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Once upon time, patients relied on physicians to tell them what to do when faced with a medical decision, and for the most part, physicians gladly accepted this responsibility. Eventually, patients and doctors came to realize that this paternalistic approach to medical decision-making placed far too much power in the hands of physicians, however beneficent their intent. Over the past 20 years or so, in part fueled by the growing interest in decision-making at the end of life, there has been a seismic change in the approach to medical decision-making and the physician–patient relationship, with increasing emphasis on a model that emphasizes patient autonomy and shared decision-making. In the extreme expression of this model, the role of the health care provider is simply to provide accurate information to patients without sharing their own views or experiences; patients are expected to make the tough medical decisions on their own, whether it be treatment preferences at the end of life or choice of medication in chronic disease management. In contrast with medical paternalism, this model places far too little responsibility on physicians to exercise their expertise with patients when faced with a difficult choice. In this issue of JGIM, Entwistle et al. argue that it is time for us to broaden the discussion of patient autonomy beyond a narrow focus on medical decision-making to one that shifts the focus to the relational context of the physician-patient relationship. They assert that a relational approach to patient autonomy allows the clinician to better understand the individual patient in a broader social/cultural context and therefore to support patient autonomy in a diversity of health care contexts. Original research articles by Beach et al. and Nguyen et al. also in this issue remind us that language, culture and socio-economic status often have a profound influence on patient–doctor communication and health related behavior. For example, Beach found that there was less patient centered communication in encounters between HIV-infected Hispanic patients and their providers compared with white patients, though surprisingly, Hispanics reported higher overall satisfaction. A Pubmed search using the search term “patient autonomy” reveals more than 12,000 published scholarly articles, 42 in JGIM alone in the past 20 years. We have come a long way since the days of physician paternalism but have not yet reached a satisfactory balance between the dual goals of respect for patient autonomy and the need for physicians to respectfully and clearly share their expertise and ideas. Clearly, when it comes to patient autonomy and medical decision-making, we are still trying to figure out how to get it just right.

Legislation passes or fails. Prospects for health care reform wax and wane. Government initiatives (on patient safety, disparities, and now comparative effectiveness) come and, just as surely, go. In the meantime, this nation’s 50,000 general internists struggle to provide high quality care to their patients. Many succeed. But large national studies from RAND and elsewhere tell a different story. Delivering the right care, to the right patient, at the right time, every time, remains, in the aggregate, an elusive goal.

An e-mail that would have usually been categorized as “junk” somehow managed to elude the university spam filter and made its way into my in-box; the subject line read: “What Doctors Need to Know About Facebook.” The e-mail was inviting me to participate in a webinar that promised the participants that, among other wonders, they would learn to use Facebook as a “valuable tool for sharing information with colleagues.” Really? As a late and somewhat reluctant adopter of Facebook, I have been unconvinced of its value for me personally or professionally, and have mainly ignored the many “friend” requests that somehow began showing up in my e-mail after I finally signed up a few months ago; some came from patients and their families, some from people whose names I barely recognized (none, alas, from long lost flames). I was surprised, however, when a former colleague found me through my new Facebook presence and said she was thrilled to see the wonderful pictures of my kids. I was surprised because I had not posted any pictures of my now grown children; surprise gave way to dismay when I realized that the photos she had accessed were actually on my 19- and 23-year-old children’s Facebook pages, many of which were not suitable for sharing at a family reunion, and certainly not what I would choose to share with colleagues or patients. The potential, and potential perils, of Facebook and other Internet and social media are the subject of several papers in this month’s JGIM. In one of the first empirical studies to examine the question of the availability and nature of physician information accessible on the Internet, Mostaghimi et al. searched the Internet to see what kind of professional and personal information was freely available to the average patient about a randomly selected sample of 250 internal medicine physicians in Massachusetts. They found, not surprisingly, that almost all the physicians (94%) had either personal or professional information that could be easily accessed with a simple Google search. Perhaps more surprising was that while most of the information available was of a professional nature (such as quality rating sites, publications and in three cases, disciplinary actions), almost 1/3 of the physicians had personal information available on-line on more than 200 web sites, including Facebook pages, political and charitable donations, and family and personal financial information. It is likely that most of these physicians were unaware of the extent of their personal information available on-line and would not have chosen to share much of it if given the choice. As Mostaghimi et al. state: “Most physicians limit their self-expression during patient encounters: few physicians would wear a political pin, discuss their ongoing litigations with their neighbor, or detail charitable contributions during a patient encounter. Our study demonstrates, however, that this type of information could easily be found with a single limited Internet search.” Physicians may not only put themselves at risk when they fail to monitor their on-line presence, but they also risk compromising the integrity of the profession. The impact of the rise of social media such as Facebook on medical professionalism is the subject of an incisive Perspective in this issue by Greysen et al. They argue that the time has come for the establishment of consensus-based standards for “online professionalism.” Too often, they argue, and as Mostaghami et al. found, physicians do not consider the potential impact of their on-line content and may inadvertently violate professional standards in cyberspace that they would never violate in real-time social interactions. Greysen et al. make the point that what we don’t know may not only hurt us, but may also hurt others such as our patients and colleagues, and the medical profession as a whole.

