Jeff Susman, MD

The solo physician holds a special place in the hearts of family physicians. Whether we think of the watchful doctor at the bedside of a feverish child or the tireless rural doctor on snow-covered roads, we romanticize the past, with images colored by TV doctors like Marcus Welby or Joel Fleishman (before E.R., St. Elsewhere, and Scrubs provided a more checkered perspective). While we wistfully remember practitioners of the past, our government seems to be doing its best to force clinicians into a homogenized practice model. And that’s very bad for our country.

As of 2008, according to the American Academy of Family Physicians, less than 18% of FPs described themselves as solo practitioners (another 8% were in a partnership with another physician). And recent policies, from dwindling support for rural clinicians to mandates for EHRs and the push for accountable care organizations, are further contributing to the solo practitioner’s demise. Economic decay and decades of decline have left rural communities and inner cities particularly ill-equipped to support sustainable practices. That’s a tragedy for America.

While most young doctors are joining large integrated groups, which promise better balance and predictable schedules with little, if any, call, the extraordinary, albeit sometimes idiosyncratic, approach to medicine practiced by solo FPs today is often overlooked. Nimble (no bureaucracy to consult when changing policies), in touch (no one knows the local population better), and increasingly likely to use EHRs and health information exchanges (like physicians in larger groups), these doctors are paving the way to a brighter future. Whether they’re focusing on lean design, integrating concepts of public health, or creating environments that foster holistic healing, I see a lot of innovation and passion among solo practitioners who aren’t afraid to take risks or fight for their patients. Moreover, practices with only one or two physicians are frequently on the cutting edge of change and leaders in providing quality health care. What’s more American than that?

Here’s the bottom line: In addition to supporting the Kaiser Permanentes and Geisingers of the world, we need to help doctors working alone and in small practices thrive. To do that, we need funding for infrastructure, relief from needless regulation, and new opportunities for virtual networking and collegiality. And make no mistake: The investment will pay off, even in these tough economic times. Maybe then we’ll be fortunate enough to see a resurgence of the solo family physician.

The solo physician holds a special place in the hearts of family physicians. Whether we think of the watchful doctor at the bedside of a feverish child or the tireless rural doctor on snow-covered roads, we romanticize the past, with images colored by TV doctors like Marcus Welby or Joel Fleishman (before E.R., St. Elsewhere, and Scrubs provided a more checkered perspective). While we wistfully remember practitioners of the past, our government seems to be doing its best to force clinicians into a homogenized practice model. And that’s very bad for our country.

As of 2008, according to the American Academy of Family Physicians, less than 18% of FPs described themselves as solo practitioners (another 8% were in a partnership with another physician). And recent policies, from dwindling support for rural clinicians to mandates for EHRs and the push for accountable care organizations, are further contributing to the solo practitioner’s demise. Economic decay and decades of decline have left rural communities and inner cities particularly ill-equipped to support sustainable practices. That’s a tragedy for America.

While most young doctors are joining large integrated groups, which promise better balance and predictable schedules with little, if any, call, the extraordinary, albeit sometimes idiosyncratic, approach to medicine practiced by solo FPs today is often overlooked. Nimble (no bureaucracy to consult when changing policies), in touch (no one knows the local population better), and increasingly likely to use EHRs and health information exchanges (like physicians in larger groups), these doctors are paving the way to a brighter future. Whether they’re focusing on lean design, integrating concepts of public health, or creating environments that foster holistic healing, I see a lot of innovation and passion among solo practitioners who aren’t afraid to take risks or fight for their patients. Moreover, practices with only one or two physicians are frequently on the cutting edge of change and leaders in providing quality health care. What’s more American than that?

Here’s the bottom line: In addition to supporting the Kaiser Permanentes and Geisingers of the world, we need to help doctors working alone and in small practices thrive. To do that, we need funding for infrastructure, relief from needless regulation, and new opportunities for virtual networking and collegiality. And make no mistake: The investment will pay off, even in these tough economic times. Maybe then we’ll be fortunate enough to see a resurgence of the solo family physician.

The solo physician holds a special place in the hearts of family physicians. Whether we think of the watchful doctor at the bedside of a feverish child or the tireless rural doctor on snow-covered roads, we romanticize the past, with images colored by TV doctors like Marcus Welby or Joel Fleishman (before E.R., St. Elsewhere, and Scrubs provided a more checkered perspective). While we wistfully remember practitioners of the past, our government seems to be doing its best to force clinicians into a homogenized practice model. And that’s very bad for our country.

As of 2008, according to the American Academy of Family Physicians, less than 18% of FPs described themselves as solo practitioners (another 8% were in a partnership with another physician). And recent policies, from dwindling support for rural clinicians to mandates for EHRs and the push for accountable care organizations, are further contributing to the solo practitioner’s demise. Economic decay and decades of decline have left rural communities and inner cities particularly ill-equipped to support sustainable practices. That’s a tragedy for America.

While most young doctors are joining large integrated groups, which promise better balance and predictable schedules with little, if any, call, the extraordinary, albeit sometimes idiosyncratic, approach to medicine practiced by solo FPs today is often overlooked. Nimble (no bureaucracy to consult when changing policies), in touch (no one knows the local population better), and increasingly likely to use EHRs and health information exchanges (like physicians in larger groups), these doctors are paving the way to a brighter future. Whether they’re focusing on lean design, integrating concepts of public health, or creating environments that foster holistic healing, I see a lot of innovation and passion among solo practitioners who aren’t afraid to take risks or fight for their patients. Moreover, practices with only one or two physicians are frequently on the cutting edge of change and leaders in providing quality health care. What’s more American than that?

Here’s the bottom line: In addition to supporting the Kaiser Permanentes and Geisingers of the world, we need to help doctors working alone and in small practices thrive. To do that, we need funding for infrastructure, relief from needless regulation, and new opportunities for virtual networking and collegiality. And make no mistake: The investment will pay off, even in these tough economic times. Maybe then we’ll be fortunate enough to see a resurgence of the solo family physician.

