Jeff Susman, MD

After serving as editor-in-chief of The Journal of Family Practice for more than 9 years, Jeff Susman, MD, is stepping down. Dr. Susman has worked tirelessly to provide readers with practical content that has been through a rigorous peer-review process and is firmly rooted in evidence-based medicine. His intelligence, insight, and wit will be greatly missed.

In this, his final editorial, Dr. Susman writes an open letter to John Hickner, MD, MSc. Dr. Hickner, chairman, Department of Family Medicine, Cleveland Clinic, has been an associate editor of the journal for 12 years and is a frequent contributor. He will assume the editor-in-chief post with the October issue.

Dear John,

What a fantastic journey you are about to begin. Here’s a bit of guidance as you start your stint as editor-in-chief.

Manage your image. Start by finding a nice photo of yourself, preferably one taken 20 years ago. You’ll be staring at that picture for years to come, and the least you deserve is a youthful image. I suggest you get a new pair of glasses, too, with anti-glare lenses to help you avoid eye strain from the many hours you’ll spend in front of a computer.

Re-engineer your office. Make room for the many dictionaries, indices, and style guides you’ll need—and which I’ll be happy to send you. I’m keeping my Pepcid and stress ball, though, as I plan to remain in my position as dean of the College of Medicine at Northeast Ohio Medical University.

Manage manuscripts. As you hone the ability to identify publication-worthy submissions and triage manuscripts, here are a few red flags to keep in mind:

• Wrong journal (“Dear Esteemed Editor of American Family Physician”)
• Wrong topic (“I’ve enclosed my manuscript on piranha bites in the Amazon …”)
• Spurious claim (“I’ve discovered a new treatment for male pattern baldness …”)

Remember, you’re an editor, not an author. You are under no obligation to rewrite a manuscript to make it understandable or act as a methods consultant on a scholarly project. You will, however, have the opportunity to encourage young authors, mentor faculty, and affect medical practice on an international level. What could be more exciting?

Develop a thick skin. Most of the letters you’ll receive will be from physicians eager to point out flaws in your logic—or what they see as your shortcomings. Don’t be discouraged. The one letter in 100 that recounts how a journal article saved a patient’s life or made a real difference in the way the doctor practices is well worth the 99 diatribes.

Be adaptive. As the saying goes, “This ain’t your father’s Oldsmobile.” In a landscape populated by QR codes and direct-to-consumer pharma ads, medical ethics is challenging and ever-changing. (Remember when it was unethical for a physician to have a display ad in the Yellow Pages?) Stay abreast of—and remain open to—the changes that are to come.

Finally, have fun! I can think of no other “job” in which I’ve had the privilege of interacting with such smart and dedicated professionals—authors, colleagues, and staff alike. As I bid my adieu, let me thank all of you, especially the readers of JFP, for whom we strive to make the journal as timely and practical as possible.

Enjoy the journey, John. As for me, I think I’ll take up golf.

After serving as editor-in-chief of The Journal of Family Practice for more than 9 years, Jeff Susman, MD, is stepping down. Dr. Susman has worked tirelessly to provide readers with practical content that has been through a rigorous peer-review process and is firmly rooted in evidence-based medicine. His intelligence, insight, and wit will be greatly missed.

In this, his final editorial, Dr. Susman writes an open letter to John Hickner, MD, MSc. Dr. Hickner, chairman, Department of Family Medicine, Cleveland Clinic, has been an associate editor of the journal for 12 years and is a frequent contributor. He will assume the editor-in-chief post with the October issue.

Dear John,

What a fantastic journey you are about to begin. Here’s a bit of guidance as you start your stint as editor-in-chief.

Manage your image. Start by finding a nice photo of yourself, preferably one taken 20 years ago. You’ll be staring at that picture for years to come, and the least you deserve is a youthful image. I suggest you get a new pair of glasses, too, with anti-glare lenses to help you avoid eye strain from the many hours you’ll spend in front of a computer.

Re-engineer your office. Make room for the many dictionaries, indices, and style guides you’ll need—and which I’ll be happy to send you. I’m keeping my Pepcid and stress ball, though, as I plan to remain in my position as dean of the College of Medicine at Northeast Ohio Medical University.

Manage manuscripts. As you hone the ability to identify publication-worthy submissions and triage manuscripts, here are a few red flags to keep in mind:

• Wrong journal (“Dear Esteemed Editor of American Family Physician”)
• Wrong topic (“I’ve enclosed my manuscript on piranha bites in the Amazon …”)
• Spurious claim (“I’ve discovered a new treatment for male pattern baldness …”)

Remember, you’re an editor, not an author. You are under no obligation to rewrite a manuscript to make it understandable or act as a methods consultant on a scholarly project. You will, however, have the opportunity to encourage young authors, mentor faculty, and affect medical practice on an international level. What could be more exciting?

Develop a thick skin. Most of the letters you’ll receive will be from physicians eager to point out flaws in your logic—or what they see as your shortcomings. Don’t be discouraged. The one letter in 100 that recounts how a journal article saved a patient’s life or made a real difference in the way the doctor practices is well worth the 99 diatribes.

Be adaptive. As the saying goes, “This ain’t your father’s Oldsmobile.” In a landscape populated by QR codes and direct-to-consumer pharma ads, medical ethics is challenging and ever-changing. (Remember when it was unethical for a physician to have a display ad in the Yellow Pages?) Stay abreast of—and remain open to—the changes that are to come.

Finally, have fun! I can think of no other “job” in which I’ve had the privilege of interacting with such smart and dedicated professionals—authors, colleagues, and staff alike. As I bid my adieu, let me thank all of you, especially the readers of JFP, for whom we strive to make the journal as timely and practical as possible.

Enjoy the journey, John. As for me, I think I’ll take up golf.

After serving as editor-in-chief of The Journal of Family Practice for more than 9 years, Jeff Susman, MD, is stepping down. Dr. Susman has worked tirelessly to provide readers with practical content that has been through a rigorous peer-review process and is firmly rooted in evidence-based medicine. His intelligence, insight, and wit will be greatly missed.

In this, his final editorial, Dr. Susman writes an open letter to John Hickner, MD, MSc. Dr. Hickner, chairman, Department of Family Medicine, Cleveland Clinic, has been an associate editor of the journal for 12 years and is a frequent contributor. He will assume the editor-in-chief post with the October issue.

Dear John,

What a fantastic journey you are about to begin. Here’s a bit of guidance as you start your stint as editor-in-chief.

Manage your image. Start by finding a nice photo of yourself, preferably one taken 20 years ago. You’ll be staring at that picture for years to come, and the least you deserve is a youthful image. I suggest you get a new pair of glasses, too, with anti-glare lenses to help you avoid eye strain from the many hours you’ll spend in front of a computer.

Re-engineer your office. Make room for the many dictionaries, indices, and style guides you’ll need—and which I’ll be happy to send you. I’m keeping my Pepcid and stress ball, though, as I plan to remain in my position as dean of the College of Medicine at Northeast Ohio Medical University.

Manage manuscripts. As you hone the ability to identify publication-worthy submissions and triage manuscripts, here are a few red flags to keep in mind:

• Wrong journal (“Dear Esteemed Editor of American Family Physician”)
• Wrong topic (“I’ve enclosed my manuscript on piranha bites in the Amazon …”)
• Spurious claim (“I’ve discovered a new treatment for male pattern baldness …”)

Remember, you’re an editor, not an author. You are under no obligation to rewrite a manuscript to make it understandable or act as a methods consultant on a scholarly project. You will, however, have the opportunity to encourage young authors, mentor faculty, and affect medical practice on an international level. What could be more exciting?

