Jeff Susman, MD

Joe was like many of my patients: middle-aged, overweight, suffering from type 2 diabetes and COPD. For many years I suggested he stop smoking, to no avail. Then, one day, out of the blue—he quit. Seems he reached 50, saw his father crippled by emphysema, and with the price of gasoline and a pack of cigarettes rivaling each other, decided he had enough. I congratulated him and offered further assistance while marveling about the mysteries of human behavior. Now I have a vocabulary for such phenomena: nonlinear dynamics.

I guess I always knew my practice was ruled by chaos and complexity. I just didn’t know how to capitalize on this phenomenon. Dr David Katerndahl—with all due respect to Sir Isaac Newton—helps translate the latest thinking about nonlinearity in medicine and offers suggestions on how to incorporate these phenomena in patient care.

Whether faced with the resistant patient with diabetes mellitus, the critically ill individual in the ICU, or the person like Joe who has an epiphany, this new look at the world adds another set of tools to our black bag. Maybe Newton could learn to be a good family doc after all.

Joe was like many of my patients: middle-aged, overweight, suffering from type 2 diabetes and COPD. For many years I suggested he stop smoking, to no avail. Then, one day, out of the blue—he quit. Seems he reached 50, saw his father crippled by emphysema, and with the price of gasoline and a pack of cigarettes rivaling each other, decided he had enough. I congratulated him and offered further assistance while marveling about the mysteries of human behavior. Now I have a vocabulary for such phenomena: nonlinear dynamics.

I guess I always knew my practice was ruled by chaos and complexity. I just didn’t know how to capitalize on this phenomenon. Dr David Katerndahl—with all due respect to Sir Isaac Newton—helps translate the latest thinking about nonlinearity in medicine and offers suggestions on how to incorporate these phenomena in patient care.

Whether faced with the resistant patient with diabetes mellitus, the critically ill individual in the ICU, or the person like Joe who has an epiphany, this new look at the world adds another set of tools to our black bag. Maybe Newton could learn to be a good family doc after all.

Joe was like many of my patients: middle-aged, overweight, suffering from type 2 diabetes and COPD. For many years I suggested he stop smoking, to no avail. Then, one day, out of the blue—he quit. Seems he reached 50, saw his father crippled by emphysema, and with the price of gasoline and a pack of cigarettes rivaling each other, decided he had enough. I congratulated him and offered further assistance while marveling about the mysteries of human behavior. Now I have a vocabulary for such phenomena: nonlinear dynamics.

I guess I always knew my practice was ruled by chaos and complexity. I just didn’t know how to capitalize on this phenomenon. Dr David Katerndahl—with all due respect to Sir Isaac Newton—helps translate the latest thinking about nonlinearity in medicine and offers suggestions on how to incorporate these phenomena in patient care.

Whether faced with the resistant patient with diabetes mellitus, the critically ill individual in the ICU, or the person like Joe who has an epiphany, this new look at the world adds another set of tools to our black bag. Maybe Newton could learn to be a good family doc after all.

“We decided we better leave when the roof caved in.”
“When we left the base, armed hijackers were waiting outside.”
“When we returned, our whole block was gone.”

I am sure many of you, like me, have friends and family affected by Hurricane Katrina. Perhaps you have heard similar personal accounts of the disaster, anguished over loved ones, or commiserated with those whose lives have been irrevocably changed. For those of us living many miles from Katrina’s path, we have gawked at the video and balked at the gas prices. Many of you, I am sure, have helped as you feel best able.

Fortunately, my relatives, and friends, and friends of friends, are predominately wealthy, mobile, professional, and able to endure such disasters, however momentous. They checked into hotels, drove or flew away, fled the maelstrom enveloping the city, and are busy filing insurance claims.

But those who suffered the most crushing blows of all—the faces I saw on television, in the newspapers, at the Superdome, stranded on roofs and on islands of terra firma—those individuals were predominately the poor, the infirm, and the underclass. Nowhere more visible a portrayal of classes divided, of racial disparities, of the worse of our socioeconomic chasms was this disaster, a case that was—how can one say this in a politically correct way—black and white.

I am dismayed by the lack of emergency preparedness in NOLA. I am galled by our federal government’s lackadaisical response. I remain flabbergasted by the nation’s inattention to public health, emergency preparedness, and disaster planning. While we worry about threats to overseas oil, spend billions on war and curricula on bioterrorism, and go on wild goose chases for imaginary weapons, it is business as usual back home. I guess I should hardly be surprised.

The price of being poor and black in America has never been clearer.

“We decided we better leave when the roof caved in.”
“When we left the base, armed hijackers were waiting outside.”
“When we returned, our whole block was gone.”

I am sure many of you, like me, have friends and family affected by Hurricane Katrina. Perhaps you have heard similar personal accounts of the disaster, anguished over loved ones, or commiserated with those whose lives have been irrevocably changed. For those of us living many miles from Katrina’s path, we have gawked at the video and balked at the gas prices. Many of you, I am sure, have helped as you feel best able.

Fortunately, my relatives, and friends, and friends of friends, are predominately wealthy, mobile, professional, and able to endure such disasters, however momentous. They checked into hotels, drove or flew away, fled the maelstrom enveloping the city, and are busy filing insurance claims.

But those who suffered the most crushing blows of all—the faces I saw on television, in the newspapers, at the Superdome, stranded on roofs and on islands of terra firma—those individuals were predominately the poor, the infirm, and the underclass. Nowhere more visible a portrayal of classes divided, of racial disparities, of the worse of our socioeconomic chasms was this disaster, a case that was—how can one say this in a politically correct way—black and white.

