RE: Re: Reducing the toxicity of our environment - changing health policy

[Guest guest]

I have had the pleasure of hearing Dr.

Grundy speak and speaking with him one on one as well. (At AAFP

Leadership meeting as well as TransforMed collaborative). Make no

mistake, he is on “our side” and fully understands the importance

of the relationship in medical care. There is “more than meets the

eye” with many of the consensus builders, both at PCPCC, TransforMed and

the AAFP. We are all playing on the same team, we just have different

roles, tactics and strategies. But that is how teams win, utilizing the strength

of each to move toward the goals of all. (You know, like the Steelers!)

J

Ramona

Ramona G. Seidel, MD

www.baycrossingfamilymedicine.com

Your Bridge to Health

NOTE NEW ADDRESS AND PHONE NUMBER:

269 Peninsula Farm Road

Suite F

Arnold, MD 21012

410 518-9808

From: [mailto: ] On Behalf Of Haresch

Sent: Monday, February 02, 2009

12:03 AM

To:

Subject:

Re: Reducing the toxicity of our environment - changing health policy

I had the chance to hear Dr. Grundy of the PCPCC

(although he says

" PCPCP " ) speak this weekend. What he had to say jibes with what I've

heard here. Perhaps he was pandering to a roomful of FPs, but he does

seem to get that fixing this unworkable payment system for primary

care is at the root of the PCMH movement. He didn't seem willing to

defend the NCQA process but described it as something he expects to

change through the pilot projects. And he encouraged those not able to

move on certification now to wait for money to be attached first.

PCMH appears to me to be the only vehicle with enough players involved

to have a hope of shifting the payment paradigm.

So, thanks to Gordon and others trying to move this process toward a

focus on true quality and away from minutiae only applicable to large

practices. And thanks to and others trying to show how this can

or cannot work for solo/IMPs. The future of our practices may hinge on

your efforts. Please keep letting us know ways you think we can help.

Haresch

>

> Solo and small practice docs need that level of support without the

costs

> and overhead. I don't mean the same content and approach as it

doesn't jibe

> with the way we do things, but we ought to be able to receive expert

help

> that really works and really makes our practices better.

>

>

>

> This is what we're growing toward in our group. We help each other,

we know

> the issues, we strive for excellence in operations, use of IT, we

> commiserate with each other around the ubiquitous failings of the

greater

> non-system and how much we get punished for trying to do the right

thing.

>

>

>

> One aspect I'm working hard on is to help shift the policy

environment to

> make it less toxic to solo and small practices. The things I'm

pushing for

> include:

>

> - Changes in payment that provide adequate funding for us

to do all

> of the work for which we were trained

>

> - Changes in the administrative burden brought by insurance

> companies in the guise of " improving quality and reducing costs "

>

> - Changes in the proposed measurement of care approaches that

> appear likely to put a stake through the heart of solo & small

practices

>

>

>

> Solo and small practices still make up a significant proportion of

the US.

>

> We can have an effect if we work together.

>

> This can be done if on occasion we work in concert to raise our

individual

> and collective voices, targeting specific policy makers with

specific policy

> suggestions.

>

>

>

> Policy makers are surrounded by the usual and customary players.

Some are

> proposing real and substantive change and are being shouted down by

those

> who advocate incrementalism and the status quo. They can move

forward only

> if they know there is a constituency outside the Beltway that is

yearning

> for real change.

>

>

>

> Our first attempt is through the petition:

>

> www.PatientsAtCenter.org <http://www.patientsatcenter.org/>

>

> It is one approach that has even in its infancy caught the attention of

> some.

>

> Some IMPs are working hard and fast to create a vehicle that can help us

> connect with policy makers fast and in large numbers.

>

> Stay tuned as we gear this up.

>

>

>

> I know that many of you have all but given up hope that change will ever

> come and/or are so close to precipice that your struggle for

survival takes

> every ounce of energy.

>

> For those of you who can raise your eyes from the morass of

helplessness and

> hopelessness please add your voice.

>

> Our strength is our profession and our numbers.

>

> Our strength is evidence supporting what we do.

>

> Our strength can only be evident if each of you can find it in you

to step

> up.

>

>

>

> Now is the time for action. Don't continue to suffer helplessly while

> merely creating noise through Brownian motion - take concerted action to

> effect real change.

