost of fixing our nation’s broken health care system—often viewed as unfathomably expensive—is well within our reach. With the presidential election behind us, it’s time to demand that the new administration do the following:

Wire the health care system; double reimbursement rates of primary care physicians; enact tort reform; mandate flexible health insurance for all Americans; and launch a healthy lifestyle campaign.

Wired health care and tort reform—eliminating frivolous lawsuits and defensive medicine—could provide a net savings of $40 billion and $200 billion, respectively, according to published reports. The other line items are a wash: savings equal costs. Doubling our reimbursement rates would involve paying less for routine procedural care (eg, cataract surgery) and more for cognitive services (eg, smoking cessation counseling).

We can all quibble about the numbers and the means of achieving these goals. But I think we can all agree that it’s time to tackle our health care crisis with the same vigor applied to presidential politics and the search for a fix for our nation’s financial follies.

Amonth before Election Day, my wife and I were discussing how much fun it is to watch our children wander the globe while we stay home and amuse ourselves with the likes of the vice presidential debate and the government’s multi-billion dollar banking bailout.

I have a hard time getting my head around $1 billion, never mind the $850 billion in the final bailout bill. To put it into perspective, consider these numbers:

$381 billion: Medicare spending in 2006
$314 billion: Health care savings from healthier lifestyles
$162 billion: Savings from “wired” health care (eg, EHRs, e-prescribing)
$125 billion: Annual cost of care for the uninsured
$120 billion: Cost of the Iraq War in 2007
$120 billion: Cost to fully implement a wired health care system

I cite these numbers to illustrate that the cost of fixing our nation’s broken health care system—often viewed as unfathomably expensive—is well within our reach. With the presidential election behind us, it’s time to demand that the new administration do the following:

Wire the health care system; double reimbursement rates of primary care physicians; enact tort reform; mandate flexible health insurance for all Americans; and launch a healthy lifestyle campaign.

Wired health care and tort reform—eliminating frivolous lawsuits and defensive medicine—could provide a net savings of $40 billion and $200 billion, respectively, according to published reports. The other line items are a wash: savings equal costs. Doubling our reimbursement rates would involve paying less for routine procedural care (eg, cataract surgery) and more for cognitive services (eg, smoking cessation counseling).

We can all quibble about the numbers and the means of achieving these goals. But I think we can all agree that it’s time to tackle our health care crisis with the same vigor applied to presidential politics and the search for a fix for our nation’s financial follies.

Harriet Smith* is 82, lives alone on a meager fixed income, and copes with diabetes, depression, osteoporosis, osteoarthritis, heart failure, and hypertension. She’s had a CVA with mild expressive aphasia and a “mild” heart attack. With the help of neighbors, she manages to see me regularly, but seems baffled by all attempts to manage her multiple medications.

Ms. Smith is beginning to typify my practice.

She had Meals On Wheels, but says the food was lousy. Home health and personal care aides lasted only a couple of visits. Her daughter-in-law takes an active interest in her care, but lives over an hour away. Ms. Smith refuses to go to an assisted living facility. “People die there,” she wryly remarks.

She teases me about my frustrations with the electronic health record; I ask when she’s coming to weed my garden. Her attitude remains largely positive despite the frustrations from her aphasia, an ever-changing array of specialists and medications, and seemingly endless medical bills.

Ms. Smith is the product of dysfunctional health and social welfare systems. I spend twice the allotted appointment time with her, and still do little justice to her medical (let alone mental health and social) needs. I dread the day when I learn that Ms. Smith has had another stroke, a debilitating fall, or a devastating MI.

The Institute of Medicine’s report, “Retooling for an Aging America: Building the Health Care Workforce” (www.iom.edu/CMS/3809/40113/53452.aspx) is a sobering reminder that the services patients like Harriet Smith need are in dangerously short supply. Home health aides earn scarcely more than cafeteria attendants, and more than 80% leave their jobs in the first year. Only 4% of social workers specialize in geriatrics. There are only 7100 geriatricians nationally, and the number is declining. Geriatricians earn half of what oncologists do.

We talk about the need to redesign family medicine and develop a new model of care, and I shake my head in remorse when I consider the challenges our elders face: a Byzantine bureaucracy of federal programs, inadequate support to stay at home, and specialists who are ill prepared to care for the growing number of aging patients. When the Boomers hit old age, will anyone be there to care for us?

My scheduled time with Ms. Smith is well past, and I send her off with a cheery, “See you next visit.”

“God willing,” she replies.

*To protect the patient’s identity, her name has been changed and her history slightly modified.

Harriet Smith* is 82, lives alone on a meager fixed income, and copes with diabetes, depression, osteoporosis, osteoarthritis, heart failure, and hypertension. She’s had a CVA with mild expressive aphasia and a “mild” heart attack. With the help of neighbors, she manages to see me regularly, but seems baffled by all attempts to manage her multiple medications.

Ms. Smith is beginning to typify my practice.

She had Meals On Wheels, but says the food was lousy. Home health and personal care aides lasted only a couple of visits. Her daughter-in-law takes an active interest in her care, but lives over an hour away. Ms. Smith refuses to go to an assisted living facility. “People die there,” she wryly remarks.

She teases me about my frustrations with the electronic health record; I ask when she’s coming to weed my garden. Her attitude remains largely positive despite the frustrations from her aphasia, an ever-changing array of specialists and medications, and seemingly endless medical bills.

Ms. Smith is the product of dysfunctional health and social welfare systems. I spend twice the allotted appointment time with her, and still do little justice to her medical (let alone mental health and social) needs. I dread the day when I learn that Ms. Smith has had another stroke, a debilitating fall, or a devastating MI.

The Institute of Medicine’s report, “Retooling for an Aging America: Building the Health Care Workforce” (www.iom.edu/CMS/3809/40113/53452.aspx) is a sobering reminder that the services patients like Harriet Smith need are in dangerously short supply. Home health aides earn scarcely more than cafeteria attendants, and more than 80% leave their jobs in the first year. Only 4% of social workers specialize in geriatrics. There are only 7100 geriatricians nationally, and the number is declining. Geriatricians earn half of what oncologists do.