I am dismayed by the lack of emergency preparedness in NOLA. I am galled by our federal government’s lackadaisical response. I remain flabbergasted by the nation’s inattention to public health, emergency preparedness, and disaster planning. While we worry about threats to overseas oil, spend billions on war and curricula on bioterrorism, and go on wild goose chases for imaginary weapons, it is business as usual back home. I guess I should hardly be surprised.

The price of being poor and black in America has never been clearer.

“We decided we better leave when the roof caved in.”
“When we left the base, armed hijackers were waiting outside.”
“When we returned, our whole block was gone.”

I am sure many of you, like me, have friends and family affected by Hurricane Katrina. Perhaps you have heard similar personal accounts of the disaster, anguished over loved ones, or commiserated with those whose lives have been irrevocably changed. For those of us living many miles from Katrina’s path, we have gawked at the video and balked at the gas prices. Many of you, I am sure, have helped as you feel best able.

Fortunately, my relatives, and friends, and friends of friends, are predominately wealthy, mobile, professional, and able to endure such disasters, however momentous. They checked into hotels, drove or flew away, fled the maelstrom enveloping the city, and are busy filing insurance claims.

But those who suffered the most crushing blows of all—the faces I saw on television, in the newspapers, at the Superdome, stranded on roofs and on islands of terra firma—those individuals were predominately the poor, the infirm, and the underclass. Nowhere more visible a portrayal of classes divided, of racial disparities, of the worse of our socioeconomic chasms was this disaster, a case that was—how can one say this in a politically correct way—black and white.

I am dismayed by the lack of emergency preparedness in NOLA. I am galled by our federal government’s lackadaisical response. I remain flabbergasted by the nation’s inattention to public health, emergency preparedness, and disaster planning. While we worry about threats to overseas oil, spend billions on war and curricula on bioterrorism, and go on wild goose chases for imaginary weapons, it is business as usual back home. I guess I should hardly be surprised.

The price of being poor and black in America has never been clearer.

It is fashionable in medical education circles to decry the value of lectures. With the wealth of scientific studies demonstrating the distant association of lectures with learning, it is a wonder that those of us educated traditionally ever mastered tying our shoes let alone managing congestive heart failure.

I would like to present a contrary opinion. I believe a well-done lecture is a tremendous way to learn–it just so happens that most lectures are lousy.

First, the presentation skills of many lecturers border on incompetence. We have all seen examples of the common pitfalls: the monotone droner; the terminally disorganized; the scientist determined to tell us about every study he ever conducted no matter how irrelevant. The number of truly organized, polished lecturers is indeed small.

Second, most lecturers still rely on anecdote and personal experience rather than a mastery of evidence. Rather than an explicit critical appraisal of the area, we are treated to “my favorite things.” While sometimes engaging, such lectures seldom make me want to change the way I practice.

Third, very few presenters take the time to figure out their 2 or 3 key messages. What few practice or behavioral changes would the presenter suggest? What barriers to change exist? How might we pave the way to performance improvement?

On the other hand, we probably all remember that gem of a talk that clarified or demystified a whole area. For example, I remember one lecture on hypercoagulable states that was remarkable for the clarity and explicitness of its practice recommendations. Even today, I can still remember a lecture from a residency practice management session in which the presenter creatively engaged the audience.

So let’s not burn the lecterns and zap the PowerPoint files. Lectures are alive and well–it’s the lecturers that need to be revitalized.

It is fashionable in medical education circles to decry the value of lectures. With the wealth of scientific studies demonstrating the distant association of lectures with learning, it is a wonder that those of us educated traditionally ever mastered tying our shoes let alone managing congestive heart failure.

I would like to present a contrary opinion. I believe a well-done lecture is a tremendous way to learn–it just so happens that most lectures are lousy.

First, the presentation skills of many lecturers border on incompetence. We have all seen examples of the common pitfalls: the monotone droner; the terminally disorganized; the scientist determined to tell us about every study he ever conducted no matter how irrelevant. The number of truly organized, polished lecturers is indeed small.

Second, most lecturers still rely on anecdote and personal experience rather than a mastery of evidence. Rather than an explicit critical appraisal of the area, we are treated to “my favorite things.” While sometimes engaging, such lectures seldom make me want to change the way I practice.

Third, very few presenters take the time to figure out their 2 or 3 key messages. What few practice or behavioral changes would the presenter suggest? What barriers to change exist? How might we pave the way to performance improvement?

On the other hand, we probably all remember that gem of a talk that clarified or demystified a whole area. For example, I remember one lecture on hypercoagulable states that was remarkable for the clarity and explicitness of its practice recommendations. Even today, I can still remember a lecture from a residency practice management session in which the presenter creatively engaged the audience.

So let’s not burn the lecterns and zap the PowerPoint files. Lectures are alive and well–it’s the lecturers that need to be revitalized.

It is fashionable in medical education circles to decry the value of lectures. With the wealth of scientific studies demonstrating the distant association of lectures with learning, it is a wonder that those of us educated traditionally ever mastered tying our shoes let alone managing congestive heart failure.

I would like to present a contrary opinion. I believe a well-done lecture is a tremendous way to learn–it just so happens that most lectures are lousy.

First, the presentation skills of many lecturers border on incompetence. We have all seen examples of the common pitfalls: the monotone droner; the terminally disorganized; the scientist determined to tell us about every study he ever conducted no matter how irrelevant. The number of truly organized, polished lecturers is indeed small.

Second, most lecturers still rely on anecdote and personal experience rather than a mastery of evidence. Rather than an explicit critical appraisal of the area, we are treated to “my favorite things.” While sometimes engaging, such lectures seldom make me want to change the way I practice.

Third, very few presenters take the time to figure out their 2 or 3 key messages. What few practice or behavioral changes would the presenter suggest? What barriers to change exist? How might we pave the way to performance improvement?