From the Editor’s Desk: Legislating Change Malathi Srinivasan, MD 1 and Mitchell D. Feldman, MD, MPhil 2 Department of Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA; 2 Department of Medicine, University of California, San Francisco, San Francisco, CA, USA. J Gen Intern Med 25(3):173 DOI: 10.1007/s11606-010-1261-9 © Society of General Internal Medicine 2010 Seismic changes in medical practice typically have come from discovery (such as DNA or penicillin) or new innovation (for example, new imaging devices such as MRI scanners), but rarely as the result of legislation. However, the American Reinvestment and Renew Act (ARRA), passed by Congress in February 2009, may do just that. The ARRA, which allocates $19 billion specifically to incentivize the use of electronic health records (EHR), is poised to dramatically change medical practice in the US. This money would be paid directly to physician’s practices, with early non-hospital-based adopters of EHRs receiving up to $63,000 per physician ($42,500 for pediatricians) over 6 years through add-ons to Medicare payments. The majority of US physicians still practice in solo, small (2– 10) or medium (11–50) size group practices. Currently, these physicians face serious financial obstacles to implementing even limited (non-enterprise) EHRs. Behavioral change can be fueled by financial incentives/disincentives that are over 10– 20% of base salary, when the downsides of the change are just moderately onerous. Under ARRA, the adoption incentive is quite high, while the non-adoption disincentive is quite low (1– 5% Medicare cuts starting 2015), especially for mid-sized group practices. While non-adopters would eventually be penalized, the incentive’s magnitude is probably sufficient to entice smaller practices to re-consider the costs and workflow changes necessary for EHR adoption. In this issue of JGIM, O’Malley and colleagues report on the results of 60 telephone interviews with small and medium group practice US physicians, highlighting six sentinel issues around EHR-related care coordination and provision. O’Malley demonstrates a need for additional integration of decision- support and inter-office communication into existing plat- forms. Additionally, her group identifies specific payment reforms that could help drive better communication between physicians (paying for intergroup care coordination, not just direct patient care), to further improve patient care. What will EHR adoption mean for the average patient? As is so often the case in health care, the answer is, “it all depends.” If the promise of seamless medical data capture and transmis- sion is realized, with simultaneous creation of patient portals for open healthcare access, the seismic transformation of medicine would be underway. In this idyllic health care environment, informed and activated patients would partner with health care providers longitudinally to improve their health. Patients and physicians would have access to decision-support tools tied to emerging evidence. Patients would be able to access health information easily, regardless of where in the country (or for that matter, in the world)they were located. Variability in the quality of care would diminish, with easier tracking of quality improvement pro- gram outcomes. Test duplication would be reduced. Encryp- tion technologies used for banking would safeguard patient data. Patients, armed with new data and enhanced motiva- tion, would modify their health behaviors, and be account- able for their own health decisions. How “blue sky” is this vision? O’Malley and colleagues point out that physicians identify a number of barriers to EHR adoption. Without additional governmental regulations to create interoperability, perhaps via health information exchanges or hubs, financial disincentives exist for health care companies to share data amongst themselves. While industry consolidation (currently occurring with enterprise level EHRs) is inevitable, the proliferation of small to mid-sized EHR companies will likely continue for the next 5–10 years. Patient EHR portals using cloud computing systems would need to be secured and customized, drawing from multiple information sources simultaneously. Although HIPAA provides some regu- latory protection of individuals, EHR-enabled patients would need to decide with whom and what health data to share—with serious implications for insurability and employment. And, disparities between those who have, and don’t have, access to these technologies could increase health disparities. Safe- guarding every patient, for every encounter, will be an enormous task across all socio-economic levels. Technological paradigm shifts, coupled with careful re- search, implementation and sufficient incentives will likely move American medicine forward in the next decade. While not as dramatic as new discoveries or innovations, well-reasoned health care legislation promises to move the dial in the direction of improved processes and outcomes in health care. Incentives to increase the adoption of new health information technology may be the right prescription for the times. Corresponding Author: Malathi Srinivasan, MD, Department of Medicine, University of California, Davis School of Medicine, 4150 V. S t re e t , S u i t e 2 4 0 0 , S a c r a m e n t o , C A 9 5 8 3 3 , U S A ( e - mail: malathi@ucdavis.edu). Published online February 17, 2010