Develop a thick skin. Most of the letters you’ll receive will be from physicians eager to point out flaws in your logic—or what they see as your shortcomings. Don’t be discouraged. The one letter in 100 that recounts how a journal article saved a patient’s life or made a real difference in the way the doctor practices is well worth the 99 diatribes.

Be adaptive. As the saying goes, “This ain’t your father’s Oldsmobile.” In a landscape populated by QR codes and direct-to-consumer pharma ads, medical ethics is challenging and ever-changing. (Remember when it was unethical for a physician to have a display ad in the Yellow Pages?) Stay abreast of—and remain open to—the changes that are to come.

Finally, have fun! I can think of no other “job” in which I’ve had the privilege of interacting with such smart and dedicated professionals—authors, colleagues, and staff alike. As I bid my adieu, let me thank all of you, especially the readers of JFP, for whom we strive to make the journal as timely and practical as possible.

Enjoy the journey, John. As for me, I think I’ll take up golf.

Reaction to the Supreme Court’s recent ruling on the constitutionality of the Patient Protection and Affordable Care Act (ACA) is a true measure of America. We can continue to politicize the health care of millions of citizens, jeopardize preventive care, and further fray the safety net—or we can finally get down to the business of good government. It’s time to embrace this law, which has the potential to greatly reduce the number of Americans who have no health coverage, without waiting for or expecting perfection.

Implementation of the ACA provisions will involve compromise and stewardship on the part of our elected officials. Yet many legislators appear to be averse to both. The House of Representatives wasted no time voting for the Repeal of Obamacare Act (HR 6079); governors began grandstanding; and talk of a “rationing board,” “job killer,” and “government takeover,” among other ridiculous sound bites, flooded the airwaves.

Although the Supreme Court ruled that states can opt out of the Medicaid expansion included in the law, reports suggesting that states that fully implement the law could actually save money^1,2 would suggest that politicians who oppose it are focused on fiscal folly.

It’s not only elected officials who are looking at the new law from their perspective alone rather than focusing on what’s best for patients and the community. Health insurers want to retain the ability to differentiate their rates, medical device manufacturers hope to repeal a tax on the sale of their products, and hospital CEOs are pushing for an expansion of Medicaid and reductions in payment cuts. Even with the expansion of Medicaid, the United States would fall far short of universal coverage, leaving millions of Americans without effective access to care.

To our country’s leaders, I have but what one question: “Will you have the courage to abandon political ideology in order to do what is possible?”

Isn’t it time we start to do what every other industrialized nation has done?

Reaction to the Supreme Court’s recent ruling on the constitutionality of the Patient Protection and Affordable Care Act (ACA) is a true measure of America. We can continue to politicize the health care of millions of citizens, jeopardize preventive care, and further fray the safety net—or we can finally get down to the business of good government. It’s time to embrace this law, which has the potential to greatly reduce the number of Americans who have no health coverage, without waiting for or expecting perfection.

Implementation of the ACA provisions will involve compromise and stewardship on the part of our elected officials. Yet many legislators appear to be averse to both. The House of Representatives wasted no time voting for the Repeal of Obamacare Act (HR 6079); governors began grandstanding; and talk of a “rationing board,” “job killer,” and “government takeover,” among other ridiculous sound bites, flooded the airwaves.

Although the Supreme Court ruled that states can opt out of the Medicaid expansion included in the law, reports suggesting that states that fully implement the law could actually save money^1,2 would suggest that politicians who oppose it are focused on fiscal folly.

It’s not only elected officials who are looking at the new law from their perspective alone rather than focusing on what’s best for patients and the community. Health insurers want to retain the ability to differentiate their rates, medical device manufacturers hope to repeal a tax on the sale of their products, and hospital CEOs are pushing for an expansion of Medicaid and reductions in payment cuts. Even with the expansion of Medicaid, the United States would fall far short of universal coverage, leaving millions of Americans without effective access to care.

To our country’s leaders, I have but what one question: “Will you have the courage to abandon political ideology in order to do what is possible?”

Isn’t it time we start to do what every other industrialized nation has done?

Reaction to the Supreme Court’s recent ruling on the constitutionality of the Patient Protection and Affordable Care Act (ACA) is a true measure of America. We can continue to politicize the health care of millions of citizens, jeopardize preventive care, and further fray the safety net—or we can finally get down to the business of good government. It’s time to embrace this law, which has the potential to greatly reduce the number of Americans who have no health coverage, without waiting for or expecting perfection.

Implementation of the ACA provisions will involve compromise and stewardship on the part of our elected officials. Yet many legislators appear to be averse to both. The House of Representatives wasted no time voting for the Repeal of Obamacare Act (HR 6079); governors began grandstanding; and talk of a “rationing board,” “job killer,” and “government takeover,” among other ridiculous sound bites, flooded the airwaves.

Although the Supreme Court ruled that states can opt out of the Medicaid expansion included in the law, reports suggesting that states that fully implement the law could actually save money^1,2 would suggest that politicians who oppose it are focused on fiscal folly.

It’s not only elected officials who are looking at the new law from their perspective alone rather than focusing on what’s best for patients and the community. Health insurers want to retain the ability to differentiate their rates, medical device manufacturers hope to repeal a tax on the sale of their products, and hospital CEOs are pushing for an expansion of Medicaid and reductions in payment cuts. Even with the expansion of Medicaid, the United States would fall far short of universal coverage, leaving millions of Americans without effective access to care.

To our country’s leaders, I have but what one question: “Will you have the courage to abandon political ideology in order to do what is possible?”

Isn’t it time we start to do what every other industrialized nation has done?

Despite recent efforts to modernize the MCAT, update the USMLE, and invigorate interdisciplinary health professional training, medical education remains a fortress of tradition and myth. Our assumptions about what it takes to prepare exemplary physicians remain largely unproven and idiosyncratic and our outcomes of medical practice, mediocre. It is time to truly reform medical education, beginning with our accrediting and testing bodies (testing drives the curriculum) and extending to our pipeline into medical school and to instructional design.

Just look at our hidebound requirements, consisting of such important subjects as organic chemistry and physics. The last time I used organic chemistry in the actual practice of medicine was … well, pretty much never. Yes, I can hear the chorus about how performance in organic chemistry is a litmus test of achievement on … well, standardized tests. And how scientific principles undergird our practice of medicine.

Poppycock, I say.

Put more emphasis on the social sciences
Medicine could be better served by a solid grounding in medical anthropology, medical sociology, and applied epidemiology. While it may be satisfying to understand the underpinnings of the treatment of diabetic ketoacidosis (although so many of our explanatory models eventually are proven wrong), far more medical mischief is caused by poor communication skills, ignorance of a patient’s culture and perspective, and the inability to apply even rudimentary statistical concepts. Surely performance in the social sciences could be used as an indicator of equal rigor—if the correct yardstick were used.

And therein lies the problem. We use MCATs and USMLE as the sum measure of performance, or assess success on the basis of admission to highly selective specialties (which use the same measures to winnow the applicants). Of course, there’s a correlation—and a tautological fallacy. What we really should be measuring is success as a physician, and until we have robust outcome data for sufficient populations of patients, we are simply deluding ourselves. Let’s stop publishing MCAT and GPA scores and fueling the US News and World Report ratings, and start choosing students who will make a real difference in our world.