On the other hand, we probably all remember that gem of a talk that clarified or demystified a whole area. For example, I remember one lecture on hypercoagulable states that was remarkable for the clarity and explicitness of its practice recommendations. Even today, I can still remember a lecture from a residency practice management session in which the presenter creatively engaged the audience.

So let’s not burn the lecterns and zap the PowerPoint files. Lectures are alive and well–it’s the lecturers that need to be revitalized.

We received our practice report card recently and were understandably disappointed—“average,” according to our local managed care organization. Were the data correct? Weren’t we at least equal to our peers? What could we do to improve? And, by the way, what happened to our “hold-back” dollars?

If you are like me, pay for performance (P4P) has gotten your attention., Though the idea behind P4P may be well intentioned, the principles seem muddy and the details poorly validated.

As for the principles, I don’t doubt that economic incentives under the right circumstances can change behaviors. But with cost savings as the primary motivator behind many P4P plans, and inadequate attention given to support performance improvement, I remain skeptical.

When we determine winners and losers in many plans, including the Medicare P4P proposal—instead of measuring performance against a fixed standard—I question the comparability of patient populations, particularly at a physician level. Moreover, reliance on administrative data, the relative infrequency of patient-oriented outcomes, and the abundance of problems managed lead to the “garbage in, garbage out” syndrome. It is difficult to demonstrate rigorous, statistically valid differences among practice groups, let alone physicians, when assessing most outcomes.

Diversity of measurement metrics is a problem. While a few diseases such as diabetes have widely accepted outcome measures, many do not. In taking care of patients from multiple plans, how do we reconcile different yardsticks of performance? Similarly, the translation of measures created for the plan level to the individual physician is troubling. Developing evidence-based, patient-oriented accountability measures is also challenging. Critical evidence is often lacking on the natural history of common diseases and important outcome indicators.

What are the alternatives? Rather than spending resources on a costly comparison among practices, why not put these dollars toward real performance improvement efforts? Instead of placing emphasis on winners and losers, let’s put these dollars into the basic EMR infrastructure required to capture data and provide basic information. Let’s take a quality improvement approach not a punative one.

Instead of pay-for-performance have we created pain for performance?

We received our practice report card recently and were understandably disappointed—“average,” according to our local managed care organization. Were the data correct? Weren’t we at least equal to our peers? What could we do to improve? And, by the way, what happened to our “hold-back” dollars?

If you are like me, pay for performance (P4P) has gotten your attention., Though the idea behind P4P may be well intentioned, the principles seem muddy and the details poorly validated.

As for the principles, I don’t doubt that economic incentives under the right circumstances can change behaviors. But with cost savings as the primary motivator behind many P4P plans, and inadequate attention given to support performance improvement, I remain skeptical.

When we determine winners and losers in many plans, including the Medicare P4P proposal—instead of measuring performance against a fixed standard—I question the comparability of patient populations, particularly at a physician level. Moreover, reliance on administrative data, the relative infrequency of patient-oriented outcomes, and the abundance of problems managed lead to the “garbage in, garbage out” syndrome. It is difficult to demonstrate rigorous, statistically valid differences among practice groups, let alone physicians, when assessing most outcomes.

Diversity of measurement metrics is a problem. While a few diseases such as diabetes have widely accepted outcome measures, many do not. In taking care of patients from multiple plans, how do we reconcile different yardsticks of performance? Similarly, the translation of measures created for the plan level to the individual physician is troubling. Developing evidence-based, patient-oriented accountability measures is also challenging. Critical evidence is often lacking on the natural history of common diseases and important outcome indicators.

What are the alternatives? Rather than spending resources on a costly comparison among practices, why not put these dollars toward real performance improvement efforts? Instead of placing emphasis on winners and losers, let’s put these dollars into the basic EMR infrastructure required to capture data and provide basic information. Let’s take a quality improvement approach not a punative one.

Instead of pay-for-performance have we created pain for performance?

We received our practice report card recently and were understandably disappointed—“average,” according to our local managed care organization. Were the data correct? Weren’t we at least equal to our peers? What could we do to improve? And, by the way, what happened to our “hold-back” dollars?

If you are like me, pay for performance (P4P) has gotten your attention., Though the idea behind P4P may be well intentioned, the principles seem muddy and the details poorly validated.

As for the principles, I don’t doubt that economic incentives under the right circumstances can change behaviors. But with cost savings as the primary motivator behind many P4P plans, and inadequate attention given to support performance improvement, I remain skeptical.

When we determine winners and losers in many plans, including the Medicare P4P proposal—instead of measuring performance against a fixed standard—I question the comparability of patient populations, particularly at a physician level. Moreover, reliance on administrative data, the relative infrequency of patient-oriented outcomes, and the abundance of problems managed lead to the “garbage in, garbage out” syndrome. It is difficult to demonstrate rigorous, statistically valid differences among practice groups, let alone physicians, when assessing most outcomes.

Diversity of measurement metrics is a problem. While a few diseases such as diabetes have widely accepted outcome measures, many do not. In taking care of patients from multiple plans, how do we reconcile different yardsticks of performance? Similarly, the translation of measures created for the plan level to the individual physician is troubling. Developing evidence-based, patient-oriented accountability measures is also challenging. Critical evidence is often lacking on the natural history of common diseases and important outcome indicators.

What are the alternatives? Rather than spending resources on a costly comparison among practices, why not put these dollars toward real performance improvement efforts? Instead of placing emphasis on winners and losers, let’s put these dollars into the basic EMR infrastructure required to capture data and provide basic information. Let’s take a quality improvement approach not a punative one.

Instead of pay-for-performance have we created pain for performance?

Family physicians are impressive in their social commitment. We declare that we must increase the numbers going into family medicine residencies, and assert that the solution chosen for most of the world—a primary care-based health system—is what the US needs. I agree. But get with it: this is America! When have Americans done what is good for them instead of what they want?