We talk about the need to redesign family medicine and develop a new model of care, and I shake my head in remorse when I consider the challenges our elders face: a Byzantine bureaucracy of federal programs, inadequate support to stay at home, and specialists who are ill prepared to care for the growing number of aging patients. When the Boomers hit old age, will anyone be there to care for us?

My scheduled time with Ms. Smith is well past, and I send her off with a cheery, “See you next visit.”

“God willing,” she replies.

*To protect the patient’s identity, her name has been changed and her history slightly modified.

Harriet Smith* is 82, lives alone on a meager fixed income, and copes with diabetes, depression, osteoporosis, osteoarthritis, heart failure, and hypertension. She’s had a CVA with mild expressive aphasia and a “mild” heart attack. With the help of neighbors, she manages to see me regularly, but seems baffled by all attempts to manage her multiple medications.

Ms. Smith is beginning to typify my practice.

She had Meals On Wheels, but says the food was lousy. Home health and personal care aides lasted only a couple of visits. Her daughter-in-law takes an active interest in her care, but lives over an hour away. Ms. Smith refuses to go to an assisted living facility. “People die there,” she wryly remarks.

She teases me about my frustrations with the electronic health record; I ask when she’s coming to weed my garden. Her attitude remains largely positive despite the frustrations from her aphasia, an ever-changing array of specialists and medications, and seemingly endless medical bills.

Ms. Smith is the product of dysfunctional health and social welfare systems. I spend twice the allotted appointment time with her, and still do little justice to her medical (let alone mental health and social) needs. I dread the day when I learn that Ms. Smith has had another stroke, a debilitating fall, or a devastating MI.

The Institute of Medicine’s report, “Retooling for an Aging America: Building the Health Care Workforce” (www.iom.edu/CMS/3809/40113/53452.aspx) is a sobering reminder that the services patients like Harriet Smith need are in dangerously short supply. Home health aides earn scarcely more than cafeteria attendants, and more than 80% leave their jobs in the first year. Only 4% of social workers specialize in geriatrics. There are only 7100 geriatricians nationally, and the number is declining. Geriatricians earn half of what oncologists do.

We talk about the need to redesign family medicine and develop a new model of care, and I shake my head in remorse when I consider the challenges our elders face: a Byzantine bureaucracy of federal programs, inadequate support to stay at home, and specialists who are ill prepared to care for the growing number of aging patients. When the Boomers hit old age, will anyone be there to care for us?

My scheduled time with Ms. Smith is well past, and I send her off with a cheery, “See you next visit.”

“God willing,” she replies.

*To protect the patient’s identity, her name has been changed and her history slightly modified.

This yearly epidemic engenders mass concern in the physician community. Alerts are frantically e-mailed, conferences are urgently convened, and the mass media salivates over the gory details. No, it’s not the latest incarnation of the influenza or an outbreak of hepatitis A. Yet, as predictable as the weeds that begin to outstrip my lettuce in early summer, I can count on the annual return of SGR Fever.

I am sure you are familiar with the symptoms: physicians threatening to withdraw from Medicare, professional societies launching public relations campaigns, congressional leaders wringing their hands, special interest groups lining up to lobby for their pet issues, and the President pontificating.

Passed by Congress in 1997, the SGR (sustainable growth rate) was meant to slow the growth in Medicare spending. Beginning in 2002, with a flagging economy, the SGR has triggered regularly scheduled cuts for Medicare reimbursement to physicians. This year was no exception, with a 10.6% proposed reduction scheduled for July 1, 2008. After much wrangling, and the Senate and House override of a presidential veto, HR 6331 was enacted, rescinding this cut. (Indeed, a 1.1% increase is in place for 2009.) I guess we should all be whooping for joy about this incredible increase; I figure it will probably buy a tank of gas for my Mini-Cooper.

But seriously, is this illness what we want our Congress to fight every year? Do we want weeks of legislative bickering and political infighting over seniors’ health care? Does society gain one iota of benefit from this perennial skirmish? Isn’t it time we send Congress a clear message to reform this system once and for all?

It’s time to tackle serious Medicare finance reform: Ditch the SGR; stop propping up special interests (such as the private Medicare Advantage Plans); eliminate waste (needless procedures) and overpayment for procedures that have become routine; develop a sustainable strategy for financing medical education; and rebalance payment to support primary care.

And leave me more time to tackle those garden weeds rather than concerning myself with congressional incompetence.

PS: For some insight into lawmakers’ views on the state of primary care and physician payment, see “Primary care’s eroding earnings: Is Congress concerned?” on page 578.

This yearly epidemic engenders mass concern in the physician community. Alerts are frantically e-mailed, conferences are urgently convened, and the mass media salivates over the gory details. No, it’s not the latest incarnation of the influenza or an outbreak of hepatitis A. Yet, as predictable as the weeds that begin to outstrip my lettuce in early summer, I can count on the annual return of SGR Fever.

I am sure you are familiar with the symptoms: physicians threatening to withdraw from Medicare, professional societies launching public relations campaigns, congressional leaders wringing their hands, special interest groups lining up to lobby for their pet issues, and the President pontificating.

Passed by Congress in 1997, the SGR (sustainable growth rate) was meant to slow the growth in Medicare spending. Beginning in 2002, with a flagging economy, the SGR has triggered regularly scheduled cuts for Medicare reimbursement to physicians. This year was no exception, with a 10.6% proposed reduction scheduled for July 1, 2008. After much wrangling, and the Senate and House override of a presidential veto, HR 6331 was enacted, rescinding this cut. (Indeed, a 1.1% increase is in place for 2009.) I guess we should all be whooping for joy about this incredible increase; I figure it will probably buy a tank of gas for my Mini-Cooper.

But seriously, is this illness what we want our Congress to fight every year? Do we want weeks of legislative bickering and political infighting over seniors’ health care? Does society gain one iota of benefit from this perennial skirmish? Isn’t it time we send Congress a clear message to reform this system once and for all?

It’s time to tackle serious Medicare finance reform: Ditch the SGR; stop propping up special interests (such as the private Medicare Advantage Plans); eliminate waste (needless procedures) and overpayment for procedures that have become routine; develop a sustainable strategy for financing medical education; and rebalance payment to support primary care.

