In our cover story, John-Henry Pfifferling, PhD, defines a dysfunctional practice as “one that enables inconsistencies and interpersonal abuses, harming the emotional and professional health of those who work there. It is a toxic work environment” (page 40). Much as I hope you do not work in such an environment, I fear that many family physicians do, and I trust that they will find the article useful. My purpose here, however, is not so much to talk about Pfifferling's article as to steal his definition and bend it to my own purposes.

Let me suggest a slight change in wording and focus: A dysfunctional health care system is one that enables inconsistencies and abuses that harm the physical, emotional and financial health of everyone involved and undermine the social and fiscal stability of society at large. It is a toxic environment.

Does that sound like any health care system you know of?

I invite you to read Pfifferling's article at least twice. The first time through, think about whether and how it applies to your practice and what you might be able to do to improve things. The second time through, take the author's description of a toxic practice as an allegory for the entire U.S. health care system. It doesn't apply from top to bottom, but certain parallels are pretty evident. For instance, is the following passage any less true of the system than a single practice? “Disorder rules. Policies and roles are either not clarified or are changed at a whim. Expectations are unclear and unrealistic. Discussion of the vision and development of an agreed upon strategic plan is avoided. Employees are subjected to impulsive requests, have no sense of stability and feel compelled to conform to arbitrary control. Their professional self-esteem is dependent on unpredictable forces. They take out their stress on other colleagues, patients or family members.”

Is it a dysfunctional system or dysfunctional practices that “do not reward collaboration and interdependence”? Is it the practice or the system where “invasive and noninvasive specialists are pitted against each other”? Is it the practice or the system that “remains ineffective because the organizational teamwork that would produce a clear vision and realistic objectives is unknown to the members”?

Unfortunately, the analogy between practice and system doesn't work as well when Pfifferling gets to potential solutions, even the most extreme: “If you're in such a situation, it's time to develop an exit strategy.” Sure, that could work for a bad practice, but even leaving medicine altogether wouldn't free you from the health care system; sooner or later, you'd be back as a patient. To escape completely, you'd have to head for a country with better health care.

Picking up the pieces

So what do we do? Perhaps because I'm not politically inclined, I tend to hold little hope for political solutions, although I would be glad to be proved wrong. Nor am I optimistic enough to think that any sweeping solution is likely. Even the complete collapse of our current system would leave us unequipped as a society to replace it with anything much better.

I am, however, a fan of brightening the corner where you are. Certainly, curing a dysfunctional practice or making a good one into a high-functioning one is an excellent place to start, and if you can reach beyond the bounds of a practice, so much the better. For instance, the Future of Family Medicine project, highlighted in this issue by articles from Bruce Bagley, MD, and Steven Spann, MD, MBA (pages 59 and 68), is an effort to brighten all of family medicine. Of course, any effort to optimize one part of a system is likely to have some unfortunate consequences, but I'm not sure we have much choice. Whatever energy and commitment you can muster is well worth throwing into the fight to enlighten those parts of the system you can touch. Even a small bubble of sanity in the chaos has to be better than none.