I am afraid that many US citizens are happy with their non-primary care-based health system—even if it kills them. With today’s enchantment with technology and choice, it’s going to take more than a medical home and an electronic health record to convince them FPs are the foundation for the future. Let’s halve our residency slots (“right-size” in today’s business parlance) and, instead of bemoaning the decline in student interest in family medicine, tackle tasks more productive.

Let’s ditch our Edsel of a curriculum that dates back to the sixties and really revamp our specialty training. Most of our residents will never deliver babies, yet we persist in an outmoded maternity care requirement. Many will not practice in the hospital, but we emphasize inpatient medicine. Let’s capitalize on the fact that we are an outpatient-based specialty and require our residents to spend most of their time in our offices. Let’s really train residents in quality improvement and outcomes measurement; let’s construct options for subspecialty experiences that might bring economic, or at least intellectual, value to our trainees. How about family physician experts in diabetes or asthma care? Or what about—horrors—paths to specialization, the current lack of which is commonly cited by students when they explain their choice of pediatrics or internal medicine rather than family medicine?

Recall the origin of the Future of Family Medicine project: much of the conclusions are based on consumer focus groups, not the interests of our prospective residents. The New Model of Practice we are touting holds little excitement for a generation that grew up with computers, want a balanced lifestyle, and wouldn’t mind a specialty that doesn’t make them go into 6-figure debt.

But the economics will improve, you counter? I guess these students all come from Missouri, and see that we drive Chevys and not Porsches. To attract new students, let’s ask them what they want, and not tell them what we think they need.

I am not saying we should give up on reforming the health care system (although we might first think about consolidating our discipline’s fragmented alphabet soup of organizations), or that we consider disruptive innovation. Rather, if we truly believe what works well for Proctor and Gamble in designing a new diaper should be applied to our discipline’s future, then it’s time to heed the feedback of our “customers”: our patients and our students. Let’s face reality.

Family physicians are impressive in their social commitment. We declare that we must increase the numbers going into family medicine residencies, and assert that the solution chosen for most of the world—a primary care-based health system—is what the US needs. I agree. But get with it: this is America! When have Americans done what is good for them instead of what they want?

I am afraid that many US citizens are happy with their non-primary care-based health system—even if it kills them. With today’s enchantment with technology and choice, it’s going to take more than a medical home and an electronic health record to convince them FPs are the foundation for the future. Let’s halve our residency slots (“right-size” in today’s business parlance) and, instead of bemoaning the decline in student interest in family medicine, tackle tasks more productive.

Let’s ditch our Edsel of a curriculum that dates back to the sixties and really revamp our specialty training. Most of our residents will never deliver babies, yet we persist in an outmoded maternity care requirement. Many will not practice in the hospital, but we emphasize inpatient medicine. Let’s capitalize on the fact that we are an outpatient-based specialty and require our residents to spend most of their time in our offices. Let’s really train residents in quality improvement and outcomes measurement; let’s construct options for subspecialty experiences that might bring economic, or at least intellectual, value to our trainees. How about family physician experts in diabetes or asthma care? Or what about—horrors—paths to specialization, the current lack of which is commonly cited by students when they explain their choice of pediatrics or internal medicine rather than family medicine?

Recall the origin of the Future of Family Medicine project: much of the conclusions are based on consumer focus groups, not the interests of our prospective residents. The New Model of Practice we are touting holds little excitement for a generation that grew up with computers, want a balanced lifestyle, and wouldn’t mind a specialty that doesn’t make them go into 6-figure debt.

But the economics will improve, you counter? I guess these students all come from Missouri, and see that we drive Chevys and not Porsches. To attract new students, let’s ask them what they want, and not tell them what we think they need.

I am not saying we should give up on reforming the health care system (although we might first think about consolidating our discipline’s fragmented alphabet soup of organizations), or that we consider disruptive innovation. Rather, if we truly believe what works well for Proctor and Gamble in designing a new diaper should be applied to our discipline’s future, then it’s time to heed the feedback of our “customers”: our patients and our students. Let’s face reality.

Family physicians are impressive in their social commitment. We declare that we must increase the numbers going into family medicine residencies, and assert that the solution chosen for most of the world—a primary care-based health system—is what the US needs. I agree. But get with it: this is America! When have Americans done what is good for them instead of what they want?

I am afraid that many US citizens are happy with their non-primary care-based health system—even if it kills them. With today’s enchantment with technology and choice, it’s going to take more than a medical home and an electronic health record to convince them FPs are the foundation for the future. Let’s halve our residency slots (“right-size” in today’s business parlance) and, instead of bemoaning the decline in student interest in family medicine, tackle tasks more productive.

Let’s ditch our Edsel of a curriculum that dates back to the sixties and really revamp our specialty training. Most of our residents will never deliver babies, yet we persist in an outmoded maternity care requirement. Many will not practice in the hospital, but we emphasize inpatient medicine. Let’s capitalize on the fact that we are an outpatient-based specialty and require our residents to spend most of their time in our offices. Let’s really train residents in quality improvement and outcomes measurement; let’s construct options for subspecialty experiences that might bring economic, or at least intellectual, value to our trainees. How about family physician experts in diabetes or asthma care? Or what about—horrors—paths to specialization, the current lack of which is commonly cited by students when they explain their choice of pediatrics or internal medicine rather than family medicine?

Recall the origin of the Future of Family Medicine project: much of the conclusions are based on consumer focus groups, not the interests of our prospective residents. The New Model of Practice we are touting holds little excitement for a generation that grew up with computers, want a balanced lifestyle, and wouldn’t mind a specialty that doesn’t make them go into 6-figure debt.

But the economics will improve, you counter? I guess these students all come from Missouri, and see that we drive Chevys and not Porsches. To attract new students, let’s ask them what they want, and not tell them what we think they need.