And leave me more time to tackle those garden weeds rather than concerning myself with congressional incompetence.

PS: For some insight into lawmakers’ views on the state of primary care and physician payment, see “Primary care’s eroding earnings: Is Congress concerned?” on page 578.

This yearly epidemic engenders mass concern in the physician community. Alerts are frantically e-mailed, conferences are urgently convened, and the mass media salivates over the gory details. No, it’s not the latest incarnation of the influenza or an outbreak of hepatitis A. Yet, as predictable as the weeds that begin to outstrip my lettuce in early summer, I can count on the annual return of SGR Fever.

I am sure you are familiar with the symptoms: physicians threatening to withdraw from Medicare, professional societies launching public relations campaigns, congressional leaders wringing their hands, special interest groups lining up to lobby for their pet issues, and the President pontificating.

Passed by Congress in 1997, the SGR (sustainable growth rate) was meant to slow the growth in Medicare spending. Beginning in 2002, with a flagging economy, the SGR has triggered regularly scheduled cuts for Medicare reimbursement to physicians. This year was no exception, with a 10.6% proposed reduction scheduled for July 1, 2008. After much wrangling, and the Senate and House override of a presidential veto, HR 6331 was enacted, rescinding this cut. (Indeed, a 1.1% increase is in place for 2009.) I guess we should all be whooping for joy about this incredible increase; I figure it will probably buy a tank of gas for my Mini-Cooper.

But seriously, is this illness what we want our Congress to fight every year? Do we want weeks of legislative bickering and political infighting over seniors’ health care? Does society gain one iota of benefit from this perennial skirmish? Isn’t it time we send Congress a clear message to reform this system once and for all?

It’s time to tackle serious Medicare finance reform: Ditch the SGR; stop propping up special interests (such as the private Medicare Advantage Plans); eliminate waste (needless procedures) and overpayment for procedures that have become routine; develop a sustainable strategy for financing medical education; and rebalance payment to support primary care.

And leave me more time to tackle those garden weeds rather than concerning myself with congressional incompetence.

PS: For some insight into lawmakers’ views on the state of primary care and physician payment, see “Primary care’s eroding earnings: Is Congress concerned?” on page 578.

I arrive on a hot August day. The exterior and grounds are immaculate: the shrubs neatly trimmed, the lawn freshly mowed, the annuals profusely flowering. As I enter, I am immediately greeted with a smile and escorted directly to my room. “Did you have a nice trip? Is there anything I can get you? Something cool to drink?” Moments later a glass of iced tea appears.

Once I am settled in, I always like to find the local paper. I walk past the lounge where live music is playing. The walls are adorned with original art. I am greeted enthusiastically by each person who passes. In fact, I marvel how every guest is acknowledged by name. I see a family laughing in the lobby, while another group leaves for the day. What a relaxing retreat this is.

As I return to my room, my reverie is broken. “Hi, Dr. Susman.” My first patient is an 87-year-old woman, here to recuperate from a hip fracture.

No, you wouldn’t confuse Autumn Years for the Four Seasons or the Ritz Carlton (at least not yet), but I enjoy every visit to this rural nursing home. The staff is warm and friendly, cats freely roam the halls, and the gardens are well tended. Even if the artwork tends toward needlepoint and feline prints, and the food is soft and bland, I am still impressed that even the youngest volunteers exude pride and compassion.

No, not every nursing home is run with such kindness. But I suspect our big city offices and hospitals could learn a bit from our rural nursing homes about teamwork, hustle, and caring. Despite the inevitable charting, nurses really know their patients. The staff will gladly find you a cup of coffee from the kitchen, and they make sure you see all the guests—er, I mean patients—and even get you their charts. There isn’t a lot of concern about who is in charge, who does what, or “that isn’t my job.” There is much discussion about the price of corn, the newest café, and how much it’s rained, which pretty much puts life into perspective.

Perhaps it is my early experience in rural practice, the stress of city life, or the often impersonal nature of large hospitals, but I find this day oddly relaxing. The patient challenges are the same—failing kidneys, faltering hearts, minds that are fading, spines that are crumbling. Maybe I just identify with the farm-bred ability to weather adversity and face life’s challenges with dignity.

I can’t imagine a better place to spend my day, murmuring over cross-stitch, and warmly greeting long-time patients. And even if the music is karaoke, the songs remain heartfelt, and optimism pervades the air.

I arrive on a hot August day. The exterior and grounds are immaculate: the shrubs neatly trimmed, the lawn freshly mowed, the annuals profusely flowering. As I enter, I am immediately greeted with a smile and escorted directly to my room. “Did you have a nice trip? Is there anything I can get you? Something cool to drink?” Moments later a glass of iced tea appears.

Once I am settled in, I always like to find the local paper. I walk past the lounge where live music is playing. The walls are adorned with original art. I am greeted enthusiastically by each person who passes. In fact, I marvel how every guest is acknowledged by name. I see a family laughing in the lobby, while another group leaves for the day. What a relaxing retreat this is.

As I return to my room, my reverie is broken. “Hi, Dr. Susman.” My first patient is an 87-year-old woman, here to recuperate from a hip fracture.

No, you wouldn’t confuse Autumn Years for the Four Seasons or the Ritz Carlton (at least not yet), but I enjoy every visit to this rural nursing home. The staff is warm and friendly, cats freely roam the halls, and the gardens are well tended. Even if the artwork tends toward needlepoint and feline prints, and the food is soft and bland, I am still impressed that even the youngest volunteers exude pride and compassion.

No, not every nursing home is run with such kindness. But I suspect our big city offices and hospitals could learn a bit from our rural nursing homes about teamwork, hustle, and caring. Despite the inevitable charting, nurses really know their patients. The staff will gladly find you a cup of coffee from the kitchen, and they make sure you see all the guests—er, I mean patients—and even get you their charts. There isn’t a lot of concern about who is in charge, who does what, or “that isn’t my job.” There is much discussion about the price of corn, the newest café, and how much it’s rained, which pretty much puts life into perspective.

Perhaps it is my early experience in rural practice, the stress of city life, or the often impersonal nature of large hospitals, but I find this day oddly relaxing. The patient challenges are the same—failing kidneys, faltering hearts, minds that are fading, spines that are crumbling. Maybe I just identify with the farm-bred ability to weather adversity and face life’s challenges with dignity.