Tradition has it that first anniversaries are celebrated with gifts of paper. Thus, it is fitting that on this first anniversary of our start as co-Editors in Chief of the Journal of General Internal Medicine, we should look back on the 12 paper issues we’ve published in 2010. The paper journal is sent to every member of the Society of General Internal Medicine and to a diminishing number of libraries who still choose to display the bound journal instead of relying solely on electronic access. As editors, we take the print journal seriously, striving to craft each issue to be a self-contained and coherent whole. This year has seen the addition of several new features that we hope add value to each issue. From the Editor's Desk directs readers’ attention to articles and themes of special interest. Exercises in Clinical Reasoning examines the diagnostic process as highly skilled clinicians work through a tough clinical case. Innovations and Improvement explores the process of quality improvement and enlivens the journal through interviews and first person narratives, and Healing Arts sounds the lived experience of general internal medicine in essays, poems, and criticism. Although we choose the articles appearing in each issue of the print journal with care, most consumers of medical journals never touch the paper of each monthly issue and instead prefer to access JGIM and other journal content as if it were on iTunes, searching through titles and abstracts and downloading individual articles. They find JGIM content through on-line sources such as Google Scholar, PubMed Central, and others. In fact, over the past year, while Springer, our publisher, mailed just over 2,000 copies of the paper journal to subscribers or members each month, there have been more than 1 million JGIM articles downloaded by readers since the publication of our inaugural issue last January. This, of course, is the present and future of medical journals; the increasing ‘webification’ of journal content and the growing irrelevance of the print journal. We are well aware of these trends and will work over the remaining 4 years of our editorship to prepare JGIM for the inevitable demise of the print journal and the predominance of the web-based journal. With the help of Associate Editor Malathi Srinivasan and others, work on eJGIM has already begun. In addition, the next 12 months will see the reinvigoration of Innovations in Medical Education, a stunning series of articles on Health Policy, and new collaborations with AHRQ, the VA, and the Annals of Internal Medicine. JGIM depends on the generosity of a committed and outstanding group of reviewers. In 2009–2010, JGIM reviewers volunteered their time and expertise to review about half of the more than 1,000 manuscripts that JGIM receives each year. During this period, 986 reviewers provided a total of 1,294 reviews with a mean quality score of 2.98 on a scale of 1–6 (as judged by JGIM Deputy Editors). Of these, 276 provided at least two reviews, and 29 provided three or more. We are indebted to them for their service. Among this group of dedicated peer reviewers, there is a cohort that stands out. Reviewers included in this prestigious group performed at least two reviews between July 2009 and June 2010, returned all reviews within 30 days, and received no quality score on any review lower than 4 on our 1–6 scale. An asterisk identifies the 131 reviewers meeting these criteria. We thank them for their efforts on behalf of the Journal. In our first “From the Editor’s Desk” in January 2010 we wrote: “In steering the journal forward over the next 5 years, we will be guided by the principle that JGIM is a journal for generalists committed to improving the world in which they practice and teach. Thus, we will seek to publish data derived from settings where real patients live and real doctors practice, as well as reviews and tools that clinicians and educators can use to do their jobs more effectively, efficiently, and humanely.” We remain committed to this vision over the next 4 years and hope that you, our readers, will join us by continuing to submit to, review for, read, and respond to JGIM. Whether in print or on-line, JGIM is your journal, and we need to hear from you. Send us an e-mail (or a paper letter!) and share your thoughts for the future of medical journalism and the future of medicine. The Editors

Most experts agree that the current rate of rise of health care costs is unsustainable. The good news, however, is that there is an emerging consensus among policymakers over what needs to be done: realign financial incentives; reinvigorate primary care; support more informed, patient-centered decision making; develop a more robust evidence base of comparative effectiveness; create standards for electronic health records; invest in public health. In addition, many feel that excessive tests, consultations, and procedures in the last year of life contribute not only to higher costs but to diminished quality of care. However, these concerns were caricatured by conservative pundits and politicians, who portrayed hospital ethics boards as “death panels” and ultimately ensured that end-of life care was exiled from the health care reform agenda.