I am not saying we should give up on reforming the health care system (although we might first think about consolidating our discipline’s fragmented alphabet soup of organizations), or that we consider disruptive innovation. Rather, if we truly believe what works well for Proctor and Gamble in designing a new diaper should be applied to our discipline’s future, then it’s time to heed the feedback of our “customers”: our patients and our students. Let’s face reality.

Most of you have seen synopses of the Future of Family Medicine Project, read discussions of the New Model of practice, and heard the call to reengineer our discipline. I am excited about challenging an acute care model that forces us to practice like hamsters in a wheel, and am enthused about a more patient-focused approach. But I am concerned about adopting a “Model” without adequate evidence, about focusing on a single solution rather than multiple creative approaches to practice, and about ignoring underlying deficiencies in American health care.

I am instinctively distrustful of claims for a single solution to a complex and diverse problem such as America’s health care crisis. To assert that we have developed a “New Model of Family Medicine” without empiric validation seems rash. Reams of focus group data and patient interviews do not a new model make. Where is the theory development and experimental data that support this? Rather than purporting to have discovered a single “New Model,” shouldn’t we be encouraging multiple creative models of family medicine? Rather than standardizing a market basket of services, shouldn’t we be encouraging a community responsive approach? By experimenting and trying many approaches to achieving better patient outcomes, we will be sure that we have developed a robust model worth replicating. Let’s leave the market baskets to Krogers.

Also, tools such as EHR, open access scheduling, or asynchronous communication via the Internet are only means to an end. Let’s have a healthy appreciation of diverse methods to enhance community health, patient outcomes including satisfaction, access to care, and timely and appropriate treatment. All these tools may indeed be crucial, but they are just tools—not patient-oriented outcomes.

What gaps might exist in this toolbox? I keep wondering how much we can improve health care of populations without a clear denominator (ie, a registered list of patients) or an insurance “system” that consistently covers the new patients for whom I care. These issues aside, the gap between practice reality and theory, and the economic challenge to meet the initial costs of the new model leave me distressed—problems many of you lament.

Finally, let us remember that even the most robustly functioning practices will not cure a demand-based workforce policy, a financing system that leaves many millions without health insurance and reimburses routine technology over careful coordination of care and cognitive services. So as we consider the Future of Family Medicine, let us demand evidence, spur creativity, and not settle for half-baked solutions that ignore the root causes of a health system in crisis.

Most of you have seen synopses of the Future of Family Medicine Project, read discussions of the New Model of practice, and heard the call to reengineer our discipline. I am excited about challenging an acute care model that forces us to practice like hamsters in a wheel, and am enthused about a more patient-focused approach. But I am concerned about adopting a “Model” without adequate evidence, about focusing on a single solution rather than multiple creative approaches to practice, and about ignoring underlying deficiencies in American health care.

I am instinctively distrustful of claims for a single solution to a complex and diverse problem such as America’s health care crisis. To assert that we have developed a “New Model of Family Medicine” without empiric validation seems rash. Reams of focus group data and patient interviews do not a new model make. Where is the theory development and experimental data that support this? Rather than purporting to have discovered a single “New Model,” shouldn’t we be encouraging multiple creative models of family medicine? Rather than standardizing a market basket of services, shouldn’t we be encouraging a community responsive approach? By experimenting and trying many approaches to achieving better patient outcomes, we will be sure that we have developed a robust model worth replicating. Let’s leave the market baskets to Krogers.

Also, tools such as EHR, open access scheduling, or asynchronous communication via the Internet are only means to an end. Let’s have a healthy appreciation of diverse methods to enhance community health, patient outcomes including satisfaction, access to care, and timely and appropriate treatment. All these tools may indeed be crucial, but they are just tools—not patient-oriented outcomes.

What gaps might exist in this toolbox? I keep wondering how much we can improve health care of populations without a clear denominator (ie, a registered list of patients) or an insurance “system” that consistently covers the new patients for whom I care. These issues aside, the gap between practice reality and theory, and the economic challenge to meet the initial costs of the new model leave me distressed—problems many of you lament.

Finally, let us remember that even the most robustly functioning practices will not cure a demand-based workforce policy, a financing system that leaves many millions without health insurance and reimburses routine technology over careful coordination of care and cognitive services. So as we consider the Future of Family Medicine, let us demand evidence, spur creativity, and not settle for half-baked solutions that ignore the root causes of a health system in crisis.

Most of you have seen synopses of the Future of Family Medicine Project, read discussions of the New Model of practice, and heard the call to reengineer our discipline. I am excited about challenging an acute care model that forces us to practice like hamsters in a wheel, and am enthused about a more patient-focused approach. But I am concerned about adopting a “Model” without adequate evidence, about focusing on a single solution rather than multiple creative approaches to practice, and about ignoring underlying deficiencies in American health care.

I am instinctively distrustful of claims for a single solution to a complex and diverse problem such as America’s health care crisis. To assert that we have developed a “New Model of Family Medicine” without empiric validation seems rash. Reams of focus group data and patient interviews do not a new model make. Where is the theory development and experimental data that support this? Rather than purporting to have discovered a single “New Model,” shouldn’t we be encouraging multiple creative models of family medicine? Rather than standardizing a market basket of services, shouldn’t we be encouraging a community responsive approach? By experimenting and trying many approaches to achieving better patient outcomes, we will be sure that we have developed a robust model worth replicating. Let’s leave the market baskets to Krogers.

Also, tools such as EHR, open access scheduling, or asynchronous communication via the Internet are only means to an end. Let’s have a healthy appreciation of diverse methods to enhance community health, patient outcomes including satisfaction, access to care, and timely and appropriate treatment. All these tools may indeed be crucial, but they are just tools—not patient-oriented outcomes.