I can’t imagine a better place to spend my day, murmuring over cross-stitch, and warmly greeting long-time patients. And even if the music is karaoke, the songs remain heartfelt, and optimism pervades the air.

I arrive on a hot August day. The exterior and grounds are immaculate: the shrubs neatly trimmed, the lawn freshly mowed, the annuals profusely flowering. As I enter, I am immediately greeted with a smile and escorted directly to my room. “Did you have a nice trip? Is there anything I can get you? Something cool to drink?” Moments later a glass of iced tea appears.

Once I am settled in, I always like to find the local paper. I walk past the lounge where live music is playing. The walls are adorned with original art. I am greeted enthusiastically by each person who passes. In fact, I marvel how every guest is acknowledged by name. I see a family laughing in the lobby, while another group leaves for the day. What a relaxing retreat this is.

As I return to my room, my reverie is broken. “Hi, Dr. Susman.” My first patient is an 87-year-old woman, here to recuperate from a hip fracture.

No, you wouldn’t confuse Autumn Years for the Four Seasons or the Ritz Carlton (at least not yet), but I enjoy every visit to this rural nursing home. The staff is warm and friendly, cats freely roam the halls, and the gardens are well tended. Even if the artwork tends toward needlepoint and feline prints, and the food is soft and bland, I am still impressed that even the youngest volunteers exude pride and compassion.

No, not every nursing home is run with such kindness. But I suspect our big city offices and hospitals could learn a bit from our rural nursing homes about teamwork, hustle, and caring. Despite the inevitable charting, nurses really know their patients. The staff will gladly find you a cup of coffee from the kitchen, and they make sure you see all the guests—er, I mean patients—and even get you their charts. There isn’t a lot of concern about who is in charge, who does what, or “that isn’t my job.” There is much discussion about the price of corn, the newest café, and how much it’s rained, which pretty much puts life into perspective.

Perhaps it is my early experience in rural practice, the stress of city life, or the often impersonal nature of large hospitals, but I find this day oddly relaxing. The patient challenges are the same—failing kidneys, faltering hearts, minds that are fading, spines that are crumbling. Maybe I just identify with the farm-bred ability to weather adversity and face life’s challenges with dignity.

I can’t imagine a better place to spend my day, murmuring over cross-stitch, and warmly greeting long-time patients. And even if the music is karaoke, the songs remain heartfelt, and optimism pervades the air.

“Information technology has transformed every service industry we know…and will also transform health care.”

– Jeff Immelt, Chairman & CEO, General Electric, March 2005

Hi Jeff, remember me? Dartmouth class of ’78? While you scrutinized the Wall Street Journal, I struggled to memorize Harrison’s Principles of Internal Medicine. Well, no matter, I figure a savvy guy like you can influence how health care is delivered in this country.

I am intrigued by GE’s vision for health care: “GE’s Centricity…is uniquely positioned to support boundary-less care…spanning ambulatory and inpatient care to create a lifelong patient record,” according to your Web site.

You and your team—say, over morning coffee—could fix our patchwork of data systems, barriers to portability, and inability to make informed health care decisions. In turn, I won’t carp about turning 5-minute visits for colds into a Byzantine documentation exercise. Nope, I want your help with the big picture, so here are some big issues for you and your corporate leaders to solve before lunch.

First, why can’t we develop seamless data sharing? I can access the Internet in rural Honduras and call home from Katmandu (or so Sprint promises), but I still can’t get results for a lab drawn yesterday in an emergency room 3 miles away. If we can agree on Blu-ray, why can’t we produce a portable electronic health record (EHR)? Those nice caregivers at the nursing home have to struggle to reconcile medications and problem lists with each transfer. And I have no simple way to hand my patients a flash drive or health record to take with them on their trip to Florida.

Second, why aren’t quality measurement and decision tools built into EHRs? I have to use 3 different third-party products for a data repository, a query/report system, and a usable disease registry. Disease prevention and management protocols have to be reinvented and programmed. Lord help me if I expect assistance from an EHR in answering questions like “What is the best treatment for herpes zoster?” or “How should I follow rheumatoid arthritis?” I get more help from the Ortho Lawn Problem Solver for my turf problems than I get from my EHR.

Finally, why does the aggregation and communication of data require cumber-some and still-rudimentary RHIOs (Regional Health Information Organizations)? I have United, Aetna, and the rest, and not one insurer can aggregate their data to show how our practice manages diabetes, let alone how Cincinnati’s performance compares to Cleveland’s. Programs like Bridges to Excellence are great beginnings, but do little globally, and they rely on the provider to be the bridge.

It’s time to disseminate the technology—and not at the sole expense of physicians. The cost to implement a national physician EHR is estimated at a bit over $17 billion¹; the cost of the Iraq war runs $10 billion each month.² Let’s vote on which effort would add more to our nation’s well-being.

So I ask you, Jeff, to gather your fellow industry stalwarts and deliver us from this mess. It would seem that the forces that created GE Capital could solve all this overnight, if not before lunch.

“Information technology has transformed every service industry we know…and will also transform health care.”

– Jeff Immelt, Chairman & CEO, General Electric, March 2005

Hi Jeff, remember me? Dartmouth class of ’78? While you scrutinized the Wall Street Journal, I struggled to memorize Harrison’s Principles of Internal Medicine. Well, no matter, I figure a savvy guy like you can influence how health care is delivered in this country.

I am intrigued by GE’s vision for health care: “GE’s Centricity…is uniquely positioned to support boundary-less care…spanning ambulatory and inpatient care to create a lifelong patient record,” according to your Web site.

You and your team—say, over morning coffee—could fix our patchwork of data systems, barriers to portability, and inability to make informed health care decisions. In turn, I won’t carp about turning 5-minute visits for colds into a Byzantine documentation exercise. Nope, I want your help with the big picture, so here are some big issues for you and your corporate leaders to solve before lunch.