>

> Gordon

[Guest guest]

I spoke to over the summer at our state academy (njafp) yearly meeting, seems like a great guy that truly believes what healthcare and primary care should be. but i have a bad feeling about changing this system from the top down, i.e. through legislation and huge overhauls. i am continuously offended by the fact that i am (suddenly) supposed to " transform " my practice into somewhere that patietns will go and call if they have a medical problem. that's our job, i don't need to reinvent the wheel. i think top down change will create more chaos, and more fragmentation. and the pcmh system smells too much like capitation for me to want to buy in complelety.

i agree we need top down government support. but if we don't change from within, it will just be the same broken system with a different name. we pay " certified " docs per patient, and the ones who take the time and don't see 40 pts per day, lose again.

don't get me wrong, i don't want to be paid for not working, i want to get paid for the job i do.

hourly? i'd be richer than the surgeons in my town, and raking it in over derm and radiology!

-tac " glass half empty " crowley

I had the chance to hear Dr. Grundy of the PCPCC (although he says " PCPCP " ) speak this weekend. What he had to say jibes with what I'veheard here. Perhaps he was pandering to a roomful of FPs, but he does

seem to get that fixing this unworkable payment system for primarycare is at the root of the PCMH movement. He didn't seem willing todefend the NCQA process but described it as something he expects tochange through the pilot projects. And he encouraged those not able to

move on certification now to wait for money to be attached first.PCMH appears to me to be the only vehicle with enough players involvedto have a hope of shifting the payment paradigm.So, thanks to Gordon and others trying to move this process toward a

focus on true quality and away from minutiae only applicable to largepractices. And thanks to and others trying to show how this canor cannot work for solo/IMPs. The future of our practices may hinge onyour efforts. Please keep letting us know ways you think we can help.

Haresch>> Solo and small practice docs need that level of support without the

costs> and overhead. I don't mean the same content and approach as itdoesn't jibe> with the way we do things, but we ought to be able to receive experthelp> that really works and really makes our practices better.

> > > > This is what we're growing toward in our group. We help each other,we know> the issues, we strive for excellence in operations, use of IT, we> commiserate with each other around the ubiquitous failings of the

greater> non-system and how much we get punished for trying to do the rightthing.> > > > One aspect I'm working hard on is to help shift the policyenvironment to> make it less toxic to solo and small practices. The things I'm

pushing for> include:> > - Changes in payment that provide adequate funding for usto do all> of the work for which we were trained> > - Changes in the administrative burden brought by insurance

> companies in the guise of " improving quality and reducing costs " > > - Changes in the proposed measurement of care approaches that> appear likely to put a stake through the heart of solo & small practices

> > > > Solo and small practices still make up a significant proportion ofthe US. > > We can have an effect if we work together.> > This can be done if on occasion we work in concert to raise our

individual> and collective voices, targeting specific policy makers withspecific policy> suggestions.> > > > Policy makers are surrounded by the usual and customary players.

Some are> proposing real and substantive change and are being shouted down bythose> who advocate incrementalism and the status quo. They can moveforward only> if they know there is a constituency outside the Beltway that is

yearning> for real change.> > > > Our first attempt is through the petition:> > www.PatientsAtCenter.org <http://www.patientsatcenter.org/>

> > It is one approach that has even in its infancy caught the attention of> some. > > Some IMPs are working hard and fast to create a vehicle that can help us> connect with policy makers fast and in large numbers.

> > Stay tuned as we gear this up.> > > > I know that many of you have all but given up hope that change will ever> come and/or are so close to precipice that your struggle for

survival takes> every ounce of energy.> > For those of you who can raise your eyes from the morass ofhelplessness and> hopelessness please add your voice.> > Our strength is our profession and our numbers.

> > Our strength is evidence supporting what we do.> > Our strength can only be evident if each of you can find it in youto step> up.> > > > Now is the time for action. Don't continue to suffer helplessly while

> merely creating noise through Brownian motion - take concerted action to> effect real change.> > Gordon -- Crowley, MD

Family MedicineCape May Courthouse NJPatients, please allow up to 48 hours for response. If you are having an urgent problem please go to the emergency department or call 911. If you have a problem or question that can't wait 48 hours, or you have not received a timely response, just call the office at 465-0882.

[Guest guest]

I have to agree with you, . The top down approach seems to be smothering my ability to care for my patients.