Do away with one-size-fits-all training
Another ridiculous myth is that we must have 4 years of training to become physicians. For some, yes. But we really must measure competencies. I’ve known students who should be in medical school for 7 years, and a few who could finish in 2. The 4-year program, I believe, is more for convenience of planning than for educationally sound reasons.

And does anyone really believe that 4th-year auditions for residency are a highly important component of the training of competent physicians? Seeing many young doctors in training has convinced me that our measures of competence are rudimentary at best.

I also think we need to differentiate between students aspiring to be research scientists and those pursuing a clinical career. Much of what we stuff into the heads of our clinicians is useless at best, and harmful to many: lengthy differential diagnoses of obscure diseases that encourage over-testing, and training at quaternary centers that cater to the sickest patients with the most unusual diseases. Moreover, becoming a successful researcher requires a more robust grounding in one’s chosen field of science, if not via an MD-PhD, then at least through advanced training. So why don’t we own up to the fact that one size does not fit all?

Reconsider specialty choice
Finally, why is an open career choice considered a god-given right for our students? Does our country really need the droves of students attracted to emergency medicine, orthopedics, and anesthesia? Should our society be supporting the whims of every 20-something medical student? I think not. And why don’t we have a required service obligation for all new physicians—a year, say, for every year of training. Let’s start to fill our rural and urban areas with an expanded National Health Service Corps that guarantees a sustainable source of health care providers.

It is time to have a frank conversation about medical education. Not a 5-year study by an august group that shuffles the same tired assumptions. Not an advocacy effort that is preordained to recommend more of the same. Isn’t it time we begin to expose our tacit assumptions about medical education and plan for an evidence-based and socially informed set of policies and practices?

Despite recent efforts to modernize the MCAT, update the USMLE, and invigorate interdisciplinary health professional training, medical education remains a fortress of tradition and myth. Our assumptions about what it takes to prepare exemplary physicians remain largely unproven and idiosyncratic and our outcomes of medical practice, mediocre. It is time to truly reform medical education, beginning with our accrediting and testing bodies (testing drives the curriculum) and extending to our pipeline into medical school and to instructional design.

Just look at our hidebound requirements, consisting of such important subjects as organic chemistry and physics. The last time I used organic chemistry in the actual practice of medicine was … well, pretty much never. Yes, I can hear the chorus about how performance in organic chemistry is a litmus test of achievement on … well, standardized tests. And how scientific principles undergird our practice of medicine.

Poppycock, I say.

Put more emphasis on the social sciences
Medicine could be better served by a solid grounding in medical anthropology, medical sociology, and applied epidemiology. While it may be satisfying to understand the underpinnings of the treatment of diabetic ketoacidosis (although so many of our explanatory models eventually are proven wrong), far more medical mischief is caused by poor communication skills, ignorance of a patient’s culture and perspective, and the inability to apply even rudimentary statistical concepts. Surely performance in the social sciences could be used as an indicator of equal rigor—if the correct yardstick were used.

And therein lies the problem. We use MCATs and USMLE as the sum measure of performance, or assess success on the basis of admission to highly selective specialties (which use the same measures to winnow the applicants). Of course, there’s a correlation—and a tautological fallacy. What we really should be measuring is success as a physician, and until we have robust outcome data for sufficient populations of patients, we are simply deluding ourselves. Let’s stop publishing MCAT and GPA scores and fueling the US News and World Report ratings, and start choosing students who will make a real difference in our world.

Do away with one-size-fits-all training
Another ridiculous myth is that we must have 4 years of training to become physicians. For some, yes. But we really must measure competencies. I’ve known students who should be in medical school for 7 years, and a few who could finish in 2. The 4-year program, I believe, is more for convenience of planning than for educationally sound reasons.

And does anyone really believe that 4th-year auditions for residency are a highly important component of the training of competent physicians? Seeing many young doctors in training has convinced me that our measures of competence are rudimentary at best.

I also think we need to differentiate between students aspiring to be research scientists and those pursuing a clinical career. Much of what we stuff into the heads of our clinicians is useless at best, and harmful to many: lengthy differential diagnoses of obscure diseases that encourage over-testing, and training at quaternary centers that cater to the sickest patients with the most unusual diseases. Moreover, becoming a successful researcher requires a more robust grounding in one’s chosen field of science, if not via an MD-PhD, then at least through advanced training. So why don’t we own up to the fact that one size does not fit all?

Reconsider specialty choice
Finally, why is an open career choice considered a god-given right for our students? Does our country really need the droves of students attracted to emergency medicine, orthopedics, and anesthesia? Should our society be supporting the whims of every 20-something medical student? I think not. And why don’t we have a required service obligation for all new physicians—a year, say, for every year of training. Let’s start to fill our rural and urban areas with an expanded National Health Service Corps that guarantees a sustainable source of health care providers.

It is time to have a frank conversation about medical education. Not a 5-year study by an august group that shuffles the same tired assumptions. Not an advocacy effort that is preordained to recommend more of the same. Isn’t it time we begin to expose our tacit assumptions about medical education and plan for an evidence-based and socially informed set of policies and practices?

Despite recent efforts to modernize the MCAT, update the USMLE, and invigorate interdisciplinary health professional training, medical education remains a fortress of tradition and myth. Our assumptions about what it takes to prepare exemplary physicians remain largely unproven and idiosyncratic and our outcomes of medical practice, mediocre. It is time to truly reform medical education, beginning with our accrediting and testing bodies (testing drives the curriculum) and extending to our pipeline into medical school and to instructional design.

Just look at our hidebound requirements, consisting of such important subjects as organic chemistry and physics. The last time I used organic chemistry in the actual practice of medicine was … well, pretty much never. Yes, I can hear the chorus about how performance in organic chemistry is a litmus test of achievement on … well, standardized tests. And how scientific principles undergird our practice of medicine.

Poppycock, I say.

Put more emphasis on the social sciences
Medicine could be better served by a solid grounding in medical anthropology, medical sociology, and applied epidemiology. While it may be satisfying to understand the underpinnings of the treatment of diabetic ketoacidosis (although so many of our explanatory models eventually are proven wrong), far more medical mischief is caused by poor communication skills, ignorance of a patient’s culture and perspective, and the inability to apply even rudimentary statistical concepts. Surely performance in the social sciences could be used as an indicator of equal rigor—if the correct yardstick were used.

And therein lies the problem. We use MCATs and USMLE as the sum measure of performance, or assess success on the basis of admission to highly selective specialties (which use the same measures to winnow the applicants). Of course, there’s a correlation—and a tautological fallacy. What we really should be measuring is success as a physician, and until we have robust outcome data for sufficient populations of patients, we are simply deluding ourselves. Let’s stop publishing MCAT and GPA scores and fueling the US News and World Report ratings, and start choosing students who will make a real difference in our world.

Do away with one-size-fits-all training
Another ridiculous myth is that we must have 4 years of training to become physicians. For some, yes. But we really must measure competencies. I’ve known students who should be in medical school for 7 years, and a few who could finish in 2. The 4-year program, I believe, is more for convenience of planning than for educationally sound reasons.

And does anyone really believe that 4th-year auditions for residency are a highly important component of the training of competent physicians? Seeing many young doctors in training has convinced me that our measures of competence are rudimentary at best.

I also think we need to differentiate between students aspiring to be research scientists and those pursuing a clinical career. Much of what we stuff into the heads of our clinicians is useless at best, and harmful to many: lengthy differential diagnoses of obscure diseases that encourage over-testing, and training at quaternary centers that cater to the sickest patients with the most unusual diseases. Moreover, becoming a successful researcher requires a more robust grounding in one’s chosen field of science, if not via an MD-PhD, then at least through advanced training. So why don’t we own up to the fact that one size does not fit all?