My daughter Katie recently asked me if a medication could be causing her friend’s light-headedness. “Well,” I opined, “That certainly wouldn’t be a common side effect.”

Then I made the mistake of consulting the PDR and reviewing the package insert.

I found the usual suspects—nausea, fatigue, and Yes, dizziness—and several oddball side effects, like increased sweating and vision disturbances, that I figured were flukes. And finally, “just a few” other problems to watch for. I gave up counting at 50.

Suffice it to say, this litany of side effects is useless to the average consumer. Providing a data dump of every single problem ever reported in a clinical trial leads to information overload. It’s also misleading. While I guess it’s a reflection of our litigious society, shouldn’t the point of package inserts be to effectively inform patients and give them the guidance they need?

Although package inserts underwent a redesign in 2006, it seems that the FDA commissioners failed to inject some common sense. I have to believe that anyone doing even a modicum of consumer research would find that our current package inserts are worse than no information at all.

How about starting over and developing a schema, such as:

• common side effects which are often related;
• uncommon, but serious side effects; and
• side effects that are occasionally reported but are probably unrelated to medication use.

While we’re at it, how about providing an expanded Medication Guide for every prescription drug that’s dispensed?

So, Katie, the answer is that light-headedness, increased sweating, vision disturbances, and a whole bunch of other side effects are there in black and white. Tell your friend to talk to her physician and, if possible, to stop taking the medicine and see if the dizziness disappears.

My daughter Katie recently asked me if a medication could be causing her friend’s light-headedness. “Well,” I opined, “That certainly wouldn’t be a common side effect.”

Then I made the mistake of consulting the PDR and reviewing the package insert.

I found the usual suspects—nausea, fatigue, and Yes, dizziness—and several oddball side effects, like increased sweating and vision disturbances, that I figured were flukes. And finally, “just a few” other problems to watch for. I gave up counting at 50.

Suffice it to say, this litany of side effects is useless to the average consumer. Providing a data dump of every single problem ever reported in a clinical trial leads to information overload. It’s also misleading. While I guess it’s a reflection of our litigious society, shouldn’t the point of package inserts be to effectively inform patients and give them the guidance they need?

Although package inserts underwent a redesign in 2006, it seems that the FDA commissioners failed to inject some common sense. I have to believe that anyone doing even a modicum of consumer research would find that our current package inserts are worse than no information at all.

How about starting over and developing a schema, such as:

• common side effects which are often related;
• uncommon, but serious side effects; and
• side effects that are occasionally reported but are probably unrelated to medication use.

While we’re at it, how about providing an expanded Medication Guide for every prescription drug that’s dispensed?

So, Katie, the answer is that light-headedness, increased sweating, vision disturbances, and a whole bunch of other side effects are there in black and white. Tell your friend to talk to her physician and, if possible, to stop taking the medicine and see if the dizziness disappears.

My daughter Katie recently asked me if a medication could be causing her friend’s light-headedness. “Well,” I opined, “That certainly wouldn’t be a common side effect.”

Then I made the mistake of consulting the PDR and reviewing the package insert.

I found the usual suspects—nausea, fatigue, and Yes, dizziness—and several oddball side effects, like increased sweating and vision disturbances, that I figured were flukes. And finally, “just a few” other problems to watch for. I gave up counting at 50.

Suffice it to say, this litany of side effects is useless to the average consumer. Providing a data dump of every single problem ever reported in a clinical trial leads to information overload. It’s also misleading. While I guess it’s a reflection of our litigious society, shouldn’t the point of package inserts be to effectively inform patients and give them the guidance they need?

Although package inserts underwent a redesign in 2006, it seems that the FDA commissioners failed to inject some common sense. I have to believe that anyone doing even a modicum of consumer research would find that our current package inserts are worse than no information at all.

How about starting over and developing a schema, such as:

• common side effects which are often related;
• uncommon, but serious side effects; and
• side effects that are occasionally reported but are probably unrelated to medication use.

While we’re at it, how about providing an expanded Medication Guide for every prescription drug that’s dispensed?

So, Katie, the answer is that light-headedness, increased sweating, vision disturbances, and a whole bunch of other side effects are there in black and white. Tell your friend to talk to her physician and, if possible, to stop taking the medicine and see if the dizziness disappears.

Authorizations to insurers, questions about medications, a possible allergic reaction—calls regarding refills are typically mundane. Then there are the patients who don’t call and who miss appointments, sometimes repeatedly. For these individuals, I would routinely write a prescription for a month’s supply, and suggest that they return promptly for follow-up. I imagine many of you do the same.

Recent experience suggests it is time to rethink this practice.

Between pharmacy benefit manager snafus, patients rationing pills because they can’t afford to buy more, and a host of logistic challenges, I figure it takes a Herculean effort simply for patients to take their medication as directed. It finally dawned on me that we may be doing more harm than good by adding to the barriers between patients and their prescription drugs.

Sure, there are reasons to regularly follow up—monitoring for adverse effects and assessing response to therapy, particularly with new prescriptions or recently increased doses. But how many individuals with stable hypothyroidism, hypertension, or even type 2 diabetes need more than yearly visits? And what evidence do we have that quarterly checks enhance adherence?

Are we better off refusing to authorize a refill and making patients jump through hoops so they can continue to take their medications, or should we provide a simple refill—particularly when we know that more than half of our patients aren’t taking them as prescribed? I’m convinced that most of our efforts—or haranguing—are in vain, at best.

So why not make it easier on patients and write a year’s prescription for most routine medications? I suspect our staff and our patients will appreciate this approach. When I’m the patient, I know I do.

Authorizations to insurers, questions about medications, a possible allergic reaction—calls regarding refills are typically mundane. Then there are the patients who don’t call and who miss appointments, sometimes repeatedly. For these individuals, I would routinely write a prescription for a month’s supply, and suggest that they return promptly for follow-up. I imagine many of you do the same.

Recent experience suggests it is time to rethink this practice.