I just filled out a ridiculous form from Medicare regarding an insulin pump for one of my diabetics. The final yes/no question on the bottom of the form states " I am a physician who manages multiple patients on insulin pumps and who works closely with a team including nurses, diabetes educators and dietitians who are knowledgeable in the use of continuous subcutaneous insulin infusion therapy. " I am supposed to answer this multi-faceted question question with a " yes " or a " no. " I have no idea of our one, part-time diabetic- certified dietician is " knowledgable in the use of [insulin pumps]... " It is also totally unclear what this information is used for. If I answer " no " , will they send me help? More likely they will reject the request for an insulin pump for my diabetic. We do not have surging teams of anything here in Durango (Okay, we do have teams of mule deer and horses).

I manage many patients on insulin pumps and this patient is an ideal candidate from my " humble " perspective. I have learned insulin pump management out of necessity, and actually, insulin pump management is not as hard as some would make it seem. Our closest endocrinologist is a minimum of a 4 hour drive to our neighboring state of New Mexico, or, if we need to stay in-state, an 8 hour drive over two mountain ranges to Denver.

I am happy that we have Gordon and others fighting for us " little guys, " but my concern is that it is too little and way, way too late.

Sorry. Hard weekend of wondering why I care. I am sure I will find the answer again, just not clear on where or when.

Durango, CO

I spoke to over the summer at our state academy (njafp) yearly meeting, seems like a great guy that truly believes what healthcare and primary care should be. but i have a bad feeling about changing this system from the top down, i.e. through legislation and huge overhauls. i am continuously offended by the fact that i am (suddenly) supposed to " transform " my practice into somewhere that patietns will go and call if they have a medical problem. that's our job, i don't need to reinvent the wheel. i think top down change will create more chaos, and more fragmentation. and the pcmh system smells too much like capitation for me to want to buy in complelety.

i agree we need top down government support. but if we don't change from within, it will just be the same broken system with a different name. we pay " certified " docs per patient, and the ones who take the time and don't see 40 pts per day, lose again.

don't get me wrong, i don't want to be paid for not working, i want to get paid for the job i do.

hourly? i'd be richer than the surgeons in my town, and raking it in over derm and radiology!

-tac " glass half empty " crowley

I had the chance to hear Dr. Grundy of the PCPCC (although he says " PCPCP " ) speak this weekend. What he had to say jibes with what I'veheard here. Perhaps he was pandering to a roomful of FPs, but he does

seem to get that fixing this unworkable payment system for primarycare is at the root of the PCMH movement. He didn't seem willing todefend the NCQA process but described it as something he expects tochange through the pilot projects. And he encouraged those not able to

move on certification now to wait for money to be attached first.PCMH appears to me to be the only vehicle with enough players involvedto have a hope of shifting the payment paradigm.So, thanks to Gordon and others trying to move this process toward a

focus on true quality and away from minutiae only applicable to largepractices. And thanks to and others trying to show how this canor cannot work for solo/IMPs. The future of our practices may hinge onyour efforts. Please keep letting us know ways you think we can help.

Haresch>> Solo and small practice docs need that level of support without the

costs> and overhead. I don't mean the same content and approach as itdoesn't jibe> with the way we do things, but we ought to be able to receive experthelp> that really works and really makes our practices better.

> > > > This is what we're growing toward in our group. We help each other,we know> the issues, we strive for excellence in operations, use of IT, we> commiserate with each other around the ubiquitous failings of the

greater> non-system and how much we get punished for trying to do the rightthing.> > > > One aspect I'm working hard on is to help shift the policyenvironment to> make it less toxic to solo and small practices. The things I'm

pushing for> include:> > - Changes in payment that provide adequate funding for usto do all> of the work for which we were trained> > - Changes in the administrative burden brought by insurance

> companies in the guise of " improving quality and reducing costs " > > - Changes in the proposed measurement of care approaches that> appear likely to put a stake through the heart of solo & small practices

> > > > Solo and small practices still make up a significant proportion ofthe US. > > We can have an effect if we work together.> > This can be done if on occasion we work in concert to raise our

individual> and collective voices, targeting specific policy makers withspecific policy> suggestions.> > > > Policy makers are surrounded by the usual and customary players.

Some are> proposing real and substantive change and are being shouted down bythose> who advocate incrementalism and the status quo. They can moveforward only> if they know there is a constituency outside the Beltway that is

yearning> for real change.> > > > Our first attempt is through the petition:> > www.PatientsAtCenter.org <http://www.patientsatcenter.org/>

> > It is one approach that has even in its infancy caught the attention of> some. > > Some IMPs are working hard and fast to create a vehicle that can help us> connect with policy makers fast and in large numbers.

