Stephen Beeson, MD, gives a very encouraging account of the perfectibility of practice in this issue. And he apparently has every right to be encouraging, since his group has accomplished a great deal of perfecting over the past several years. Given FPM’s focus on practice improvement, I’m delighted to be encouraged. Still, I find myself thinking how hard it can be to make significant and lasting improvements in a system that depends heavily on human input.

The stumbling block is human nature, of course. While training and coaching can accomplish a lot, there’s a point beyond which they’re powerless. In the end, you need the right people to get the right stuff done. Jim Collins, in Good to Great, his much-cited study of companies that transformed themselves, arrived at the at-first-surprising finding that people are more important than vision: “The executives who ignited the transformations from good to great did not first figure out where to drive the bus and then get people to take it there. No, they first got the right people on the bus (and the wrong people off the bus) and then figured out where to drive it.”¹

What do you think? Is everyone in your practice “the right people”? Are they all capable of giving and taking (and profiting from) objective feedback? Do they all believe that they are perfectible, not perfect? Are they all open to trying different approaches? Can they all support and work toward a shared vision? Can they communicate with one another across all levels of the practice? ² If not, your vision of a better future may be hard to reach. And if “the wrong people” include physician or administrative leaders of your practice, it may even be a mirage.

I don’t mean to be depressing, just realistic. And with so much said and written these days about practice redesign and medical home construction, a dose of reality can hit awfully hard. You can make a difference. You can improve your practice. It’s just that, as you and I both know, the job is harder than success stories can make it seem. That’s no reason not to keep trying. Just don’t expect it to be a pushover, and you’ll be less likely to give up prematurely.