Between pharmacy benefit manager snafus, patients rationing pills because they can’t afford to buy more, and a host of logistic challenges, I figure it takes a Herculean effort simply for patients to take their medication as directed. It finally dawned on me that we may be doing more harm than good by adding to the barriers between patients and their prescription drugs.

Sure, there are reasons to regularly follow up—monitoring for adverse effects and assessing response to therapy, particularly with new prescriptions or recently increased doses. But how many individuals with stable hypothyroidism, hypertension, or even type 2 diabetes need more than yearly visits? And what evidence do we have that quarterly checks enhance adherence?

Are we better off refusing to authorize a refill and making patients jump through hoops so they can continue to take their medications, or should we provide a simple refill—particularly when we know that more than half of our patients aren’t taking them as prescribed? I’m convinced that most of our efforts—or haranguing—are in vain, at best.

So why not make it easier on patients and write a year’s prescription for most routine medications? I suspect our staff and our patients will appreciate this approach. When I’m the patient, I know I do.

Authorizations to insurers, questions about medications, a possible allergic reaction—calls regarding refills are typically mundane. Then there are the patients who don’t call and who miss appointments, sometimes repeatedly. For these individuals, I would routinely write a prescription for a month’s supply, and suggest that they return promptly for follow-up. I imagine many of you do the same.

Recent experience suggests it is time to rethink this practice.

Between pharmacy benefit manager snafus, patients rationing pills because they can’t afford to buy more, and a host of logistic challenges, I figure it takes a Herculean effort simply for patients to take their medication as directed. It finally dawned on me that we may be doing more harm than good by adding to the barriers between patients and their prescription drugs.

Sure, there are reasons to regularly follow up—monitoring for adverse effects and assessing response to therapy, particularly with new prescriptions or recently increased doses. But how many individuals with stable hypothyroidism, hypertension, or even type 2 diabetes need more than yearly visits? And what evidence do we have that quarterly checks enhance adherence?

Are we better off refusing to authorize a refill and making patients jump through hoops so they can continue to take their medications, or should we provide a simple refill—particularly when we know that more than half of our patients aren’t taking them as prescribed? I’m convinced that most of our efforts—or haranguing—are in vain, at best.

So why not make it easier on patients and write a year’s prescription for most routine medications? I suspect our staff and our patients will appreciate this approach. When I’m the patient, I know I do.

On April 13—a day before I sat down to write this editorial—the US House of Representatives passed HR 1217, a bill that, if signed into law, would repeal the Health Reform Prevention and Public Health Fund. This fund—developed under the auspices of the Patient Protection and Affordable Care Act—has given Health and Human Services Secretary Kathleen Sebelius the latitude to award more than $500 million in grants to states and communities. In addition, another $750 million has been allocated for the oversight of preventive services programs.

Opponents of the public health fund have characterized it as a slush fund without adequate oversight. Before condemning it, I would urge our elected officials (and primary care physicians) to consider the services this fund supports:

• training and development of primary care providers to use evidence-based interventions to address tobacco control, obesity prevention, and HIV-related health disparities
• integration of primary care and behavioral health care
• promotion of healthy lifestyles and activities aimed at reducing obesity-related conditions and costs, including the First Lady’s “Let’s Move!” initiative
• implementation of anti-tobacco media campaigns, telephone-based smoking cessation services, and outreach programs targeting vulnerable populations
• provision of grants to increase the capacity of epidemiology and laboratory services to prevent, detect, and respond to infectious disease outbreaks
• strengthening the Centers for Disease Control and Prevention by supporting community services and expanding public health workforce programs and public involvement
• training public health providers to advance preventive medicine and health promotion and improve the access and quality of health services in medically underserved communities.

Although HR 1217 passed the House by a vote of 236 to 183, the legislation is expected to die in the Senate. Here’s hoping that the Prevention and Public Health Fund—an investment in our nation’s future—prevails.

On April 13—a day before I sat down to write this editorial—the US House of Representatives passed HR 1217, a bill that, if signed into law, would repeal the Health Reform Prevention and Public Health Fund. This fund—developed under the auspices of the Patient Protection and Affordable Care Act—has given Health and Human Services Secretary Kathleen Sebelius the latitude to award more than $500 million in grants to states and communities. In addition, another $750 million has been allocated for the oversight of preventive services programs.

Opponents of the public health fund have characterized it as a slush fund without adequate oversight. Before condemning it, I would urge our elected officials (and primary care physicians) to consider the services this fund supports:

• training and development of primary care providers to use evidence-based interventions to address tobacco control, obesity prevention, and HIV-related health disparities
• integration of primary care and behavioral health care
• promotion of healthy lifestyles and activities aimed at reducing obesity-related conditions and costs, including the First Lady’s “Let’s Move!” initiative
• implementation of anti-tobacco media campaigns, telephone-based smoking cessation services, and outreach programs targeting vulnerable populations
• provision of grants to increase the capacity of epidemiology and laboratory services to prevent, detect, and respond to infectious disease outbreaks
• strengthening the Centers for Disease Control and Prevention by supporting community services and expanding public health workforce programs and public involvement
• training public health providers to advance preventive medicine and health promotion and improve the access and quality of health services in medically underserved communities.

Although HR 1217 passed the House by a vote of 236 to 183, the legislation is expected to die in the Senate. Here’s hoping that the Prevention and Public Health Fund—an investment in our nation’s future—prevails.

On April 13—a day before I sat down to write this editorial—the US House of Representatives passed HR 1217, a bill that, if signed into law, would repeal the Health Reform Prevention and Public Health Fund. This fund—developed under the auspices of the Patient Protection and Affordable Care Act—has given Health and Human Services Secretary Kathleen Sebelius the latitude to award more than $500 million in grants to states and communities. In addition, another $750 million has been allocated for the oversight of preventive services programs.