> > Stay tuned as we gear this up.> > > > I know that many of you have all but given up hope that change will ever> come and/or are so close to precipice that your struggle for

survival takes> every ounce of energy.> > For those of you who can raise your eyes from the morass ofhelplessness and> hopelessness please add your voice.> > Our strength is our profession and our numbers.

> > Our strength is evidence supporting what we do.> > Our strength can only be evident if each of you can find it in youto step> up.> > > > Now is the time for action. Don't continue to suffer helplessly while

> merely creating noise through Brownian motion - take concerted action to> effect real change.> > Gordon

-- Crowley, MDFamily MedicineCape May Courthouse NJPatients, please allow up to 48 hours for response. If you are having an urgent problem please go to the emergency department or call 911. If you have a problem or question that can't wait 48 hours, or you have not received a timely response, just call the office at 465-0882.

[Guest guest]

,

You should answer “yes.” The team is you.

dts

From:

[mailto: ] On Behalf Of

Sent: Monday, February 02, 2009 8:46 AM

To:

Subject: Re: Re: Reducing the toxicity of our

environment - changing health policy

I have to agree with you, . The top down

approach seems to be smothering my ability to care for my patients.

I just filled out a ridiculous form from Medicare regarding

an insulin pump for one of my diabetics. The final yes/no question on the

bottom of the form states " I am a physician who manages multiple patients

on insulin pumps and who works closely with a team including nurses, diabetes

educators and dietitians who are knowledgeable in the use of continuous

subcutaneous insulin infusion therapy. " I am supposed to answer this

multi-faceted question question with a " yes " or a

" no. " I have no idea of our one, part-time diabetic- certified

dietician is " knowledgable in the use of [insulin

pumps]... " It is also totally unclear what this information is used

for. If I answer " no " , will they send me help? More

likely they will reject the request for an insulin pump for my diabetic.

We do not have surging teams of anything here in Durango (Okay, we do have

teams of mule deer and horses).

I manage many patients on insulin pumps and this

patient is an ideal candidate from my " humble " perspective. I

have learned insulin pump management out of necessity, and

actually, insulin pump management is not as hard as some would make

it seem. Our closest endocrinologist is a minimum of a 4 hour drive to

our neighboring state of New Mexico, or, if we need to stay in-state, an 8 hour

drive over two mountain ranges to Denver.

I am happy that we have Gordon and others fighting

for us " little guys, " but my concern is that it is

too little and way, way too late.

Sorry. Hard weekend of wondering why I care. I

am sure I will find the answer again, just not clear on where or when.

Durango, CO

I spoke to over the summer at

our state academy (njafp) yearly meeting, seems like a great guy that truly believes

what healthcare and primary care should be. but i have a bad feeling

about changing this system from the top down, i.e. through legislation and huge

overhauls. i am continuously offended by the fact that i am (suddenly) supposed

to " transform " my practice into somewhere that patietns will go and

call if they have a medical problem. that's our job, i don't need to

reinvent the wheel. i think top down change will create more chaos, and

more fragmentation. and the pcmh system smells too much like capitation

for me to want to buy in complelety.

i agree we need top down government

support. but if we don't change from within, it will just be the same broken

system with a different name. we pay " certified " docs per

patient, and the ones who take the time and don't see 40 pts per day, lose

again.

don't get me wrong, i don't want to

be paid for not working, i want to get paid for the job i do.

hourly? i'd be richer than

the surgeons in my town, and raking it in over derm and radiology!

-tac " glass half empty "

crowley

On Mon, Feb 2, 2009 at 12:02 AM,

Haresch

wrote:

I had the chance to hear Dr.

Grundy of the PCPCC (although he says

" PCPCP " ) speak this weekend. What he had to say jibes with what I've

heard here. Perhaps he was pandering to a roomful of FPs, but he does

seem to get that fixing this unworkable payment system for primary

care is at the root of the PCMH movement. He didn't seem willing to

defend the NCQA process but described it as something he expects to

change through the pilot projects. And he encouraged those not able to

move on certification now to wait for money to be attached first.

PCMH appears to me to be the only vehicle with enough players involved

to have a hope of shifting the payment paradigm.

So, thanks to Gordon and others trying to move this process toward a

focus on true quality and away from minutiae only applicable to large

practices. And thanks to and others trying to show how this can

or cannot work for solo/IMPs. The future of our practices may hinge on

your efforts. Please keep letting us know ways you think we can help.