What gaps might exist in this toolbox? I keep wondering how much we can improve health care of populations without a clear denominator (ie, a registered list of patients) or an insurance “system” that consistently covers the new patients for whom I care. These issues aside, the gap between practice reality and theory, and the economic challenge to meet the initial costs of the new model leave me distressed—problems many of you lament.

Finally, let us remember that even the most robustly functioning practices will not cure a demand-based workforce policy, a financing system that leaves many millions without health insurance and reimburses routine technology over careful coordination of care and cognitive services. So as we consider the Future of Family Medicine, let us demand evidence, spur creativity, and not settle for half-baked solutions that ignore the root causes of a health system in crisis.

We are in the midst of an unseen epidemic. I am not talking about the Marburg virus or Chlamydia, not teenage pregnancy, and not the plight of our patients with disabilities and dwindling support from Medicaid.

This epidemic is spreading across the Internet, and point sources appear to be the editorial facilities of our major medical publications. As yet unvalidated, reports are being heard of rapid transmission among publishers and medical and specialty societies. What is this epidemic? Let me describe my encounter with it.

Recently, I started to update a talk on low back pain. On a yearly basis I review my file of clipped articles on the topic and do a new search on PubMed, TRIP, and similar evidence-based resources. What a joy it is to have at my fingertips the worlds’ medical literature.

NOT!!!

You, too, may have discovered that access to actual articles is denied to we “riff-raff.” With only a few exceptions, I was asked to pay an up-front user fee or to subscribe before access to a desired article would be granted. What has become of the promise of rapid communication of scientific information?

Now, you might say this was the state of affairs in the good ole days: after laboriously reviewing Index Medicus, you would pore through the stacks hoping your library subscribed to the journal of interest. And of course you can say that publishing companies, journals, and medical societies must turn a profit. If you work at a large university, as I do, you probably have access to many full text journals on line. There are even a few free, but limited, access points provided by commercial sponsors. But with deep disappointment, I contemplate our unfettered access to scientific information becoming more limited.

Let me propose a couple of measures to counter this epidemic. A few journals have allowed open access to the current issue, but limit access to the last year to subscribers only. Older issues are open. While not ideal, this option does make available articles “in the news” as well as older information.

Or, instead of providing us another pen or plush toy, why don’t commercial sponsors support access to the top databases, references, and journals?

Perhaps, then, we can defeat this epidemic and regain rapid availability of medical information.

We are in the midst of an unseen epidemic. I am not talking about the Marburg virus or Chlamydia, not teenage pregnancy, and not the plight of our patients with disabilities and dwindling support from Medicaid.

This epidemic is spreading across the Internet, and point sources appear to be the editorial facilities of our major medical publications. As yet unvalidated, reports are being heard of rapid transmission among publishers and medical and specialty societies. What is this epidemic? Let me describe my encounter with it.

Recently, I started to update a talk on low back pain. On a yearly basis I review my file of clipped articles on the topic and do a new search on PubMed, TRIP, and similar evidence-based resources. What a joy it is to have at my fingertips the worlds’ medical literature.

NOT!!!

You, too, may have discovered that access to actual articles is denied to we “riff-raff.” With only a few exceptions, I was asked to pay an up-front user fee or to subscribe before access to a desired article would be granted. What has become of the promise of rapid communication of scientific information?

Now, you might say this was the state of affairs in the good ole days: after laboriously reviewing Index Medicus, you would pore through the stacks hoping your library subscribed to the journal of interest. And of course you can say that publishing companies, journals, and medical societies must turn a profit. If you work at a large university, as I do, you probably have access to many full text journals on line. There are even a few free, but limited, access points provided by commercial sponsors. But with deep disappointment, I contemplate our unfettered access to scientific information becoming more limited.

Let me propose a couple of measures to counter this epidemic. A few journals have allowed open access to the current issue, but limit access to the last year to subscribers only. Older issues are open. While not ideal, this option does make available articles “in the news” as well as older information.

Or, instead of providing us another pen or plush toy, why don’t commercial sponsors support access to the top databases, references, and journals?

Perhaps, then, we can defeat this epidemic and regain rapid availability of medical information.

We are in the midst of an unseen epidemic. I am not talking about the Marburg virus or Chlamydia, not teenage pregnancy, and not the plight of our patients with disabilities and dwindling support from Medicaid.

This epidemic is spreading across the Internet, and point sources appear to be the editorial facilities of our major medical publications. As yet unvalidated, reports are being heard of rapid transmission among publishers and medical and specialty societies. What is this epidemic? Let me describe my encounter with it.

Recently, I started to update a talk on low back pain. On a yearly basis I review my file of clipped articles on the topic and do a new search on PubMed, TRIP, and similar evidence-based resources. What a joy it is to have at my fingertips the worlds’ medical literature.

NOT!!!

You, too, may have discovered that access to actual articles is denied to we “riff-raff.” With only a few exceptions, I was asked to pay an up-front user fee or to subscribe before access to a desired article would be granted. What has become of the promise of rapid communication of scientific information?

Now, you might say this was the state of affairs in the good ole days: after laboriously reviewing Index Medicus, you would pore through the stacks hoping your library subscribed to the journal of interest. And of course you can say that publishing companies, journals, and medical societies must turn a profit. If you work at a large university, as I do, you probably have access to many full text journals on line. There are even a few free, but limited, access points provided by commercial sponsors. But with deep disappointment, I contemplate our unfettered access to scientific information becoming more limited.

Let me propose a couple of measures to counter this epidemic. A few journals have allowed open access to the current issue, but limit access to the last year to subscribers only. Older issues are open. While not ideal, this option does make available articles “in the news” as well as older information.

Or, instead of providing us another pen or plush toy, why don’t commercial sponsors support access to the top databases, references, and journals?

Perhaps, then, we can defeat this epidemic and regain rapid availability of medical information.