Reconsider specialty choice
Finally, why is an open career choice considered a god-given right for our students? Does our country really need the droves of students attracted to emergency medicine, orthopedics, and anesthesia? Should our society be supporting the whims of every 20-something medical student? I think not. And why don’t we have a required service obligation for all new physicians—a year, say, for every year of training. Let’s start to fill our rural and urban areas with an expanded National Health Service Corps that guarantees a sustainable source of health care providers.

It is time to have a frank conversation about medical education. Not a 5-year study by an august group that shuffles the same tired assumptions. Not an advocacy effort that is preordained to recommend more of the same. Isn’t it time we begin to expose our tacit assumptions about medical education and plan for an evidence-based and socially informed set of policies and practices?

Recently I had the opportunity to hear Stephen Bergman, psychiatrist and author of The House of God¹—the classic satire about newly minted physicians—speak at a local hospital. So on Class Day, when it was my turn to address our graduating medical students, I began by sharing a few of the dictums of a key character in the novel—better known as the Fat Man’s Rules:

• At a cardiac arrest, the first procedure is to take your own pulse
• If you don’t take a temperature, you can’t find a fever
• The delivery of good medical care is to do as much nothing as possible.

Perhaps it was my delivery, but there was very little reaction to what I fondly remember as a dark comedy informed by a core of truth. Afterwards, I learned that most of the students had read Bergman’s book, but simply could not relate to the unsupervised care, unbearable workloads, and unthinkable demands that are the cornerstone of the story.

After a bit of reflection, I realized that this makes sense. Residents are no longer expected to work 72 hours in a row, run the emergency room alone, or live 5 minutes from the hospital—or face dismissal. Internship and residency remain rigorous. But the mistreatment of interns and residents is no longer routine, overt demeaning of patients and families is rare, and zero-tolerance policies for drunk attending physicians are in place.

In short, the world in which I trained is long gone, and the excesses of a bygone era seem as anachronistic as Mad Men advertising executives having cocktails at lunch.

Nowhere is the transformation more visible than at VA facilities. Once a bastion of smoking patients, absent attendings, and inadequate resources, Veterans Affairs hospitals have become models of quality improvement, integrated services, and exemplary care.

Indeed, the change is heartening. Now, instead of telling students I remember when we walked 5 miles uphill both ways, I talk about how much medical education has changed for the better. Yes, I understand that today’s trainees don’t get the breadth or volume of experiences that my peers and I did. But the closer I get to the age when hospital care is virtually inevitable, I’m happy that The House of God has gone the way of trephining and rotating tourniquets.

Recently I had the opportunity to hear Stephen Bergman, psychiatrist and author of The House of God¹—the classic satire about newly minted physicians—speak at a local hospital. So on Class Day, when it was my turn to address our graduating medical students, I began by sharing a few of the dictums of a key character in the novel—better known as the Fat Man’s Rules:

• At a cardiac arrest, the first procedure is to take your own pulse
• If you don’t take a temperature, you can’t find a fever
• The delivery of good medical care is to do as much nothing as possible.

Perhaps it was my delivery, but there was very little reaction to what I fondly remember as a dark comedy informed by a core of truth. Afterwards, I learned that most of the students had read Bergman’s book, but simply could not relate to the unsupervised care, unbearable workloads, and unthinkable demands that are the cornerstone of the story.

After a bit of reflection, I realized that this makes sense. Residents are no longer expected to work 72 hours in a row, run the emergency room alone, or live 5 minutes from the hospital—or face dismissal. Internship and residency remain rigorous. But the mistreatment of interns and residents is no longer routine, overt demeaning of patients and families is rare, and zero-tolerance policies for drunk attending physicians are in place.

In short, the world in which I trained is long gone, and the excesses of a bygone era seem as anachronistic as Mad Men advertising executives having cocktails at lunch.

Nowhere is the transformation more visible than at VA facilities. Once a bastion of smoking patients, absent attendings, and inadequate resources, Veterans Affairs hospitals have become models of quality improvement, integrated services, and exemplary care.

Indeed, the change is heartening. Now, instead of telling students I remember when we walked 5 miles uphill both ways, I talk about how much medical education has changed for the better. Yes, I understand that today’s trainees don’t get the breadth or volume of experiences that my peers and I did. But the closer I get to the age when hospital care is virtually inevitable, I’m happy that The House of God has gone the way of trephining and rotating tourniquets.

Recently I had the opportunity to hear Stephen Bergman, psychiatrist and author of The House of God¹—the classic satire about newly minted physicians—speak at a local hospital. So on Class Day, when it was my turn to address our graduating medical students, I began by sharing a few of the dictums of a key character in the novel—better known as the Fat Man’s Rules:

• At a cardiac arrest, the first procedure is to take your own pulse
• If you don’t take a temperature, you can’t find a fever
• The delivery of good medical care is to do as much nothing as possible.

Perhaps it was my delivery, but there was very little reaction to what I fondly remember as a dark comedy informed by a core of truth. Afterwards, I learned that most of the students had read Bergman’s book, but simply could not relate to the unsupervised care, unbearable workloads, and unthinkable demands that are the cornerstone of the story.

After a bit of reflection, I realized that this makes sense. Residents are no longer expected to work 72 hours in a row, run the emergency room alone, or live 5 minutes from the hospital—or face dismissal. Internship and residency remain rigorous. But the mistreatment of interns and residents is no longer routine, overt demeaning of patients and families is rare, and zero-tolerance policies for drunk attending physicians are in place.

In short, the world in which I trained is long gone, and the excesses of a bygone era seem as anachronistic as Mad Men advertising executives having cocktails at lunch.

Nowhere is the transformation more visible than at VA facilities. Once a bastion of smoking patients, absent attendings, and inadequate resources, Veterans Affairs hospitals have become models of quality improvement, integrated services, and exemplary care.

Indeed, the change is heartening. Now, instead of telling students I remember when we walked 5 miles uphill both ways, I talk about how much medical education has changed for the better. Yes, I understand that today’s trainees don’t get the breadth or volume of experiences that my peers and I did. But the closer I get to the age when hospital care is virtually inevitable, I’m happy that The House of God has gone the way of trephining and rotating tourniquets.

At first, I couldn’t believe that the filthy, inebriated man whom I led onto a van for the homeless had served as an officer in the Vietnam War. But as I took his medical history and examined him, my doubt dissolved. Horrible nightmares, shakes, alcoholism, a life on the street—“things no man should see.” It all fit together.

On another occasion, I met Mike, a victim of an improvised explosive device, whose wife patiently explained that he’d never been the same since he came home from Iraq with a significant traumatic brain injury (TBI). And Jim, a former soldier on a special operations unit who lived for danger, long after his stint in the service ended. Jim liked to fly helicopters that he built—and crashed with some frequency.

The New York Times recently reported that while one American soldier dies every day and a half, veterans commit suicide at a rate of one every 80 minutes, and at least one in 5 veterans of the Iraq and Afghanistan wars suffers from post-traumatic stress disorder or TBI.¹

It’s easy to criticize the military for not providing proper protection for our troops or to blame the Veterans Administration for the dearth of mental health providers. As usual, we look for a quick fix to a complex problem. But war is an experience that keeps on giving: addiction, divorce, and flashbacks. Our soldiers and their families need all the support we can provide.

War is an experience that keeps on giving: addiction, divorce, and flashbacks.