First, why can’t we develop seamless data sharing? I can access the Internet in rural Honduras and call home from Katmandu (or so Sprint promises), but I still can’t get results for a lab drawn yesterday in an emergency room 3 miles away. If we can agree on Blu-ray, why can’t we produce a portable electronic health record (EHR)? Those nice caregivers at the nursing home have to struggle to reconcile medications and problem lists with each transfer. And I have no simple way to hand my patients a flash drive or health record to take with them on their trip to Florida.

Second, why aren’t quality measurement and decision tools built into EHRs? I have to use 3 different third-party products for a data repository, a query/report system, and a usable disease registry. Disease prevention and management protocols have to be reinvented and programmed. Lord help me if I expect assistance from an EHR in answering questions like “What is the best treatment for herpes zoster?” or “How should I follow rheumatoid arthritis?” I get more help from the Ortho Lawn Problem Solver for my turf problems than I get from my EHR.

Finally, why does the aggregation and communication of data require cumber-some and still-rudimentary RHIOs (Regional Health Information Organizations)? I have United, Aetna, and the rest, and not one insurer can aggregate their data to show how our practice manages diabetes, let alone how Cincinnati’s performance compares to Cleveland’s. Programs like Bridges to Excellence are great beginnings, but do little globally, and they rely on the provider to be the bridge.

It’s time to disseminate the technology—and not at the sole expense of physicians. The cost to implement a national physician EHR is estimated at a bit over $17 billion¹; the cost of the Iraq war runs $10 billion each month.² Let’s vote on which effort would add more to our nation’s well-being.

So I ask you, Jeff, to gather your fellow industry stalwarts and deliver us from this mess. It would seem that the forces that created GE Capital could solve all this overnight, if not before lunch.

“Information technology has transformed every service industry we know…and will also transform health care.”

– Jeff Immelt, Chairman & CEO, General Electric, March 2005

Hi Jeff, remember me? Dartmouth class of ’78? While you scrutinized the Wall Street Journal, I struggled to memorize Harrison’s Principles of Internal Medicine. Well, no matter, I figure a savvy guy like you can influence how health care is delivered in this country.

I am intrigued by GE’s vision for health care: “GE’s Centricity…is uniquely positioned to support boundary-less care…spanning ambulatory and inpatient care to create a lifelong patient record,” according to your Web site.

You and your team—say, over morning coffee—could fix our patchwork of data systems, barriers to portability, and inability to make informed health care decisions. In turn, I won’t carp about turning 5-minute visits for colds into a Byzantine documentation exercise. Nope, I want your help with the big picture, so here are some big issues for you and your corporate leaders to solve before lunch.

First, why can’t we develop seamless data sharing? I can access the Internet in rural Honduras and call home from Katmandu (or so Sprint promises), but I still can’t get results for a lab drawn yesterday in an emergency room 3 miles away. If we can agree on Blu-ray, why can’t we produce a portable electronic health record (EHR)? Those nice caregivers at the nursing home have to struggle to reconcile medications and problem lists with each transfer. And I have no simple way to hand my patients a flash drive or health record to take with them on their trip to Florida.

Second, why aren’t quality measurement and decision tools built into EHRs? I have to use 3 different third-party products for a data repository, a query/report system, and a usable disease registry. Disease prevention and management protocols have to be reinvented and programmed. Lord help me if I expect assistance from an EHR in answering questions like “What is the best treatment for herpes zoster?” or “How should I follow rheumatoid arthritis?” I get more help from the Ortho Lawn Problem Solver for my turf problems than I get from my EHR.

Finally, why does the aggregation and communication of data require cumber-some and still-rudimentary RHIOs (Regional Health Information Organizations)? I have United, Aetna, and the rest, and not one insurer can aggregate their data to show how our practice manages diabetes, let alone how Cincinnati’s performance compares to Cleveland’s. Programs like Bridges to Excellence are great beginnings, but do little globally, and they rely on the provider to be the bridge.

It’s time to disseminate the technology—and not at the sole expense of physicians. The cost to implement a national physician EHR is estimated at a bit over $17 billion¹; the cost of the Iraq war runs $10 billion each month.² Let’s vote on which effort would add more to our nation’s well-being.

So I ask you, Jeff, to gather your fellow industry stalwarts and deliver us from this mess. It would seem that the forces that created GE Capital could solve all this overnight, if not before lunch.

The ads were as plentiful and as welcome as new ties on Fathers’ Day. From the Wall Street Journal to USA Today, the ads proclaimed, “STRONG MEDICINE FOR AMERICA.” I showed my wife and asked random patients, “Tell me what this tagline means to you.”

“Must mean cancer” or “Is it an ad for alternative medicine, maybe a steroid?”

And how about that logo: “The torch’s guiding light embodies honor, valor, and victory.” I began to think I was reading a recruitment ad for the Marines.

OK, call me a curmudgeon, but the launch of the new AAFP brand seems a lot like the Future of Family Medicine (FFM) project, the New Model, and recent efforts promoting a Patient-Centered Medical Home (PCMH): slick Madison Avenue types, who for millions of dollars are repackaging our specialty to be an appealing flavor of the day. I was happy with carrying on a tradition of comprehensive care, continuity, and compassion.

I am not a Luddite. We are implementing an EHR and I give my patients my cell phone number and e-mail address. Heck, I have even encouraged our clinical leaders to review the National Committee for Quality Assurance–PCMH criteria and see how we score. Like almost all of you, we rely heavily on clinical income to balance our budget. We worry about the influence of big insurers, and we truly believe family medicine is the answer to caring for the uninsured. We want a rational health care system.

But I cringe when I see our specialty society focusing more attention on tag-lines than teaching, and promoting advocacy more than activism. It all brings to mind another ad campaign: “Where’s the beef?”

I decry our misguided reliance on branding, business, and balderdash. Stop telling me how an EHR will cure a broken health system, when most products lack even rudimentary quality improvement tools. Cease spending my dues on “key decision makers” who read Forbes, and start spending more on recruiting high quality US applicants to our residencies. Bring us better reimbursement for counseling a pregnant teen or coordinating care of a depressed elder with diabetes.

I don’t want a logo that draws from Greek mythology, but one that reflects our dreams for the future. Instead of an army of marketers, how about a little care for those 47 million uninsured Americans? Don’t sell America the snake oil of strong medicine, when what we really need is the resiliency and resourcefulness of the next generation of family physicians.