One of the benefits of hosting a visiting professor from England has been access to the British Medical Journal, and perhaps less esteemed but equally fascinating publications like GP. This tabloid, similar to FP News, highlights the striking similarities between our practices—once you get beyond the discussion of “list sizes,” the NHS (National Health Service), and of course, the term “GP” itself.

There are calls for GPs to ban together to fight kidney disease, obesity, and hypertension, to provide mammography on request, and to more effectively treat atrial fibrillation. Judged by my rigorous scientific sampling over tea and scones (well, maybe it was a Starbucks and a bagel) the clinical issues are immediately recognizable: screening for occult problems, effectively managing chronic disease, improving quality of care.

But what about the social and economic fronts? There are debates about maintenance of certification and “revalidation,” struggles to reduce hospitalization and rein in costs, and pharmaceutical advertising galore. Editorials reflect on whether physicians should be salaried, the demise of 24-hour responsibility of physicians, the influx of nurse practitioners—I could lift the copy verbatim for JFP. Underlying these discussions are debates about financing healthcare, workforce composition, and the eroding lifestyle and incentives to GPs.

As I get to know my new GP colleague, it is clear our hopes, struggles, and challenges are quite similar. Although, I do admit to wistfully dreaming about the “paper-light practice with no out-of-hours or weekend work, with 10,000 patients all very well trained.”

One of the benefits of hosting a visiting professor from England has been access to the British Medical Journal, and perhaps less esteemed but equally fascinating publications like GP. This tabloid, similar to FP News, highlights the striking similarities between our practices—once you get beyond the discussion of “list sizes,” the NHS (National Health Service), and of course, the term “GP” itself.

There are calls for GPs to ban together to fight kidney disease, obesity, and hypertension, to provide mammography on request, and to more effectively treat atrial fibrillation. Judged by my rigorous scientific sampling over tea and scones (well, maybe it was a Starbucks and a bagel) the clinical issues are immediately recognizable: screening for occult problems, effectively managing chronic disease, improving quality of care.

But what about the social and economic fronts? There are debates about maintenance of certification and “revalidation,” struggles to reduce hospitalization and rein in costs, and pharmaceutical advertising galore. Editorials reflect on whether physicians should be salaried, the demise of 24-hour responsibility of physicians, the influx of nurse practitioners—I could lift the copy verbatim for JFP. Underlying these discussions are debates about financing healthcare, workforce composition, and the eroding lifestyle and incentives to GPs.

As I get to know my new GP colleague, it is clear our hopes, struggles, and challenges are quite similar. Although, I do admit to wistfully dreaming about the “paper-light practice with no out-of-hours or weekend work, with 10,000 patients all very well trained.”

One of the benefits of hosting a visiting professor from England has been access to the British Medical Journal, and perhaps less esteemed but equally fascinating publications like GP. This tabloid, similar to FP News, highlights the striking similarities between our practices—once you get beyond the discussion of “list sizes,” the NHS (National Health Service), and of course, the term “GP” itself.

There are calls for GPs to ban together to fight kidney disease, obesity, and hypertension, to provide mammography on request, and to more effectively treat atrial fibrillation. Judged by my rigorous scientific sampling over tea and scones (well, maybe it was a Starbucks and a bagel) the clinical issues are immediately recognizable: screening for occult problems, effectively managing chronic disease, improving quality of care.

But what about the social and economic fronts? There are debates about maintenance of certification and “revalidation,” struggles to reduce hospitalization and rein in costs, and pharmaceutical advertising galore. Editorials reflect on whether physicians should be salaried, the demise of 24-hour responsibility of physicians, the influx of nurse practitioners—I could lift the copy verbatim for JFP. Underlying these discussions are debates about financing healthcare, workforce composition, and the eroding lifestyle and incentives to GPs.

As I get to know my new GP colleague, it is clear our hopes, struggles, and challenges are quite similar. Although, I do admit to wistfully dreaming about the “paper-light practice with no out-of-hours or weekend work, with 10,000 patients all very well trained.”

I just finished seeing a room full of monsters. No giant with a single eye in the middle of his forehead. No green, fire-breathing dragon with a ferocious disposition. No patient with an unfortunate tendency toward cannibalism. Simply a concerned mother with 2 children who turned out to have the usual upper respiratory infections, nothing more.

This mother and her children looked like other people you know: your children, your mother or daughter, your next door neighbor. No horns to uncover, no tentacles to expose. But recently I learned that they are walking incarnations of a ferocious phantasm, monsters out to eat us all.

Why, certainly you have heard the name of this monster?

“We must tame the Medicaid monster,” decried our governor at his State of the State Address. The news media were quick to use similar language: Medicaid was “devouring” the budget and generally enjoying a veritable smorgasbord at our expense.

As is true of many states, Ohio faces financial challenges. Deemed chief among these is the growing cost of Medicaid. I do not question that state budgets are in jeopardy or that we should thoughtfully assess the value of our health care dollar. But what does this language connote to the people Medicaid is intended to help?

I see no monsters in my examination room.

All I see are 2 small children and their mother wanting a little reassurance. A bit of help. Access to health care and the services you and I—and yes, our governors—take for granted.

In trying to name our fiscal ailments, let’s be careful we do not act monstrously.

I just finished seeing a room full of monsters. No giant with a single eye in the middle of his forehead. No green, fire-breathing dragon with a ferocious disposition. No patient with an unfortunate tendency toward cannibalism. Simply a concerned mother with 2 children who turned out to have the usual upper respiratory infections, nothing more.

This mother and her children looked like other people you know: your children, your mother or daughter, your next door neighbor. No horns to uncover, no tentacles to expose. But recently I learned that they are walking incarnations of a ferocious phantasm, monsters out to eat us all.

Why, certainly you have heard the name of this monster?