Haresch

>

> Solo and small practice docs need that level of support without the

costs

> and overhead. I don't mean the same content and approach as it

doesn't jibe

> with the way we do things, but we ought to be able to receive expert

help

> that really works and really makes our practices better.

>

>

>

> This is what we're growing toward in our group. We help each other,

we know

> the issues, we strive for excellence in operations, use of IT, we

> commiserate with each other around the ubiquitous failings of the

greater

> non-system and how much we get punished for trying to do the right

thing.

>

>

>

> One aspect I'm working hard on is to help shift the policy

environment to

> make it less toxic to solo and small practices. The things I'm

pushing for

> include:

>

> - Changes in payment that provide adequate funding for us

to do all

> of the work for which we were trained

>

> - Changes in the administrative burden brought by insurance

> companies in the guise of " improving quality and reducing costs "

>

> - Changes in the proposed measurement of care approaches that

> appear likely to put a stake through the heart of solo & small

practices

>

>

>

> Solo and small practices still make up a significant proportion of

the US.

>

> We can have an effect if we work together.

>

> This can be done if on occasion we work in concert to raise our

individual

> and collective voices, targeting specific policy makers with

specific policy

> suggestions.

>

>

>

> Policy makers are surrounded by the usual and customary players.

Some are

> proposing real and substantive change and are being shouted down by

those

> who advocate incrementalism and the status quo. They can move

forward only

> if they know there is a constituency outside the Beltway that is

yearning

> for real change.

>

>

>

> Our first attempt is through the petition:

>

> www.PatientsAtCenter.org

<http://www.patientsatcenter.org/>

>

> It is one approach that has even in its infancy caught the attention of

> some.

>

> Some IMPs are working hard and fast to create a vehicle that can help us

> connect with policy makers fast and in large numbers.

>

> Stay tuned as we gear this up.

>

>

>

> I know that many of you have all but given up hope that change will ever

> come and/or are so close to precipice that your struggle for

survival takes

> every ounce of energy.

>

> For those of you who can raise your eyes from the morass of

helplessness and

> hopelessness please add your voice.

>

> Our strength is our profession and our numbers.

>

> Our strength is evidence supporting what we do.

>

> Our strength can only be evident if each of you can find it in you

to step

> up.

>

>

>

> Now is the time for action. Don't continue to suffer helplessly while

> merely creating noise through Brownian motion - take concerted action to

> effect real change.

>

> Gordon

--

Crowley, MD

Family Medicine

Cape May Courthouse NJ

Patients, please allow up to 48 hours for response. If you are having an urgent

problem please go to the emergency department or call 911. If you have a

problem or question that can't wait 48 hours, or you have not received a timely

response, just call the office at 465-0882.

[Guest guest]

Thanks, Don. That made me smile.

" I am an Army of One... " ( and the armed forces wondered why that one did not catch on

Maybe this should be our new IMP mantra...Oh yes, and our " weapons " are our brains, tongue depressors and stethescopes.

Durango, CO

,

You should answer "yes." The team is you.

dts

From: [mailto: ] On Behalf Of

Sent: Monday, February 02, 2009 8:46 AMTo: Subject: Re: Re: Reducing the toxicity of our environment - changing health policy

I have to agree with you, . The top down approach seems to be smothering my ability to care for my patients.

I just filled out a ridiculous form from Medicare regarding an insulin pump for one of my diabetics. The final yes/no question on the bottom of the form states " I am a physician who manages multiple patients on insulin pumps and who works closely with a team including nurses, diabetes educators and dietitians who are knowledgeable in the use of continuous subcutaneous insulin infusion therapy. " I am supposed to answer this multi-faceted question question with a " yes " or a " no. " I have no idea of our one, part-time diabetic- certified dietician is " knowledgable in the use of [insulin pumps]... " It is also totally unclear what this information is used for. If I answer " no " , will they send me help? More likely they will reject the request for an insulin pump for my diabetic. We do not have surging teams of anything here in Durango (Okay, we do have teams of mule deer and horses).

I manage many patients on insulin pumps and this patient is an ideal candidate from my " humble " perspective. I have learned insulin pump management out of necessity, and actually, insulin pump management is not as hard as some would make it seem. Our closest endocrinologist is a minimum of a 4 hour drive to our neighboring state of New Mexico, or, if we need to stay in-state, an 8 hour drive over two mountain ranges to Denver.