The ads were as plentiful and as welcome as new ties on Fathers’ Day. From the Wall Street Journal to USA Today, the ads proclaimed, “STRONG MEDICINE FOR AMERICA.” I showed my wife and asked random patients, “Tell me what this tagline means to you.”

“Must mean cancer” or “Is it an ad for alternative medicine, maybe a steroid?”

And how about that logo: “The torch’s guiding light embodies honor, valor, and victory.” I began to think I was reading a recruitment ad for the Marines.

OK, call me a curmudgeon, but the launch of the new AAFP brand seems a lot like the Future of Family Medicine (FFM) project, the New Model, and recent efforts promoting a Patient-Centered Medical Home (PCMH): slick Madison Avenue types, who for millions of dollars are repackaging our specialty to be an appealing flavor of the day. I was happy with carrying on a tradition of comprehensive care, continuity, and compassion.

I am not a Luddite. We are implementing an EHR and I give my patients my cell phone number and e-mail address. Heck, I have even encouraged our clinical leaders to review the National Committee for Quality Assurance–PCMH criteria and see how we score. Like almost all of you, we rely heavily on clinical income to balance our budget. We worry about the influence of big insurers, and we truly believe family medicine is the answer to caring for the uninsured. We want a rational health care system.

But I cringe when I see our specialty society focusing more attention on tag-lines than teaching, and promoting advocacy more than activism. It all brings to mind another ad campaign: “Where’s the beef?”

I decry our misguided reliance on branding, business, and balderdash. Stop telling me how an EHR will cure a broken health system, when most products lack even rudimentary quality improvement tools. Cease spending my dues on “key decision makers” who read Forbes, and start spending more on recruiting high quality US applicants to our residencies. Bring us better reimbursement for counseling a pregnant teen or coordinating care of a depressed elder with diabetes.

I don’t want a logo that draws from Greek mythology, but one that reflects our dreams for the future. Instead of an army of marketers, how about a little care for those 47 million uninsured Americans? Don’t sell America the snake oil of strong medicine, when what we really need is the resiliency and resourcefulness of the next generation of family physicians.

The ads were as plentiful and as welcome as new ties on Fathers’ Day. From the Wall Street Journal to USA Today, the ads proclaimed, “STRONG MEDICINE FOR AMERICA.” I showed my wife and asked random patients, “Tell me what this tagline means to you.”

“Must mean cancer” or “Is it an ad for alternative medicine, maybe a steroid?”

And how about that logo: “The torch’s guiding light embodies honor, valor, and victory.” I began to think I was reading a recruitment ad for the Marines.

OK, call me a curmudgeon, but the launch of the new AAFP brand seems a lot like the Future of Family Medicine (FFM) project, the New Model, and recent efforts promoting a Patient-Centered Medical Home (PCMH): slick Madison Avenue types, who for millions of dollars are repackaging our specialty to be an appealing flavor of the day. I was happy with carrying on a tradition of comprehensive care, continuity, and compassion.

I am not a Luddite. We are implementing an EHR and I give my patients my cell phone number and e-mail address. Heck, I have even encouraged our clinical leaders to review the National Committee for Quality Assurance–PCMH criteria and see how we score. Like almost all of you, we rely heavily on clinical income to balance our budget. We worry about the influence of big insurers, and we truly believe family medicine is the answer to caring for the uninsured. We want a rational health care system.

But I cringe when I see our specialty society focusing more attention on tag-lines than teaching, and promoting advocacy more than activism. It all brings to mind another ad campaign: “Where’s the beef?”

I decry our misguided reliance on branding, business, and balderdash. Stop telling me how an EHR will cure a broken health system, when most products lack even rudimentary quality improvement tools. Cease spending my dues on “key decision makers” who read Forbes, and start spending more on recruiting high quality US applicants to our residencies. Bring us better reimbursement for counseling a pregnant teen or coordinating care of a depressed elder with diabetes.

I don’t want a logo that draws from Greek mythology, but one that reflects our dreams for the future. Instead of an army of marketers, how about a little care for those 47 million uninsured Americans? Don’t sell America the snake oil of strong medicine, when what we really need is the resiliency and resourcefulness of the next generation of family physicians.

We were really worried about our 2-year-old, Lucy. Our fears began when we picked her up and she whimpered. A little closer inspection revealed pain when we moved her right hip. She was eating well, didn’t seem to have a fever, and was walking just fine. I ran through the differential diagnosis in my mind, as my wife voiced her worst fears: “What if it’s cancer?” A quick call and our appointment was made. Lucky for us, Lucy’s doctor has Sunday hours.

We really like the office where Lucy goes. We are always greeted by name, and even with the controlled chaos of a really full range of patients, everything always seems calm.

Lucy and my wife are seen promptly. The doctor gives Lucy her careful attention, gaining Lucy’s confidence and proceeding with the examination slowly. And even when the doctor manipulates the painful limb, it doesn’t seem to unduly bother Lucy. The doctor does the requisite x-ray and labs and takes her time explaining the differential diagnosis—which thankfully does not include cancer. We even get the medication right in the office and the doc is careful to discuss what to look for. Our young princess is given a special treat as we pay our bill and we’re on our way no more than one-half hour after arriving.

“Happy New Year!” says the doc, “and do let me know how she’s doing.”

The medication seems to be working and Lucy is as lively as any other 2-year-old. There are the occasional tantrums, and she definitely has stranger anxiety.

Excuse me, but I hear Lucy barking now…

The funny thing is that the experience of care for our 2-year-old beagle is significantly better than our own experiences with health care providers. Instead of large networks of anonymous physicians and corporate care, it seems vets still place a priority on knowing their patients and families, and they practice in small autonomous groups.

The phone is answered expeditiously, there are convenient appointment times, and the wait to be seen is never long. We get notices when preventive care is due, there is one-stop shopping for services, and plenty of time is spent with the patient (and the patient’s owner).

There are no annoying co-pays, the bills are clear, and while the patient—or should I say, owner—is fully responsible, we promptly settle up after each visit. Even the medications are reasonable. Ever compare the price of drugs for dogs and humans—even for the same medication?

Sort of makes you wonder if we should emulate our veterinarian friends.