We need to enhance social services, ensure access to mental health care, and provide an integrated medical home for our vets and their families. We need barrier-free housing for those who have lost limbs. We need to do more to reintegrate returning vets into civilian life. The reality is that we owe our vets—and their families—far more than we provide.

I’m writing this from Washington, DC, a month before we celebrate Memorial Day and remember those who died in service of our country. On the flight into our nation’s capital, I sat next to a young man returning from his tour of military duty. He seemed mature, upbeat, whole. But when I asked him about his experience, he responded: “Sir, I gotta tell you, what I saw was hell.”

At first, I couldn’t believe that the filthy, inebriated man whom I led onto a van for the homeless had served as an officer in the Vietnam War. But as I took his medical history and examined him, my doubt dissolved. Horrible nightmares, shakes, alcoholism, a life on the street—“things no man should see.” It all fit together.

On another occasion, I met Mike, a victim of an improvised explosive device, whose wife patiently explained that he’d never been the same since he came home from Iraq with a significant traumatic brain injury (TBI). And Jim, a former soldier on a special operations unit who lived for danger, long after his stint in the service ended. Jim liked to fly helicopters that he built—and crashed with some frequency.

The New York Times recently reported that while one American soldier dies every day and a half, veterans commit suicide at a rate of one every 80 minutes, and at least one in 5 veterans of the Iraq and Afghanistan wars suffers from post-traumatic stress disorder or TBI.¹

It’s easy to criticize the military for not providing proper protection for our troops or to blame the Veterans Administration for the dearth of mental health providers. As usual, we look for a quick fix to a complex problem. But war is an experience that keeps on giving: addiction, divorce, and flashbacks. Our soldiers and their families need all the support we can provide.

War is an experience that keeps on giving: addiction, divorce, and flashbacks.

We need to enhance social services, ensure access to mental health care, and provide an integrated medical home for our vets and their families. We need barrier-free housing for those who have lost limbs. We need to do more to reintegrate returning vets into civilian life. The reality is that we owe our vets—and their families—far more than we provide.

I’m writing this from Washington, DC, a month before we celebrate Memorial Day and remember those who died in service of our country. On the flight into our nation’s capital, I sat next to a young man returning from his tour of military duty. He seemed mature, upbeat, whole. But when I asked him about his experience, he responded: “Sir, I gotta tell you, what I saw was hell.”

At first, I couldn’t believe that the filthy, inebriated man whom I led onto a van for the homeless had served as an officer in the Vietnam War. But as I took his medical history and examined him, my doubt dissolved. Horrible nightmares, shakes, alcoholism, a life on the street—“things no man should see.” It all fit together.

On another occasion, I met Mike, a victim of an improvised explosive device, whose wife patiently explained that he’d never been the same since he came home from Iraq with a significant traumatic brain injury (TBI). And Jim, a former soldier on a special operations unit who lived for danger, long after his stint in the service ended. Jim liked to fly helicopters that he built—and crashed with some frequency.

The New York Times recently reported that while one American soldier dies every day and a half, veterans commit suicide at a rate of one every 80 minutes, and at least one in 5 veterans of the Iraq and Afghanistan wars suffers from post-traumatic stress disorder or TBI.¹

It’s easy to criticize the military for not providing proper protection for our troops or to blame the Veterans Administration for the dearth of mental health providers. As usual, we look for a quick fix to a complex problem. But war is an experience that keeps on giving: addiction, divorce, and flashbacks. Our soldiers and their families need all the support we can provide.

War is an experience that keeps on giving: addiction, divorce, and flashbacks.

We need to enhance social services, ensure access to mental health care, and provide an integrated medical home for our vets and their families. We need barrier-free housing for those who have lost limbs. We need to do more to reintegrate returning vets into civilian life. The reality is that we owe our vets—and their families—far more than we provide.

I’m writing this from Washington, DC, a month before we celebrate Memorial Day and remember those who died in service of our country. On the flight into our nation’s capital, I sat next to a young man returning from his tour of military duty. He seemed mature, upbeat, whole. But when I asked him about his experience, he responded: “Sir, I gotta tell you, what I saw was hell.”

Sam L was a roofer with an unfortunate penchant for alcohol. The combination turned tragic when he fell off a roof and incurred a traumatic brain injury. From Sam’s initial emergency management to the longer term rehabilitation, his care involved multiple providers: physicians, nurses, and pharmacists; occupational, speech, and physical therapists; psychologists, social workers, and substance abuse counselors, all coordinated by a family physician in our patient-centered medical home. Thanks to the collaborative care he received, Sam is sober and back up on roofs, looking healthier than ever before.

But we all know far too many patients who are not as lucky as Sam. Patients whose health care team did not collaborate, and whose outcomes were not maximized, as a result. It is these patients who remind me that it’s not just our health care system, but also the way health care professionals are educated, that requires radical retooling.

If we expect health professionals to have shared goals, we need to ensure that they are taught to collaborate and communicate effectively. Despite the challenges of differing accreditation and licensing standards, countless logistic details, and professional pride, we need to reengineer health education—starting now.

Here’s what I propose:

• Develop a common pre-professional pathway, starting in undergraduate school, to better prepare future health care providers to work collaboratively
• Provide training that emphasizes patient-oriented outcomes and wellness, rather than a sickness model of care
• Require future health care providers to take common courses in subjects that apply across disciplines, such as evidence-based medicine, patient-oriented communication, basic science, and physical assessment skills; integrate public health, population health, and preventive care into the curriculum.

I’m not suggesting that we eliminate professional disciplines, each of which has a rich history and a vital contribution to make. But I do think that physicians need to better understand the conceptual models underlying nursing and social work, say, and the special skills that pharmacists and dentists, among other health professionals, bring to the table.

I imagine a future in which all members of the health care team are prepared to collaborate and communicate for the good of our patients. I imagine a world in which teams like the one that Sam benefitted from are the norm—rather than the exception.

Sam L was a roofer with an unfortunate penchant for alcohol. The combination turned tragic when he fell off a roof and incurred a traumatic brain injury. From Sam’s initial emergency management to the longer term rehabilitation, his care involved multiple providers: physicians, nurses, and pharmacists; occupational, speech, and physical therapists; psychologists, social workers, and substance abuse counselors, all coordinated by a family physician in our patient-centered medical home. Thanks to the collaborative care he received, Sam is sober and back up on roofs, looking healthier than ever before.

But we all know far too many patients who are not as lucky as Sam. Patients whose health care team did not collaborate, and whose outcomes were not maximized, as a result. It is these patients who remind me that it’s not just our health care system, but also the way health care professionals are educated, that requires radical retooling.

If we expect health professionals to have shared goals, we need to ensure that they are taught to collaborate and communicate effectively. Despite the challenges of differing accreditation and licensing standards, countless logistic details, and professional pride, we need to reengineer health education—starting now.

Here’s what I propose:

• Develop a common pre-professional pathway, starting in undergraduate school, to better prepare future health care providers to work collaboratively
• Provide training that emphasizes patient-oriented outcomes and wellness, rather than a sickness model of care
• Require future health care providers to take common courses in subjects that apply across disciplines, such as evidence-based medicine, patient-oriented communication, basic science, and physical assessment skills; integrate public health, population health, and preventive care into the curriculum.

I’m not suggesting that we eliminate professional disciplines, each of which has a rich history and a vital contribution to make. But I do think that physicians need to better understand the conceptual models underlying nursing and social work, say, and the special skills that pharmacists and dentists, among other health professionals, bring to the table.

I imagine a future in which all members of the health care team are prepared to collaborate and communicate for the good of our patients. I imagine a world in which teams like the one that Sam benefitted from are the norm—rather than the exception.