Opponents of the public health fund have characterized it as a slush fund without adequate oversight. Before condemning it, I would urge our elected officials (and primary care physicians) to consider the services this fund supports:

• training and development of primary care providers to use evidence-based interventions to address tobacco control, obesity prevention, and HIV-related health disparities
• integration of primary care and behavioral health care
• promotion of healthy lifestyles and activities aimed at reducing obesity-related conditions and costs, including the First Lady’s “Let’s Move!” initiative
• implementation of anti-tobacco media campaigns, telephone-based smoking cessation services, and outreach programs targeting vulnerable populations
• provision of grants to increase the capacity of epidemiology and laboratory services to prevent, detect, and respond to infectious disease outbreaks
• strengthening the Centers for Disease Control and Prevention by supporting community services and expanding public health workforce programs and public involvement
• training public health providers to advance preventive medicine and health promotion and improve the access and quality of health services in medically underserved communities.

Although HR 1217 passed the House by a vote of 236 to 183, the legislation is expected to die in the Senate. Here’s hoping that the Prevention and Public Health Fund—an investment in our nation’s future—prevails.

“I can’t understand why you didn’t even give my son an interview. After all we’ve done….”

So begins another call from a disgruntled donor. I patiently explain that I’m purposefully removed from the admissions process and that many factors go into decisions about medical school admission. Often, I tactfully suggest that the caller talk to his son (or daughter) about that “little incident” in college, or his grade point average (GPA). (What I’m tempted to say is, “You can’t buy a seat in medical school.”)

Some acceptance decisions, of course, are easy. So many others are not. We get thousands of candidates each year who are accomplished, articulate, and affable. The simplest approach would be to skim the top of the applicant pool. But great grades (and test scores) don’t guarantee great graduates. Doctors don’t take multiple-choice exams for a living, and there’s little evidence linking National Board of Medical Examiners scores to performance in practice.

Medical schools (particularly public institutions) have a stewardship role: to guarantee student diversity and train doctors who will diligently serve the public—all the public. The nation needs physicians who will care for prisoners, the chronically mentally ill, the homeless, our rural and urban underserved populations, and the transgendered. I, for one, am willing to risk a few more student failures in the quest to fulfill our mission.

I’m reminded of one of our students who, until a few years ago, thought a career in sports was his only way out of the inner city. “I never thought of medical school,” he says. “I didn’t even know how to create a resume or apply.” With encouragement from advisors and time spent in a post-baccalaureate program to improve his GPA and complete medical school requirements, he gained admission. I am delighted that this thoughtful and articulate student will soon be a physician, one who plans to practice in an inner city like the one he grew up in.

To attract more minority students and build the diverse physician workforce our country needs, we must create an educational system that offers opportunities to all children, and serves as a pipeline from elementary school to medical practice.

Then, students from all walks of life can earn—not buy—a seat in medical school.

“I can’t understand why you didn’t even give my son an interview. After all we’ve done….”

So begins another call from a disgruntled donor. I patiently explain that I’m purposefully removed from the admissions process and that many factors go into decisions about medical school admission. Often, I tactfully suggest that the caller talk to his son (or daughter) about that “little incident” in college, or his grade point average (GPA). (What I’m tempted to say is, “You can’t buy a seat in medical school.”)

Some acceptance decisions, of course, are easy. So many others are not. We get thousands of candidates each year who are accomplished, articulate, and affable. The simplest approach would be to skim the top of the applicant pool. But great grades (and test scores) don’t guarantee great graduates. Doctors don’t take multiple-choice exams for a living, and there’s little evidence linking National Board of Medical Examiners scores to performance in practice.

Medical schools (particularly public institutions) have a stewardship role: to guarantee student diversity and train doctors who will diligently serve the public—all the public. The nation needs physicians who will care for prisoners, the chronically mentally ill, the homeless, our rural and urban underserved populations, and the transgendered. I, for one, am willing to risk a few more student failures in the quest to fulfill our mission.

I’m reminded of one of our students who, until a few years ago, thought a career in sports was his only way out of the inner city. “I never thought of medical school,” he says. “I didn’t even know how to create a resume or apply.” With encouragement from advisors and time spent in a post-baccalaureate program to improve his GPA and complete medical school requirements, he gained admission. I am delighted that this thoughtful and articulate student will soon be a physician, one who plans to practice in an inner city like the one he grew up in.

To attract more minority students and build the diverse physician workforce our country needs, we must create an educational system that offers opportunities to all children, and serves as a pipeline from elementary school to medical practice.

Then, students from all walks of life can earn—not buy—a seat in medical school.

“I can’t understand why you didn’t even give my son an interview. After all we’ve done….”

So begins another call from a disgruntled donor. I patiently explain that I’m purposefully removed from the admissions process and that many factors go into decisions about medical school admission. Often, I tactfully suggest that the caller talk to his son (or daughter) about that “little incident” in college, or his grade point average (GPA). (What I’m tempted to say is, “You can’t buy a seat in medical school.”)

Some acceptance decisions, of course, are easy. So many others are not. We get thousands of candidates each year who are accomplished, articulate, and affable. The simplest approach would be to skim the top of the applicant pool. But great grades (and test scores) don’t guarantee great graduates. Doctors don’t take multiple-choice exams for a living, and there’s little evidence linking National Board of Medical Examiners scores to performance in practice.

Medical schools (particularly public institutions) have a stewardship role: to guarantee student diversity and train doctors who will diligently serve the public—all the public. The nation needs physicians who will care for prisoners, the chronically mentally ill, the homeless, our rural and urban underserved populations, and the transgendered. I, for one, am willing to risk a few more student failures in the quest to fulfill our mission.

I’m reminded of one of our students who, until a few years ago, thought a career in sports was his only way out of the inner city. “I never thought of medical school,” he says. “I didn’t even know how to create a resume or apply.” With encouragement from advisors and time spent in a post-baccalaureate program to improve his GPA and complete medical school requirements, he gained admission. I am delighted that this thoughtful and articulate student will soon be a physician, one who plans to practice in an inner city like the one he grew up in.

To attract more minority students and build the diverse physician workforce our country needs, we must create an educational system that offers opportunities to all children, and serves as a pipeline from elementary school to medical practice.

Then, students from all walks of life can earn—not buy—a seat in medical school.