We were really worried about our 2-year-old, Lucy. Our fears began when we picked her up and she whimpered. A little closer inspection revealed pain when we moved her right hip. She was eating well, didn’t seem to have a fever, and was walking just fine. I ran through the differential diagnosis in my mind, as my wife voiced her worst fears: “What if it’s cancer?” A quick call and our appointment was made. Lucky for us, Lucy’s doctor has Sunday hours.

We really like the office where Lucy goes. We are always greeted by name, and even with the controlled chaos of a really full range of patients, everything always seems calm.

Lucy and my wife are seen promptly. The doctor gives Lucy her careful attention, gaining Lucy’s confidence and proceeding with the examination slowly. And even when the doctor manipulates the painful limb, it doesn’t seem to unduly bother Lucy. The doctor does the requisite x-ray and labs and takes her time explaining the differential diagnosis—which thankfully does not include cancer. We even get the medication right in the office and the doc is careful to discuss what to look for. Our young princess is given a special treat as we pay our bill and we’re on our way no more than one-half hour after arriving.

“Happy New Year!” says the doc, “and do let me know how she’s doing.”

The medication seems to be working and Lucy is as lively as any other 2-year-old. There are the occasional tantrums, and she definitely has stranger anxiety.

Excuse me, but I hear Lucy barking now…

The funny thing is that the experience of care for our 2-year-old beagle is significantly better than our own experiences with health care providers. Instead of large networks of anonymous physicians and corporate care, it seems vets still place a priority on knowing their patients and families, and they practice in small autonomous groups.

The phone is answered expeditiously, there are convenient appointment times, and the wait to be seen is never long. We get notices when preventive care is due, there is one-stop shopping for services, and plenty of time is spent with the patient (and the patient’s owner).

There are no annoying co-pays, the bills are clear, and while the patient—or should I say, owner—is fully responsible, we promptly settle up after each visit. Even the medications are reasonable. Ever compare the price of drugs for dogs and humans—even for the same medication?

Sort of makes you wonder if we should emulate our veterinarian friends.

We were really worried about our 2-year-old, Lucy. Our fears began when we picked her up and she whimpered. A little closer inspection revealed pain when we moved her right hip. She was eating well, didn’t seem to have a fever, and was walking just fine. I ran through the differential diagnosis in my mind, as my wife voiced her worst fears: “What if it’s cancer?” A quick call and our appointment was made. Lucky for us, Lucy’s doctor has Sunday hours.

We really like the office where Lucy goes. We are always greeted by name, and even with the controlled chaos of a really full range of patients, everything always seems calm.

Lucy and my wife are seen promptly. The doctor gives Lucy her careful attention, gaining Lucy’s confidence and proceeding with the examination slowly. And even when the doctor manipulates the painful limb, it doesn’t seem to unduly bother Lucy. The doctor does the requisite x-ray and labs and takes her time explaining the differential diagnosis—which thankfully does not include cancer. We even get the medication right in the office and the doc is careful to discuss what to look for. Our young princess is given a special treat as we pay our bill and we’re on our way no more than one-half hour after arriving.

“Happy New Year!” says the doc, “and do let me know how she’s doing.”

The medication seems to be working and Lucy is as lively as any other 2-year-old. There are the occasional tantrums, and she definitely has stranger anxiety.

Excuse me, but I hear Lucy barking now…

The funny thing is that the experience of care for our 2-year-old beagle is significantly better than our own experiences with health care providers. Instead of large networks of anonymous physicians and corporate care, it seems vets still place a priority on knowing their patients and families, and they practice in small autonomous groups.

The phone is answered expeditiously, there are convenient appointment times, and the wait to be seen is never long. We get notices when preventive care is due, there is one-stop shopping for services, and plenty of time is spent with the patient (and the patient’s owner).

There are no annoying co-pays, the bills are clear, and while the patient—or should I say, owner—is fully responsible, we promptly settle up after each visit. Even the medications are reasonable. Ever compare the price of drugs for dogs and humans—even for the same medication?

Sort of makes you wonder if we should emulate our veterinarian friends.

Do you feel overwhelmed by the volume of new research in family medicine? Wondering where to turn for authoritative updates? Unable to decipher which articles are must reads, let alone which ones should dictate a change in practice? In this issue of The Journal of Family Practice, we introduce Priority Updates from the Research Literature (PURLs)—a solution to this vexing problem.

PURLs: Reviews that meet reality

PURLs provides a literature review system that systematically identifies practice changing research and facilitates the integration of these innovations into the realities of today’s clinical environment.

Each month our PURLs Editor, Bernard Ewigman, MD, MSPH, and the trusted Family Physicians Inquiries Network (which brings us Clinical Inquiries) rigorously survey the literature to identify those few articles (usually less than a half dozen) that might warrant a change in clinical practice. They assess the article for scientific validity and for its generalizability to the usual family practice setting, place the study’s findings in the context of the literature and current clinical recommendations, and identify those few studies that warrant a change in practice.

But having identified a practice changer is only half the battle— the PURLs authors ask, “What are the barriers to implementation of this change into our daily routine? Are there challenges in reimbursement? Who is responsible for this change? How could we hasten diffusion of this innovation?

How is a PURLs review different?

While there are many literature surveillance systems available to our readers, PURLs alone asks the question, “Should we change practice on the basis of this article?” To answer this question, not only do our experts and peer reviewers critically appraise the article, but they look at what current practice is (as assessed by resources such as UpToDate, PEPID, Dynamed, relevant practice guidelines, and recommendations from other authoritative sources). If the practice is significantly different, we then try to weigh the importance of this change, how well it can be implemented, and challenges in changing practice. So rather than a simple literature review, we go further, and ask, “Does the value of this innovation warrant implementation and how do we diffuse this change into practice?”

The PURLs system is rigorous

If you are like me, you want to be sure that when you make a practice change, it is truly warranted. That’s why PURLs is built around a rigorous development and peer review process (and provides these details at www.jfponline.com). In the next issue of the journal, Dr Ewigman will outline more completely the science behind PURLs. But rest assured, we take seriously the issue of scientific rigor.