“We must tame the Medicaid monster,” decried our governor at his State of the State Address. The news media were quick to use similar language: Medicaid was “devouring” the budget and generally enjoying a veritable smorgasbord at our expense.

As is true of many states, Ohio faces financial challenges. Deemed chief among these is the growing cost of Medicaid. I do not question that state budgets are in jeopardy or that we should thoughtfully assess the value of our health care dollar. But what does this language connote to the people Medicaid is intended to help?

I see no monsters in my examination room.

All I see are 2 small children and their mother wanting a little reassurance. A bit of help. Access to health care and the services you and I—and yes, our governors—take for granted.

In trying to name our fiscal ailments, let’s be careful we do not act monstrously.

I just finished seeing a room full of monsters. No giant with a single eye in the middle of his forehead. No green, fire-breathing dragon with a ferocious disposition. No patient with an unfortunate tendency toward cannibalism. Simply a concerned mother with 2 children who turned out to have the usual upper respiratory infections, nothing more.

This mother and her children looked like other people you know: your children, your mother or daughter, your next door neighbor. No horns to uncover, no tentacles to expose. But recently I learned that they are walking incarnations of a ferocious phantasm, monsters out to eat us all.

Why, certainly you have heard the name of this monster?

“We must tame the Medicaid monster,” decried our governor at his State of the State Address. The news media were quick to use similar language: Medicaid was “devouring” the budget and generally enjoying a veritable smorgasbord at our expense.

As is true of many states, Ohio faces financial challenges. Deemed chief among these is the growing cost of Medicaid. I do not question that state budgets are in jeopardy or that we should thoughtfully assess the value of our health care dollar. But what does this language connote to the people Medicaid is intended to help?

I see no monsters in my examination room.

All I see are 2 small children and their mother wanting a little reassurance. A bit of help. Access to health care and the services you and I—and yes, our governors—take for granted.

In trying to name our fiscal ailments, let’s be careful we do not act monstrously.

The year was 1811. The setting: Nottinghamshire, England. More than 800 textile frames were destroyed in an effort to forestall the progress of technology in transforming the weaving industry. The mythical leader of this revolution was King Ludd, a dweller of Sherwood Forest, land of Robin Hood. Loom destruction became a capital offense in 1812, but it didn’t diminish laments about the pace of technology. And now, for all of you Luddites, the JOURNAL OF FAMILY PRACTICE is undergoing a technology revolution of its own: the move to fully electronic, web-based submission and review of manuscripts.

Beginning immediately, I invite you to submit your articles using the Manuscript Central website: http://mc.manuscriptcentral.com/jfp. This system, used by a number of leading medical and academic journals, automates the submission and review process. When you first arrive at the JFP Manuscript Central site, you will be asked to log on or create a new account. This process allows you to submit your manuscript or to review other authors’ manuscripts. For our editors, the system notifies us when manuscripts are submitted, tracks reviews, and does all those things computers can do (like crash periodically).

Lest I sound like a modern-age Luddite, I invite your submission electronically via our Manuscript Central site. Let us know your experience, particularly any glitches or opportunities for improvement. Unlike the Empire, we promise not to hang anyone who clings to their old fashioned ways. In the meantime, I am going to see if I can get a few more manuscripts off my desk.

The year was 1811. The setting: Nottinghamshire, England. More than 800 textile frames were destroyed in an effort to forestall the progress of technology in transforming the weaving industry. The mythical leader of this revolution was King Ludd, a dweller of Sherwood Forest, land of Robin Hood. Loom destruction became a capital offense in 1812, but it didn’t diminish laments about the pace of technology. And now, for all of you Luddites, the JOURNAL OF FAMILY PRACTICE is undergoing a technology revolution of its own: the move to fully electronic, web-based submission and review of manuscripts.

Beginning immediately, I invite you to submit your articles using the Manuscript Central website: http://mc.manuscriptcentral.com/jfp. This system, used by a number of leading medical and academic journals, automates the submission and review process. When you first arrive at the JFP Manuscript Central site, you will be asked to log on or create a new account. This process allows you to submit your manuscript or to review other authors’ manuscripts. For our editors, the system notifies us when manuscripts are submitted, tracks reviews, and does all those things computers can do (like crash periodically).

Lest I sound like a modern-age Luddite, I invite your submission electronically via our Manuscript Central site. Let us know your experience, particularly any glitches or opportunities for improvement. Unlike the Empire, we promise not to hang anyone who clings to their old fashioned ways. In the meantime, I am going to see if I can get a few more manuscripts off my desk.

The year was 1811. The setting: Nottinghamshire, England. More than 800 textile frames were destroyed in an effort to forestall the progress of technology in transforming the weaving industry. The mythical leader of this revolution was King Ludd, a dweller of Sherwood Forest, land of Robin Hood. Loom destruction became a capital offense in 1812, but it didn’t diminish laments about the pace of technology. And now, for all of you Luddites, the JOURNAL OF FAMILY PRACTICE is undergoing a technology revolution of its own: the move to fully electronic, web-based submission and review of manuscripts.

Beginning immediately, I invite you to submit your articles using the Manuscript Central website: http://mc.manuscriptcentral.com/jfp. This system, used by a number of leading medical and academic journals, automates the submission and review process. When you first arrive at the JFP Manuscript Central site, you will be asked to log on or create a new account. This process allows you to submit your manuscript or to review other authors’ manuscripts. For our editors, the system notifies us when manuscripts are submitted, tracks reviews, and does all those things computers can do (like crash periodically).

Lest I sound like a modern-age Luddite, I invite your submission electronically via our Manuscript Central site. Let us know your experience, particularly any glitches or opportunities for improvement. Unlike the Empire, we promise not to hang anyone who clings to their old fashioned ways. In the meantime, I am going to see if I can get a few more manuscripts off my desk.