This issue of the JACM (25:4) focuses on changes in physician leadership and practice, key lynchpins to eventual, serious quality improvement in ambulatory care. Edited by a physician and hospital system's chief executive officer, Dr. Ronald Goodspeed brings to bear a wealth of experience to this critical issue facing ambulatory care professionals.

I must say that I am still somewhat depressed after reading the excellent articles in this issue. The myriad of payment systems that we, as health care professionals, confront guarantees a lack of focus on quality improvement. Granted that in a relatively small number of clinical practices, such as the Lahey Clinic, a CEO, by dint of leadership, can provide a focus on quality. Such leadership is rare in today's dog-eat-dog, fee-schedule constrained system. Fee-for-service ensures a focus on visits by a human, not the human being. While we await a focus on quality that can only be brought about by reasonable payment that encourages population management (i.e., fair capitation), this issue of the journal brings to bear many of the current issues facing physician leadership in ambulatory care and physician-hospital relationships.

We continue with several regular features including:

* Ray Carey's outstanding series on statistical aspects of quality management

* A note from Physicians for Human Rights reminding us that we have more to health carethan the doctor/health care team-patient relationship

* Mark Holt's series on the maddening world of health care that, in the final analysis, onlyhumor can cure