Accountable care organizations (ACOs), the latest attempt in a storied effort to stabilize spiraling health care costs, are a policy wonk’s dream of a solution to America’s health care challenges. But is the concept a fad or a real game changer?

Proponents of ACOs claim that global reimbursement for comprehensive service delivery—rather than a piecemeal approach to costly services—will result in improved care and higher value. Tightly integrated networks such as Kaiser and Geisinger, say supporters, are models of the efficiency and effectiveness ACOs will provide. Drivers of this revolution include CMS, cash-strapped states, and legions of insurers looking for the next big thing.

Skeptics, however, see this as déjà vu all over again—citing the disintegration of such managed care marvels as capitation, tightly controlled panels, and the alignment of patients, physicians, and hospitals. Critics also claim that the public has little appetite for narrowly defined networks. In addition, they say the challenges of developing effective and legal mechanisms of cooperation are daunting.

Who’s right?

I suspect that very few health systems, provider groups, or independent practice associations (IPAs) have the technical expertise, organizational culture, or will to undergo this sweeping transformation. While today’s physicians may be more willing to be employed by large health systems, how many systems are willing to share governance in a meaningful way, assure an appropriate balance of primary and specialty care, and give up their addiction to the star wars of medical technology? How many groups of specialty surgeons and family physicians are likely to work together? And how many truly effective IPAs have lasted over time?

I would advise family physicians interested in supporting their local ACO effort to consider the governance structure of their health care organization, and whether there is a tradition of bringing everyone to the table (or are the real deals made behind closed doors?). Among other considerations: How will allocation of resources be decided and savings be distributed? Is the medical home seen as the foundation of the ACO effort, or a barrier to its success? Is there a sufficient Medicare population?

What do you think? Will ACOs be a panacea or just another dead end? E-mail me your thoughts and experiences.

Accountable care organizations (ACOs), the latest attempt in a storied effort to stabilize spiraling health care costs, are a policy wonk’s dream of a solution to America’s health care challenges. But is the concept a fad or a real game changer?

Proponents of ACOs claim that global reimbursement for comprehensive service delivery—rather than a piecemeal approach to costly services—will result in improved care and higher value. Tightly integrated networks such as Kaiser and Geisinger, say supporters, are models of the efficiency and effectiveness ACOs will provide. Drivers of this revolution include CMS, cash-strapped states, and legions of insurers looking for the next big thing.

Skeptics, however, see this as déjà vu all over again—citing the disintegration of such managed care marvels as capitation, tightly controlled panels, and the alignment of patients, physicians, and hospitals. Critics also claim that the public has little appetite for narrowly defined networks. In addition, they say the challenges of developing effective and legal mechanisms of cooperation are daunting.

Who’s right?

I suspect that very few health systems, provider groups, or independent practice associations (IPAs) have the technical expertise, organizational culture, or will to undergo this sweeping transformation. While today’s physicians may be more willing to be employed by large health systems, how many systems are willing to share governance in a meaningful way, assure an appropriate balance of primary and specialty care, and give up their addiction to the star wars of medical technology? How many groups of specialty surgeons and family physicians are likely to work together? And how many truly effective IPAs have lasted over time?

I would advise family physicians interested in supporting their local ACO effort to consider the governance structure of their health care organization, and whether there is a tradition of bringing everyone to the table (or are the real deals made behind closed doors?). Among other considerations: How will allocation of resources be decided and savings be distributed? Is the medical home seen as the foundation of the ACO effort, or a barrier to its success? Is there a sufficient Medicare population?

What do you think? Will ACOs be a panacea or just another dead end? E-mail me your thoughts and experiences.

Accountable care organizations (ACOs), the latest attempt in a storied effort to stabilize spiraling health care costs, are a policy wonk’s dream of a solution to America’s health care challenges. But is the concept a fad or a real game changer?

Proponents of ACOs claim that global reimbursement for comprehensive service delivery—rather than a piecemeal approach to costly services—will result in improved care and higher value. Tightly integrated networks such as Kaiser and Geisinger, say supporters, are models of the efficiency and effectiveness ACOs will provide. Drivers of this revolution include CMS, cash-strapped states, and legions of insurers looking for the next big thing.

Skeptics, however, see this as déjà vu all over again—citing the disintegration of such managed care marvels as capitation, tightly controlled panels, and the alignment of patients, physicians, and hospitals. Critics also claim that the public has little appetite for narrowly defined networks. In addition, they say the challenges of developing effective and legal mechanisms of cooperation are daunting.

Who’s right?

I suspect that very few health systems, provider groups, or independent practice associations (IPAs) have the technical expertise, organizational culture, or will to undergo this sweeping transformation. While today’s physicians may be more willing to be employed by large health systems, how many systems are willing to share governance in a meaningful way, assure an appropriate balance of primary and specialty care, and give up their addiction to the star wars of medical technology? How many groups of specialty surgeons and family physicians are likely to work together? And how many truly effective IPAs have lasted over time?

I would advise family physicians interested in supporting their local ACO effort to consider the governance structure of their health care organization, and whether there is a tradition of bringing everyone to the table (or are the real deals made behind closed doors?). Among other considerations: How will allocation of resources be decided and savings be distributed? Is the medical home seen as the foundation of the ACO effort, or a barrier to its success? Is there a sufficient Medicare population?

What do you think? Will ACOs be a panacea or just another dead end? E-mail me your thoughts and experiences.

Christina Green, a 9-year-old girl born on 9/11, is one of 6 people slain outside a supermarket in Tucson amid a vicious attack on a popular Congresswoman. Vicki Kaspar, an assistant principal, dies hours after a shooting at Millard South High School in Omaha. Police officers Brandon Paudert and Bill Evans die in West Memphis after a traffic stop turns violent. Virginia Tech, Columbine, Pearl High School—the images of violence, death, and despair never seem to end.

Then again, why should that come as a surprise? We have a system that allows gun buyers to escape scrutiny at gun shows in certain states and in private transactions, a dysfunctional background check process that lets the dangerously mentally ill obtain guns with impunity (people with mental disorders have Second Amendment rights, too), and a patchwork of state reporting laws that leaves wide gaps in compliance.