Sam L was a roofer with an unfortunate penchant for alcohol. The combination turned tragic when he fell off a roof and incurred a traumatic brain injury. From Sam’s initial emergency management to the longer term rehabilitation, his care involved multiple providers: physicians, nurses, and pharmacists; occupational, speech, and physical therapists; psychologists, social workers, and substance abuse counselors, all coordinated by a family physician in our patient-centered medical home. Thanks to the collaborative care he received, Sam is sober and back up on roofs, looking healthier than ever before.

But we all know far too many patients who are not as lucky as Sam. Patients whose health care team did not collaborate, and whose outcomes were not maximized, as a result. It is these patients who remind me that it’s not just our health care system, but also the way health care professionals are educated, that requires radical retooling.

If we expect health professionals to have shared goals, we need to ensure that they are taught to collaborate and communicate effectively. Despite the challenges of differing accreditation and licensing standards, countless logistic details, and professional pride, we need to reengineer health education—starting now.

Here’s what I propose:

• Develop a common pre-professional pathway, starting in undergraduate school, to better prepare future health care providers to work collaboratively
• Provide training that emphasizes patient-oriented outcomes and wellness, rather than a sickness model of care
• Require future health care providers to take common courses in subjects that apply across disciplines, such as evidence-based medicine, patient-oriented communication, basic science, and physical assessment skills; integrate public health, population health, and preventive care into the curriculum.

I’m not suggesting that we eliminate professional disciplines, each of which has a rich history and a vital contribution to make. But I do think that physicians need to better understand the conceptual models underlying nursing and social work, say, and the special skills that pharmacists and dentists, among other health professionals, bring to the table.

I imagine a future in which all members of the health care team are prepared to collaborate and communicate for the good of our patients. I imagine a world in which teams like the one that Sam benefitted from are the norm—rather than the exception.

Who are you here to see? Do you still live on Lakefront Drive? Are you still with Medical Mutual? Do you have your insurance card?”

So begins another visit to my physician.

Don’t get me wrong, I really like and trust my doctor, and I understand the need for such basics. But given all of our discipline’s emphasis on teamwork, electronic health records, and patient satisfaction in recent years, I’m trying to figure out how patients got lost in—or left out of—what is supposed to be a patient-centered medical home.

I realize there are patient navigators, care management nurses, and a small army of other clinicians eager to assist me and ensure that I get patient satisfaction surveys, offers of new services, and reminders to keep my appointments. And it’s reassuring to know that there is someone in my doctor’s office who’s ready to administer a comprehensive pain scale if I so much as stub my toe. Still, I wish the patient experience could be more like a Burger King order—I want it my way!

Why can’t I use a Web-based scheduling system to make an appointment at a time that’s most convenient for me? How come I have to pay for parking? Why don’t I have a smart card that would streamline the check-in procedure so I don’t have to repeat the same information over and over again?

Come to think of it, why are doctors’ offices closed during lunch hour (or their phones switched to their service), at the very time working people can slip away for a quick doctor visit or make a phone call? And why is there a waiting room with those “helpful” videos on prostate cancer?

Instead of being tailored to the needs of patients, many medical practices have been designed for provider convenience—and to maximize profits. If even half of the resources typically used to devise a better billing process were invested in improving the patient experience, we’d be well on the way to creating patient-centered medical homes.

I know that some family physicians have been quite innovative in designing medical practices that are truly patient-centric. If you’re among them, I would love to hear from you. If you’re not, it’s time to get busy—and put the patient at the center of the patient-centered medical home.

Who are you here to see? Do you still live on Lakefront Drive? Are you still with Medical Mutual? Do you have your insurance card?”

So begins another visit to my physician.

Don’t get me wrong, I really like and trust my doctor, and I understand the need for such basics. But given all of our discipline’s emphasis on teamwork, electronic health records, and patient satisfaction in recent years, I’m trying to figure out how patients got lost in—or left out of—what is supposed to be a patient-centered medical home.

I realize there are patient navigators, care management nurses, and a small army of other clinicians eager to assist me and ensure that I get patient satisfaction surveys, offers of new services, and reminders to keep my appointments. And it’s reassuring to know that there is someone in my doctor’s office who’s ready to administer a comprehensive pain scale if I so much as stub my toe. Still, I wish the patient experience could be more like a Burger King order—I want it my way!

Why can’t I use a Web-based scheduling system to make an appointment at a time that’s most convenient for me? How come I have to pay for parking? Why don’t I have a smart card that would streamline the check-in procedure so I don’t have to repeat the same information over and over again?

Come to think of it, why are doctors’ offices closed during lunch hour (or their phones switched to their service), at the very time working people can slip away for a quick doctor visit or make a phone call? And why is there a waiting room with those “helpful” videos on prostate cancer?

Instead of being tailored to the needs of patients, many medical practices have been designed for provider convenience—and to maximize profits. If even half of the resources typically used to devise a better billing process were invested in improving the patient experience, we’d be well on the way to creating patient-centered medical homes.

I know that some family physicians have been quite innovative in designing medical practices that are truly patient-centric. If you’re among them, I would love to hear from you. If you’re not, it’s time to get busy—and put the patient at the center of the patient-centered medical home.

Who are you here to see? Do you still live on Lakefront Drive? Are you still with Medical Mutual? Do you have your insurance card?”

So begins another visit to my physician.

Don’t get me wrong, I really like and trust my doctor, and I understand the need for such basics. But given all of our discipline’s emphasis on teamwork, electronic health records, and patient satisfaction in recent years, I’m trying to figure out how patients got lost in—or left out of—what is supposed to be a patient-centered medical home.

I realize there are patient navigators, care management nurses, and a small army of other clinicians eager to assist me and ensure that I get patient satisfaction surveys, offers of new services, and reminders to keep my appointments. And it’s reassuring to know that there is someone in my doctor’s office who’s ready to administer a comprehensive pain scale if I so much as stub my toe. Still, I wish the patient experience could be more like a Burger King order—I want it my way!

Why can’t I use a Web-based scheduling system to make an appointment at a time that’s most convenient for me? How come I have to pay for parking? Why don’t I have a smart card that would streamline the check-in procedure so I don’t have to repeat the same information over and over again?

Come to think of it, why are doctors’ offices closed during lunch hour (or their phones switched to their service), at the very time working people can slip away for a quick doctor visit or make a phone call? And why is there a waiting room with those “helpful” videos on prostate cancer?

Instead of being tailored to the needs of patients, many medical practices have been designed for provider convenience—and to maximize profits. If even half of the resources typically used to devise a better billing process were invested in improving the patient experience, we’d be well on the way to creating patient-centered medical homes.

I know that some family physicians have been quite innovative in designing medical practices that are truly patient-centric. If you’re among them, I would love to hear from you. If you’re not, it’s time to get busy—and put the patient at the center of the patient-centered medical home.

It’s that time of year—top 10 movies, holiday book lists, and hopes for the future. Here, now, is my 2012 health care wish list.

10. Permanently solve Sustainable Growth Rate (SGR) mayhem. To avoid the time and money wasted on the annual ritual of rescinding cuts to Medicare payments to physicians, let’s own up to the challenge and fix the SGR dilemma for good.

9. Sufficiently fund the NIH. The economic payoff of strong biomedical science is impressive. Yet ongoing cuts to the NIH threaten a generation of researchers and keep us from reaping the benefits of the medical breakthroughs their work could provide.