More innovations to come

As PURLs becomes a standard for evaluating new practice innovations, we will be developing more interactive ways to engage you, our readers. We are already developing a Web based platform that will allow voting on the selection of an individual PURL, discussion of implementation challenges, and reactions to each PURL—in short, we are bringing together a community of family physician and primary care clinician learners. Our goal is to engage every reader in the creation and dissemination of PURLs, a place where “research meets reality.”

Send us your comments

While PURLs’ rigorous methodology will remain the foundation of our efforts, we view these updates as a work in progress. How can the presentation of this information be improved? Do we appropriately address challenges in implementation? What pieces of this translation of research into reality have we missed? E-mail me at [email protected] with your suggestions.

Happy PURL diving!

Do you feel overwhelmed by the volume of new research in family medicine? Wondering where to turn for authoritative updates? Unable to decipher which articles are must reads, let alone which ones should dictate a change in practice? In this issue of The Journal of Family Practice, we introduce Priority Updates from the Research Literature (PURLs)—a solution to this vexing problem.

PURLs: Reviews that meet reality

PURLs provides a literature review system that systematically identifies practice changing research and facilitates the integration of these innovations into the realities of today’s clinical environment.

Each month our PURLs Editor, Bernard Ewigman, MD, MSPH, and the trusted Family Physicians Inquiries Network (which brings us Clinical Inquiries) rigorously survey the literature to identify those few articles (usually less than a half dozen) that might warrant a change in clinical practice. They assess the article for scientific validity and for its generalizability to the usual family practice setting, place the study’s findings in the context of the literature and current clinical recommendations, and identify those few studies that warrant a change in practice.

But having identified a practice changer is only half the battle— the PURLs authors ask, “What are the barriers to implementation of this change into our daily routine? Are there challenges in reimbursement? Who is responsible for this change? How could we hasten diffusion of this innovation?

How is a PURLs review different?

While there are many literature surveillance systems available to our readers, PURLs alone asks the question, “Should we change practice on the basis of this article?” To answer this question, not only do our experts and peer reviewers critically appraise the article, but they look at what current practice is (as assessed by resources such as UpToDate, PEPID, Dynamed, relevant practice guidelines, and recommendations from other authoritative sources). If the practice is significantly different, we then try to weigh the importance of this change, how well it can be implemented, and challenges in changing practice. So rather than a simple literature review, we go further, and ask, “Does the value of this innovation warrant implementation and how do we diffuse this change into practice?”

The PURLs system is rigorous

If you are like me, you want to be sure that when you make a practice change, it is truly warranted. That’s why PURLs is built around a rigorous development and peer review process (and provides these details at www.jfponline.com). In the next issue of the journal, Dr Ewigman will outline more completely the science behind PURLs. But rest assured, we take seriously the issue of scientific rigor.

More innovations to come

As PURLs becomes a standard for evaluating new practice innovations, we will be developing more interactive ways to engage you, our readers. We are already developing a Web based platform that will allow voting on the selection of an individual PURL, discussion of implementation challenges, and reactions to each PURL—in short, we are bringing together a community of family physician and primary care clinician learners. Our goal is to engage every reader in the creation and dissemination of PURLs, a place where “research meets reality.”

Send us your comments

While PURLs’ rigorous methodology will remain the foundation of our efforts, we view these updates as a work in progress. How can the presentation of this information be improved? Do we appropriately address challenges in implementation? What pieces of this translation of research into reality have we missed? E-mail me at [email protected] with your suggestions.

Happy PURL diving!

Do you feel overwhelmed by the volume of new research in family medicine? Wondering where to turn for authoritative updates? Unable to decipher which articles are must reads, let alone which ones should dictate a change in practice? In this issue of The Journal of Family Practice, we introduce Priority Updates from the Research Literature (PURLs)—a solution to this vexing problem.

PURLs: Reviews that meet reality

PURLs provides a literature review system that systematically identifies practice changing research and facilitates the integration of these innovations into the realities of today’s clinical environment.

Each month our PURLs Editor, Bernard Ewigman, MD, MSPH, and the trusted Family Physicians Inquiries Network (which brings us Clinical Inquiries) rigorously survey the literature to identify those few articles (usually less than a half dozen) that might warrant a change in clinical practice. They assess the article for scientific validity and for its generalizability to the usual family practice setting, place the study’s findings in the context of the literature and current clinical recommendations, and identify those few studies that warrant a change in practice.

But having identified a practice changer is only half the battle— the PURLs authors ask, “What are the barriers to implementation of this change into our daily routine? Are there challenges in reimbursement? Who is responsible for this change? How could we hasten diffusion of this innovation?

How is a PURLs review different?

While there are many literature surveillance systems available to our readers, PURLs alone asks the question, “Should we change practice on the basis of this article?” To answer this question, not only do our experts and peer reviewers critically appraise the article, but they look at what current practice is (as assessed by resources such as UpToDate, PEPID, Dynamed, relevant practice guidelines, and recommendations from other authoritative sources). If the practice is significantly different, we then try to weigh the importance of this change, how well it can be implemented, and challenges in changing practice. So rather than a simple literature review, we go further, and ask, “Does the value of this innovation warrant implementation and how do we diffuse this change into practice?”

The PURLs system is rigorous

If you are like me, you want to be sure that when you make a practice change, it is truly warranted. That’s why PURLs is built around a rigorous development and peer review process (and provides these details at www.jfponline.com). In the next issue of the journal, Dr Ewigman will outline more completely the science behind PURLs. But rest assured, we take seriously the issue of scientific rigor.

More innovations to come

As PURLs becomes a standard for evaluating new practice innovations, we will be developing more interactive ways to engage you, our readers. We are already developing a Web based platform that will allow voting on the selection of an individual PURL, discussion of implementation challenges, and reactions to each PURL—in short, we are bringing together a community of family physician and primary care clinician learners. Our goal is to engage every reader in the creation and dissemination of PURLs, a place where “research meets reality.”

Send us your comments

While PURLs’ rigorous methodology will remain the foundation of our efforts, we view these updates as a work in progress. How can the presentation of this information be improved? Do we appropriately address challenges in implementation? What pieces of this translation of research into reality have we missed? E-mail me at [email protected] with your suggestions.

Happy PURL diving!