Everyone needs a high-capacity semiautomatic Glock 19! It made sense to allow the Federal Assault Weapons Ban to lapse in 2004. After all, who knows when I might need an Uzi while navigating the latest traffic snarl! And I am particularly delighted to know that I don’t need a permit for a gun in Arizona and that it’s legal to carry my concealed weapon on school grounds, just in case some students get rowdy!

I am truly delighted by the tone of our political rhetoric: of hit lists, cross-hairs, and targets. What nice subliminal messages to send our youth about solving problems and civil discourse. How can I express my pride in a country where resources for violence prevention and care of the mentally ill take a back seat to budget slashing and reducing “Big Government,” and where active psychosis need not be a barrier to bearing arms?

I was so “happy” to hear Sen. Chris Coons (D-DE) reframe the issue: “I think, frankly, that we need to move forward toward the biggest challenges in front of us, making sure we get Americans back to work, tackling our deficit and our debt, dealing with the conflict in Afghanistan.” Thank you so much, Senator, for your edifying remarks.

I, for one, am sick of such complacency, and I hope many of my fellow family physicians are, too.

I am troubled by the National Rifle Association, whose Web site offers prayers for the victims of the Arizona shootout while touting its Golden Bullseye Award and decrying attempts to strengthen gun controls. I’m offended by Sarah Palin and her disingenuous distancing from her Twitter comments urging “Commonsense Conservatives & lovers of America: Don’t Retreat, Instead—RELOAD!” I’ve had it with the rhetoric from Sen. Rand Paul (R-KY) that “…weapons don’t kill people. It’s the individual that killed these people.”

Tell that to Christina’s family.

Christina Green, a 9-year-old girl born on 9/11, is one of 6 people slain outside a supermarket in Tucson amid a vicious attack on a popular Congresswoman. Vicki Kaspar, an assistant principal, dies hours after a shooting at Millard South High School in Omaha. Police officers Brandon Paudert and Bill Evans die in West Memphis after a traffic stop turns violent. Virginia Tech, Columbine, Pearl High School—the images of violence, death, and despair never seem to end.

Then again, why should that come as a surprise? We have a system that allows gun buyers to escape scrutiny at gun shows in certain states and in private transactions, a dysfunctional background check process that lets the dangerously mentally ill obtain guns with impunity (people with mental disorders have Second Amendment rights, too), and a patchwork of state reporting laws that leaves wide gaps in compliance.

Everyone needs a high-capacity semiautomatic Glock 19! It made sense to allow the Federal Assault Weapons Ban to lapse in 2004. After all, who knows when I might need an Uzi while navigating the latest traffic snarl! And I am particularly delighted to know that I don’t need a permit for a gun in Arizona and that it’s legal to carry my concealed weapon on school grounds, just in case some students get rowdy!

I am truly delighted by the tone of our political rhetoric: of hit lists, cross-hairs, and targets. What nice subliminal messages to send our youth about solving problems and civil discourse. How can I express my pride in a country where resources for violence prevention and care of the mentally ill take a back seat to budget slashing and reducing “Big Government,” and where active psychosis need not be a barrier to bearing arms?

I was so “happy” to hear Sen. Chris Coons (D-DE) reframe the issue: “I think, frankly, that we need to move forward toward the biggest challenges in front of us, making sure we get Americans back to work, tackling our deficit and our debt, dealing with the conflict in Afghanistan.” Thank you so much, Senator, for your edifying remarks.

I, for one, am sick of such complacency, and I hope many of my fellow family physicians are, too.

I am troubled by the National Rifle Association, whose Web site offers prayers for the victims of the Arizona shootout while touting its Golden Bullseye Award and decrying attempts to strengthen gun controls. I’m offended by Sarah Palin and her disingenuous distancing from her Twitter comments urging “Commonsense Conservatives & lovers of America: Don’t Retreat, Instead—RELOAD!” I’ve had it with the rhetoric from Sen. Rand Paul (R-KY) that “…weapons don’t kill people. It’s the individual that killed these people.”

Tell that to Christina’s family.

Christina Green, a 9-year-old girl born on 9/11, is one of 6 people slain outside a supermarket in Tucson amid a vicious attack on a popular Congresswoman. Vicki Kaspar, an assistant principal, dies hours after a shooting at Millard South High School in Omaha. Police officers Brandon Paudert and Bill Evans die in West Memphis after a traffic stop turns violent. Virginia Tech, Columbine, Pearl High School—the images of violence, death, and despair never seem to end.

Then again, why should that come as a surprise? We have a system that allows gun buyers to escape scrutiny at gun shows in certain states and in private transactions, a dysfunctional background check process that lets the dangerously mentally ill obtain guns with impunity (people with mental disorders have Second Amendment rights, too), and a patchwork of state reporting laws that leaves wide gaps in compliance.

Everyone needs a high-capacity semiautomatic Glock 19! It made sense to allow the Federal Assault Weapons Ban to lapse in 2004. After all, who knows when I might need an Uzi while navigating the latest traffic snarl! And I am particularly delighted to know that I don’t need a permit for a gun in Arizona and that it’s legal to carry my concealed weapon on school grounds, just in case some students get rowdy!

I am truly delighted by the tone of our political rhetoric: of hit lists, cross-hairs, and targets. What nice subliminal messages to send our youth about solving problems and civil discourse. How can I express my pride in a country where resources for violence prevention and care of the mentally ill take a back seat to budget slashing and reducing “Big Government,” and where active psychosis need not be a barrier to bearing arms?

I was so “happy” to hear Sen. Chris Coons (D-DE) reframe the issue: “I think, frankly, that we need to move forward toward the biggest challenges in front of us, making sure we get Americans back to work, tackling our deficit and our debt, dealing with the conflict in Afghanistan.” Thank you so much, Senator, for your edifying remarks.

I, for one, am sick of such complacency, and I hope many of my fellow family physicians are, too.