I am happy that we have Gordon and others fighting for us " little guys, " but my concern is that it is too little and way, way too late.

Sorry. Hard weekend of wondering why I care. I am sure I will find the answer again, just not clear on where or when.

Durango, CO

I spoke to over the summer at our state academy (njafp) yearly meeting, seems like a great guy that truly believes what healthcare and primary care should be. but i have a bad feeling about changing this system from the top down, i.e. through legislation and huge overhauls. i am continuously offended by the fact that i am (suddenly) supposed to " transform " my practice into somewhere that patietns will go and call if they have a medical problem. that's our job, i don't need to reinvent the wheel. i think top down change will create more chaos, and more fragmentation. and the pcmh system smells too much like capitation for me to want to buy in complelety.

i agree we need top down government support. but if we don't change from within, it will just be the same broken system with a different name. we pay " certified " docs per patient, and the ones who take the time and don't see 40 pts per day, lose again.

don't get me wrong, i don't want to be paid for not working, i want to get paid for the job i do.

hourly? i'd be richer than the surgeons in my town, and raking it in over derm and radiology!

-tac " glass half empty " crowley

I had the chance to hear Dr. Grundy of the PCPCC (although he says " PCPCP " ) speak this weekend. What he had to say jibes with what I'veheard here. Perhaps he was pandering to a roomful of FPs, but he does

seem to get that fixing this unworkable payment system for primarycare is at the root of the PCMH movement. He didn't seem willing todefend the NCQA process but described it as something he expects tochange through the pilot projects. And he encouraged those not able to

move on certification now to wait for money to be attached first.PCMH appears to me to be the only vehicle with enough players involvedto have a hope of shifting the payment paradigm.So, thanks to Gordon and others trying to move this process toward a

focus on true quality and away from minutiae only applicable to largepractices. And thanks to and others trying to show how this canor cannot work for solo/IMPs. The future of our practices may hinge onyour efforts. Please keep letting us know ways you think we can help.

Haresch>> Solo and small practice docs need that level of support without the

costs> and overhead. I don't mean the same content and approach as itdoesn't jibe> with the way we do things, but we ought to be able to receive experthelp> that really works and really makes our practices better.

> > > > This is what we're growing toward in our group. We help each other,we know> the issues, we strive for excellence in operations, use of IT, we> commiserate with each other around the ubiquitous failings of the

greater> non-system and how much we get punished for trying to do the rightthing.> > > > One aspect I'm working hard on is to help shift the policyenvironment to> make it less toxic to solo and small practices. The things I'm

pushing for> include:> > - Changes in payment that provide adequate funding for usto do all> of the work for which we were trained> > - Changes in the administrative burden brought by insurance

> companies in the guise of " improving quality and reducing costs " > > - Changes in the proposed measurement of care approaches that> appear likely to put a stake through the heart of solo & small practices

> > > > Solo and small practices still make up a significant proportion ofthe US. > > We can have an effect if we work together.> > This can be done if on occasion we work in concert to raise our

individual> and collective voices, targeting specific policy makers withspecific policy> suggestions.> > > > Policy makers are surrounded by the usual and customary players.

Some are> proposing real and substantive change and are being shouted down bythose> who advocate incrementalism and the status quo. They can moveforward only> if they know there is a constituency outside the Beltway that is

yearning> for real change.> > > > Our first attempt is through the petition:> > www.PatientsAtCenter.org <http://www.patientsatcenter.org/>

> > It is one approach that has even in its infancy caught the attention of> some. > > Some IMPs are working hard and fast to create a vehicle that can help us> connect with policy makers fast and in large numbers.

> > Stay tuned as we gear this up.> > > > I know that many of you have all but given up hope that change will ever> come and/or are so close to precipice that your struggle for

survival takes> every ounce of energy.> > For those of you who can raise your eyes from the morass ofhelplessness and> hopelessness please add your voice.> > Our strength is our profession and our numbers.

> > Our strength is evidence supporting what we do.> > Our strength can only be evident if each of you can find it in youto step> up.> > > > Now is the time for action. Don't continue to suffer helplessly while

> merely creating noise through Brownian motion - take concerted action to> effect real change.> > Gordon

-- Crowley, MDFamily MedicineCape May Courthouse NJPatients, please allow up to 48 hours for response. If you are having an urgent problem please go to the emergency department or call 911. If you have a problem or question that can't wait 48 hours, or you have not received a timely response, just call the office at 465-0882.