8. Make medical “smart cards” mandatory. How come I can get money from a machine in Honduras, but I have to answer the same basic questions 3 times during a single medical encounter? Let’s require all health insurers, public and private, to put basic clinical information (a mini continuity-of-care record) on a card that is swiped at each visit—and stop worrying about “invasion of privacy.”

7. Stop the impending medical education crisis. Unless we invest in a system that favors primary care training and eliminates inequities, there will soon come a time when applicants for US residency programs outnumber residency positions.

6. Compare physician quality in a meaningful way. It’s time we focus on assessing outpatient care and physician quality using transparent, nationally vetted, and publicly reported measures.

5. Integrate primary and mental health care. Let’s provide incentives and initial capitalization to make this a reality—and ensure that every patient with both a chronic medical condition and a serious mental illness receives comprehensive care.

4. Pay us what we’re worth. Revalue primary care physician services, particularly E and M codes, to reflect the importance of preventive and chronic care. Start paying for care management and coordination, phone calls, and other non–face-to-face services.

3. Replace patient satisfaction surveys. Establish a national system for assessing the experiences of Medicare and Medicaid subscribers. It’s time to develop a validated tool to replace patient satisfaction surveys of dubious stringency.

2. Eliminate pharmacy benefit managers (my favorite target). In my experience, PBMs do precious little to enhance health care. It’s high time an investigative reporter took on this hidden detriment to our patients’ health.

And now, to No. 1. (Drum roll, please):

1. Establish a basic universal health care package for every US citizen. It’s time our nation caught up with other industrialized countries and began providing health care for all.

I suspect—actually, I know—that many of you won’t agree with the items on my list, especially No. 1, and will have completely different items on your 2012 wish list. I encourage you to let me know what they are. In the meantime, my best wishes for a healthy and prosperous New Year to you, your families, and your patients.

It’s that time of year—top 10 movies, holiday book lists, and hopes for the future. Here, now, is my 2012 health care wish list.

10. Permanently solve Sustainable Growth Rate (SGR) mayhem. To avoid the time and money wasted on the annual ritual of rescinding cuts to Medicare payments to physicians, let’s own up to the challenge and fix the SGR dilemma for good.

9. Sufficiently fund the NIH. The economic payoff of strong biomedical science is impressive. Yet ongoing cuts to the NIH threaten a generation of researchers and keep us from reaping the benefits of the medical breakthroughs their work could provide.

8. Make medical “smart cards” mandatory. How come I can get money from a machine in Honduras, but I have to answer the same basic questions 3 times during a single medical encounter? Let’s require all health insurers, public and private, to put basic clinical information (a mini continuity-of-care record) on a card that is swiped at each visit—and stop worrying about “invasion of privacy.”

7. Stop the impending medical education crisis. Unless we invest in a system that favors primary care training and eliminates inequities, there will soon come a time when applicants for US residency programs outnumber residency positions.

6. Compare physician quality in a meaningful way. It’s time we focus on assessing outpatient care and physician quality using transparent, nationally vetted, and publicly reported measures.

5. Integrate primary and mental health care. Let’s provide incentives and initial capitalization to make this a reality—and ensure that every patient with both a chronic medical condition and a serious mental illness receives comprehensive care.

4. Pay us what we’re worth. Revalue primary care physician services, particularly E and M codes, to reflect the importance of preventive and chronic care. Start paying for care management and coordination, phone calls, and other non–face-to-face services.

3. Replace patient satisfaction surveys. Establish a national system for assessing the experiences of Medicare and Medicaid subscribers. It’s time to develop a validated tool to replace patient satisfaction surveys of dubious stringency.

2. Eliminate pharmacy benefit managers (my favorite target). In my experience, PBMs do precious little to enhance health care. It’s high time an investigative reporter took on this hidden detriment to our patients’ health.

And now, to No. 1. (Drum roll, please):

1. Establish a basic universal health care package for every US citizen. It’s time our nation caught up with other industrialized countries and began providing health care for all.

I suspect—actually, I know—that many of you won’t agree with the items on my list, especially No. 1, and will have completely different items on your 2012 wish list. I encourage you to let me know what they are. In the meantime, my best wishes for a healthy and prosperous New Year to you, your families, and your patients.

It’s that time of year—top 10 movies, holiday book lists, and hopes for the future. Here, now, is my 2012 health care wish list.

10. Permanently solve Sustainable Growth Rate (SGR) mayhem. To avoid the time and money wasted on the annual ritual of rescinding cuts to Medicare payments to physicians, let’s own up to the challenge and fix the SGR dilemma for good.

9. Sufficiently fund the NIH. The economic payoff of strong biomedical science is impressive. Yet ongoing cuts to the NIH threaten a generation of researchers and keep us from reaping the benefits of the medical breakthroughs their work could provide.

8. Make medical “smart cards” mandatory. How come I can get money from a machine in Honduras, but I have to answer the same basic questions 3 times during a single medical encounter? Let’s require all health insurers, public and private, to put basic clinical information (a mini continuity-of-care record) on a card that is swiped at each visit—and stop worrying about “invasion of privacy.”

7. Stop the impending medical education crisis. Unless we invest in a system that favors primary care training and eliminates inequities, there will soon come a time when applicants for US residency programs outnumber residency positions.

6. Compare physician quality in a meaningful way. It’s time we focus on assessing outpatient care and physician quality using transparent, nationally vetted, and publicly reported measures.

5. Integrate primary and mental health care. Let’s provide incentives and initial capitalization to make this a reality—and ensure that every patient with both a chronic medical condition and a serious mental illness receives comprehensive care.

4. Pay us what we’re worth. Revalue primary care physician services, particularly E and M codes, to reflect the importance of preventive and chronic care. Start paying for care management and coordination, phone calls, and other non–face-to-face services.

3. Replace patient satisfaction surveys. Establish a national system for assessing the experiences of Medicare and Medicaid subscribers. It’s time to develop a validated tool to replace patient satisfaction surveys of dubious stringency.

2. Eliminate pharmacy benefit managers (my favorite target). In my experience, PBMs do precious little to enhance health care. It’s high time an investigative reporter took on this hidden detriment to our patients’ health.

And now, to No. 1. (Drum roll, please):

1. Establish a basic universal health care package for every US citizen. It’s time our nation caught up with other industrialized countries and began providing health care for all.

I suspect—actually, I know—that many of you won’t agree with the items on my list, especially No. 1, and will have completely different items on your 2012 wish list. I encourage you to let me know what they are. In the meantime, my best wishes for a healthy and prosperous New Year to you, your families, and your patients.

I was so "pleased" when the letter arrived from my personal care manager, informing me that she was "dedicated to effectively meeting my health care needs." The letter writer promised to help me find more energy to devote to hobbies, manage my pain, achieve a healthy weight, and get a handle on stress.

And to think, I didn’t know I was in pain or overweight.

Three letters later (the care manager assigned to me is quite persistent), I find my stress level increasing just from trying to keep up with her relentless campaign on my behalf. What little time I did have for hobbies is now taken up with opening mail from my new best friend. The FAQs that accompany her letters explain that "since doctors may be hard to reach … we work with your health care providers to reinforce their prescribed plan of care." Of course, my care manager is only available Monday through Friday 9 to 5 Eastern Standard Time. And, as far as I can tell, Myrna (Is it OK to call my care manager by her first name?) has yet to contact my busy doctor. I guess she’s busy, too.

