Clearly, it's possible to improve your practice one piece at a time. You can improve your coding now, institute a better procedure for tracking lab orders later and, after a while, figure out ways to cut patient waiting time. But can you ever achieve radical practice redesign by this route, or does it doom you to merely better practice and not the kind of transformed practice being held up as the ideal today? It has been argued that true transformation requires a massive, even convulsive effort – a leap to the top of the mountain rather than a step-by-step climb.

On page 18 of this issue, Anton Kuzel, MD, MHPE, argues that gradual transformation is possible – that you can start by making manageable changes to increase practice revenue and, 10 manageable steps later, end by turning your practice into a full-fledged patient-centered medical home (PCMH). The prospect offered by his article is certainly enticing, especially considering the number of family medicine practices that don't believe they are up to leaping tall mountains in a single bound.

I do think Kuzel's approach is at least harder than the article makes it sound. For one thing, it requires a practice full of people with the right attitude – physicians and staff who are dedicated to the practice, flexible, creative and willing to try new things. True, some of that can probably be built step-by-step using team development approaches (see, for instance, the “Practice-based care team” section of FPM's PCMH article collection at https://www.aafp.org/fpm/collections/pcmh).

But I can well imagine Kuzel's approach failing in some practices for lack of support – either from physicians who can't get used to the idea of accepting input from staff or from staff who view their jobs as limited to doing what they're told. Wherever you start your climb, you won't get far unless you're climbing with the right people.

That said, I hope some practices out there are brave enough to follow Kuzel's route to the top. If it works, it should minimize the stress and financial hardships involved. If it takes you even part way to the top, it should leave you with a better, healthier practice and a better shot at going all the way later.