I am troubled by the National Rifle Association, whose Web site offers prayers for the victims of the Arizona shootout while touting its Golden Bullseye Award and decrying attempts to strengthen gun controls. I’m offended by Sarah Palin and her disingenuous distancing from her Twitter comments urging “Commonsense Conservatives & lovers of America: Don’t Retreat, Instead—RELOAD!” I’ve had it with the rhetoric from Sen. Rand Paul (R-KY) that “…weapons don’t kill people. It’s the individual that killed these people.”

Tell that to Christina’s family.

I remember the day I was suspended from elementary school.

The neighborhood bully decided my white socks were a fashion faux pas—or maybe it was my nerdy glasses. Whatever the reason, his sucker punch and the subsequent scuffle landed us both in the principal’s office and ended with an unscheduled trip home. My parents wrote this off as one of the typical traumas of grade school—behavior that was, if not commendable, certainly not a cause for alarm.

Today, we are aware of the link between bullying and school violence (including the tragedy at Columbine), low self-esteem, posttraumatic stress disorder (PTSD), and even suicide. Indeed, bullying exacts a toll on the bullied, the bully, and society itself.

Bullying is not confined to school, and can occur in the workplace, home, or even online. Recent high-profile cases have included instances of cyber-bullying, ranging from distribution of revealing photos to cyber-vigilantism.

The case of 13-year-old Megan Meier is particularly disturbing. Megan met a friend, “Josh,” on a social networking site. It was later revealed that Josh was fictitious, and the product of the mother of one of Megan’s friends. After an alleged slight to her daughter, the mother sought to befriend and then humiliate Megan. Shortly after Josh broke off communication—weeks before her 14th birthday—Megan committed suicide.

The effects on the bullied are far ranging and may include PTSD, failing grades, and substance abuse, as well as depression and suicide. Sadly, as with many other types of abuse, those who are bullied often perpetuate the cycle of abuse themselves. Bullies suffer, too, from high rates of psychiatric and personality disorders, substance abuse, and incarceration, and are at risk for a lifetime of dysfunctional relationships.

Bullying is an important public health issue, not a minor problem to be ignored. Intervention requires a concerted, multidisciplinary effort—and the help of family physicians. We need to be on the lookout for victims of bullying (children who are “different” are frequent targets, including those who are developmentally disabled, gifted, overweight, or mentally ill). We can ask parents and young patients about changes in school performance and investigate underlying causes of behavioral and mental health problems. We can support school-based and community programs that help children develop resilience and work to create social environments that discourage bullying—and, ultimately, prevent it.

I remember the day I was suspended from elementary school.

The neighborhood bully decided my white socks were a fashion faux pas—or maybe it was my nerdy glasses. Whatever the reason, his sucker punch and the subsequent scuffle landed us both in the principal’s office and ended with an unscheduled trip home. My parents wrote this off as one of the typical traumas of grade school—behavior that was, if not commendable, certainly not a cause for alarm.

Today, we are aware of the link between bullying and school violence (including the tragedy at Columbine), low self-esteem, posttraumatic stress disorder (PTSD), and even suicide. Indeed, bullying exacts a toll on the bullied, the bully, and society itself.

Bullying is not confined to school, and can occur in the workplace, home, or even online. Recent high-profile cases have included instances of cyber-bullying, ranging from distribution of revealing photos to cyber-vigilantism.

The case of 13-year-old Megan Meier is particularly disturbing. Megan met a friend, “Josh,” on a social networking site. It was later revealed that Josh was fictitious, and the product of the mother of one of Megan’s friends. After an alleged slight to her daughter, the mother sought to befriend and then humiliate Megan. Shortly after Josh broke off communication—weeks before her 14th birthday—Megan committed suicide.

The effects on the bullied are far ranging and may include PTSD, failing grades, and substance abuse, as well as depression and suicide. Sadly, as with many other types of abuse, those who are bullied often perpetuate the cycle of abuse themselves. Bullies suffer, too, from high rates of psychiatric and personality disorders, substance abuse, and incarceration, and are at risk for a lifetime of dysfunctional relationships.

Bullying is an important public health issue, not a minor problem to be ignored. Intervention requires a concerted, multidisciplinary effort—and the help of family physicians. We need to be on the lookout for victims of bullying (children who are “different” are frequent targets, including those who are developmentally disabled, gifted, overweight, or mentally ill). We can ask parents and young patients about changes in school performance and investigate underlying causes of behavioral and mental health problems. We can support school-based and community programs that help children develop resilience and work to create social environments that discourage bullying—and, ultimately, prevent it.

I remember the day I was suspended from elementary school.

The neighborhood bully decided my white socks were a fashion faux pas—or maybe it was my nerdy glasses. Whatever the reason, his sucker punch and the subsequent scuffle landed us both in the principal’s office and ended with an unscheduled trip home. My parents wrote this off as one of the typical traumas of grade school—behavior that was, if not commendable, certainly not a cause for alarm.

Today, we are aware of the link between bullying and school violence (including the tragedy at Columbine), low self-esteem, posttraumatic stress disorder (PTSD), and even suicide. Indeed, bullying exacts a toll on the bullied, the bully, and society itself.

Bullying is not confined to school, and can occur in the workplace, home, or even online. Recent high-profile cases have included instances of cyber-bullying, ranging from distribution of revealing photos to cyber-vigilantism.

The case of 13-year-old Megan Meier is particularly disturbing. Megan met a friend, “Josh,” on a social networking site. It was later revealed that Josh was fictitious, and the product of the mother of one of Megan’s friends. After an alleged slight to her daughter, the mother sought to befriend and then humiliate Megan. Shortly after Josh broke off communication—weeks before her 14th birthday—Megan committed suicide.

The effects on the bullied are far ranging and may include PTSD, failing grades, and substance abuse, as well as depression and suicide. Sadly, as with many other types of abuse, those who are bullied often perpetuate the cycle of abuse themselves. Bullies suffer, too, from high rates of psychiatric and personality disorders, substance abuse, and incarceration, and are at risk for a lifetime of dysfunctional relationships.