Perhaps you could help me break the news to Myrna and the outreach company that employs her that I really don’t want a faceless care manager of unknown competence to assist me. That I already have to work with a pharmacy benefit manager who has reached out beyond numerous time zones to speak with me (but whom I can barely understand) and a prior authorizations specialist whose thick local "accent" is not much easier to decipher. And that I’m happy as pie to have my family physician and his health care team manage my care.

So, Myrna, I hope you won’t mind if I ignore your missives, save time for a walk, and continue to rely on the best care manager in the world: my family physician.

I was so "pleased" when the letter arrived from my personal care manager, informing me that she was "dedicated to effectively meeting my health care needs." The letter writer promised to help me find more energy to devote to hobbies, manage my pain, achieve a healthy weight, and get a handle on stress.

And to think, I didn’t know I was in pain or overweight.

Three letters later (the care manager assigned to me is quite persistent), I find my stress level increasing just from trying to keep up with her relentless campaign on my behalf. What little time I did have for hobbies is now taken up with opening mail from my new best friend. The FAQs that accompany her letters explain that "since doctors may be hard to reach … we work with your health care providers to reinforce their prescribed plan of care." Of course, my care manager is only available Monday through Friday 9 to 5 Eastern Standard Time. And, as far as I can tell, Myrna (Is it OK to call my care manager by her first name?) has yet to contact my busy doctor. I guess she’s busy, too.

Perhaps you could help me break the news to Myrna and the outreach company that employs her that I really don’t want a faceless care manager of unknown competence to assist me. That I already have to work with a pharmacy benefit manager who has reached out beyond numerous time zones to speak with me (but whom I can barely understand) and a prior authorizations specialist whose thick local "accent" is not much easier to decipher. And that I’m happy as pie to have my family physician and his health care team manage my care.

So, Myrna, I hope you won’t mind if I ignore your missives, save time for a walk, and continue to rely on the best care manager in the world: my family physician.

I was so "pleased" when the letter arrived from my personal care manager, informing me that she was "dedicated to effectively meeting my health care needs." The letter writer promised to help me find more energy to devote to hobbies, manage my pain, achieve a healthy weight, and get a handle on stress.

And to think, I didn’t know I was in pain or overweight.

Three letters later (the care manager assigned to me is quite persistent), I find my stress level increasing just from trying to keep up with her relentless campaign on my behalf. What little time I did have for hobbies is now taken up with opening mail from my new best friend. The FAQs that accompany her letters explain that "since doctors may be hard to reach … we work with your health care providers to reinforce their prescribed plan of care." Of course, my care manager is only available Monday through Friday 9 to 5 Eastern Standard Time. And, as far as I can tell, Myrna (Is it OK to call my care manager by her first name?) has yet to contact my busy doctor. I guess she’s busy, too.

Perhaps you could help me break the news to Myrna and the outreach company that employs her that I really don’t want a faceless care manager of unknown competence to assist me. That I already have to work with a pharmacy benefit manager who has reached out beyond numerous time zones to speak with me (but whom I can barely understand) and a prior authorizations specialist whose thick local "accent" is not much easier to decipher. And that I’m happy as pie to have my family physician and his health care team manage my care.

So, Myrna, I hope you won’t mind if I ignore your missives, save time for a walk, and continue to rely on the best care manager in the world: my family physician.

Recently I had the opportunity to participate in the American Academy of Family Physicians (AAFP)’s Primary Care Valuation Task Force, which is tackling the issue of value and payment for primary care services by the Centers for Medicare and Medicaid Services (CMS). This all-star cast discussed many innovative means of improving the current Resource-Based Relative Value Scale (RVS) and correcting deficiencies in the American Medical Association/Specialty Society Relative Value Update Committee, or RUC. Enhancing payment for existing evaluation and management codes, adding payments for tasks such as care management, and increasing transparency and primary care representation at RUC were among the options we discussed.

Frankly, I worry that our wishes will be granted, but fundamental disparities in physician payment will persist.

One of the basic tenets of quality improvement is to eliminate work-arounds and processes that are dysfunctional and don’t add value. RVS and RUC are two such anachronisms; both have been flawed from their inception. As some individuals argued at the AAFP’s Annual Scientific Assembly Congress of Delegates, there has never been a more auspicious time to speak truth to power and walk away from the RUC table.

I applaud the AAFP’s wisdom in exploring modifications to RUC and alternatives to the existing RVS, but I firmly believe that we need to make a more potent political statement. The time for reasoned argument and careful consideration is past. While I suspect that the recently filed lawsuit against CMS will be futile, at least it is calling attention to the shackles of payment inequity that primary care physicians face.

It is time for the AAFP to walk away from the RUC and demand real payment reform. The time has come for a new accountability to primary care physicians and the public to ensure that all Americans get the care they deserve.

Recently I had the opportunity to participate in the American Academy of Family Physicians (AAFP)’s Primary Care Valuation Task Force, which is tackling the issue of value and payment for primary care services by the Centers for Medicare and Medicaid Services (CMS). This all-star cast discussed many innovative means of improving the current Resource-Based Relative Value Scale (RVS) and correcting deficiencies in the American Medical Association/Specialty Society Relative Value Update Committee, or RUC. Enhancing payment for existing evaluation and management codes, adding payments for tasks such as care management, and increasing transparency and primary care representation at RUC were among the options we discussed.

Frankly, I worry that our wishes will be granted, but fundamental disparities in physician payment will persist.

One of the basic tenets of quality improvement is to eliminate work-arounds and processes that are dysfunctional and don’t add value. RVS and RUC are two such anachronisms; both have been flawed from their inception. As some individuals argued at the AAFP’s Annual Scientific Assembly Congress of Delegates, there has never been a more auspicious time to speak truth to power and walk away from the RUC table.

I applaud the AAFP’s wisdom in exploring modifications to RUC and alternatives to the existing RVS, but I firmly believe that we need to make a more potent political statement. The time for reasoned argument and careful consideration is past. While I suspect that the recently filed lawsuit against CMS will be futile, at least it is calling attention to the shackles of payment inequity that primary care physicians face.

It is time for the AAFP to walk away from the RUC and demand real payment reform. The time has come for a new accountability to primary care physicians and the public to ensure that all Americans get the care they deserve.

Recently I had the opportunity to participate in the American Academy of Family Physicians (AAFP)’s Primary Care Valuation Task Force, which is tackling the issue of value and payment for primary care services by the Centers for Medicare and Medicaid Services (CMS). This all-star cast discussed many innovative means of improving the current Resource-Based Relative Value Scale (RVS) and correcting deficiencies in the American Medical Association/Specialty Society Relative Value Update Committee, or RUC. Enhancing payment for existing evaluation and management codes, adding payments for tasks such as care management, and increasing transparency and primary care representation at RUC were among the options we discussed.

Frankly, I worry that our wishes will be granted, but fundamental disparities in physician payment will persist.

One of the basic tenets of quality improvement is to eliminate work-arounds and processes that are dysfunctional and don’t add value. RVS and RUC are two such anachronisms; both have been flawed from their inception. As some individuals argued at the AAFP’s Annual Scientific Assembly Congress of Delegates, there has never been a more auspicious time to speak truth to power and walk away from the RUC table.

I applaud the AAFP’s wisdom in exploring modifications to RUC and alternatives to the existing RVS, but I firmly believe that we need to make a more potent political statement. The time for reasoned argument and careful consideration is past. While I suspect that the recently filed lawsuit against CMS will be futile, at least it is calling attention to the shackles of payment inequity that primary care physicians face.

It is time for the AAFP to walk away from the RUC and demand real payment reform. The time has come for a new accountability to primary care physicians and the public to ensure that all Americans get the care they deserve.