Bullying is an important public health issue, not a minor problem to be ignored. Intervention requires a concerted, multidisciplinary effort—and the help of family physicians. We need to be on the lookout for victims of bullying (children who are “different” are frequent targets, including those who are developmentally disabled, gifted, overweight, or mentally ill). We can ask parents and young patients about changes in school performance and investigate underlying causes of behavioral and mental health problems. We can support school-based and community programs that help children develop resilience and work to create social environments that discourage bullying—and, ultimately, prevent it.

It is time—time to abandon our damagingly divisive, politically Pyrrhic, and ultimately unsustainable struggle with advanced practice nurses (APNs). I urge my fellow family physicians to accept—actually, to embrace—a full partnership with APNs.

Why do I call for such a fundamental change in policy? First, because it’s the reality.

In 16 states, nurse practitioners already practice independently. And in many more states, there is a clear indication that both the public and politicians favor further erosion of barriers to independent nursing practice. Indeed, such independence is outlined in “The Future of Nursing: Leading Change, Advancing Health,” published by the Institute of Medicine (IOM) in October 2010. Among the IOM’s conclusions:

• Nurses should practice to the full extent of their education and training.
• Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
• Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

Second, I believe our arguments against such a shift in policy don’t hold up. Despite the endless arguments about outcomes, training, and patient preferences, I honestly believe that most nursing professionals—just like most physicians—practice within the bounds of their experience and training.

Indeed, the arguments family physicians make against APNs sound suspiciously like specialists’ arguments against us. (Surely, the gastroenterologists assert, their greater experience and expertise should favor colonoscopy privileges only for physicians within their specialty, not for lowly primary care practitioners.) Rather than repeating the cycle of oppression that we in family medicine battle as the oppressed, let’s celebrate differences in practice, explore opportunities for collaboration, and develop diverse models of care.

Third, I call for a fundamental shift in policy because I fear that, from a political perspective, we have much to lose by continuing to do battle on this front. Fighting fractures our support and reduces our effectiveness with our legislative, business, and consumer advocates.

Finally, I’m convinced that joining forces with APNs to develop innovative models of team care will lead to the best health outcomes. In a world of accountable health care organizations, health innovation zones, and medical “neighborhoods,” we gain far more from collaboration than from competition.

As we ring in the new year, let’s stop clinging to the past—and redirect our energies toward envisioning the future of health care.

It is time—time to abandon our damagingly divisive, politically Pyrrhic, and ultimately unsustainable struggle with advanced practice nurses (APNs). I urge my fellow family physicians to accept—actually, to embrace—a full partnership with APNs.

Why do I call for such a fundamental change in policy? First, because it’s the reality.

In 16 states, nurse practitioners already practice independently. And in many more states, there is a clear indication that both the public and politicians favor further erosion of barriers to independent nursing practice. Indeed, such independence is outlined in “The Future of Nursing: Leading Change, Advancing Health,” published by the Institute of Medicine (IOM) in October 2010. Among the IOM’s conclusions:

• Nurses should practice to the full extent of their education and training.
• Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
• Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

Second, I believe our arguments against such a shift in policy don’t hold up. Despite the endless arguments about outcomes, training, and patient preferences, I honestly believe that most nursing professionals—just like most physicians—practice within the bounds of their experience and training.

Indeed, the arguments family physicians make against APNs sound suspiciously like specialists’ arguments against us. (Surely, the gastroenterologists assert, their greater experience and expertise should favor colonoscopy privileges only for physicians within their specialty, not for lowly primary care practitioners.) Rather than repeating the cycle of oppression that we in family medicine battle as the oppressed, let’s celebrate differences in practice, explore opportunities for collaboration, and develop diverse models of care.

Third, I call for a fundamental shift in policy because I fear that, from a political perspective, we have much to lose by continuing to do battle on this front. Fighting fractures our support and reduces our effectiveness with our legislative, business, and consumer advocates.

Finally, I’m convinced that joining forces with APNs to develop innovative models of team care will lead to the best health outcomes. In a world of accountable health care organizations, health innovation zones, and medical “neighborhoods,” we gain far more from collaboration than from competition.

As we ring in the new year, let’s stop clinging to the past—and redirect our energies toward envisioning the future of health care.

It is time—time to abandon our damagingly divisive, politically Pyrrhic, and ultimately unsustainable struggle with advanced practice nurses (APNs). I urge my fellow family physicians to accept—actually, to embrace—a full partnership with APNs.

Why do I call for such a fundamental change in policy? First, because it’s the reality.

In 16 states, nurse practitioners already practice independently. And in many more states, there is a clear indication that both the public and politicians favor further erosion of barriers to independent nursing practice. Indeed, such independence is outlined in “The Future of Nursing: Leading Change, Advancing Health,” published by the Institute of Medicine (IOM) in October 2010. Among the IOM’s conclusions:

• Nurses should practice to the full extent of their education and training.
• Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
• Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.

Second, I believe our arguments against such a shift in policy don’t hold up. Despite the endless arguments about outcomes, training, and patient preferences, I honestly believe that most nursing professionals—just like most physicians—practice within the bounds of their experience and training.

Indeed, the arguments family physicians make against APNs sound suspiciously like specialists’ arguments against us. (Surely, the gastroenterologists assert, their greater experience and expertise should favor colonoscopy privileges only for physicians within their specialty, not for lowly primary care practitioners.) Rather than repeating the cycle of oppression that we in family medicine battle as the oppressed, let’s celebrate differences in practice, explore opportunities for collaboration, and develop diverse models of care.

Third, I call for a fundamental shift in policy because I fear that, from a political perspective, we have much to lose by continuing to do battle on this front. Fighting fractures our support and reduces our effectiveness with our legislative, business, and consumer advocates.

Finally, I’m convinced that joining forces with APNs to develop innovative models of team care will lead to the best health outcomes. In a world of accountable health care organizations, health innovation zones, and medical “neighborhoods,” we gain far more from collaboration than from competition.

As we ring in the new year, let’s stop clinging to the past—and redirect our energies toward envisioning the future of health care.