This issue is focused on the ultimate customer-the patient. Maxwell Drain, a researcher on patient-related issues, serves as guest editor. In addition, we continue with our regular columns on human rights and the commentary on the state of managed care from the "Republic" of Texas.

Payers, particularly large employers, have decided that they are unable to control skyrocketing health care costs. Managed care did not provide the silver bullet. Wherever there is no union contract, payers are either demanding that consumers foot a much greater percentage of health care expenses or they are not renewing coverage at all. At least some consumers are demanding "value" for all the money they are laying out. This, in part, explains the need on the part of managers of ambulatory care to be more customer focused.

An entirely separate stream of research literature demonstrates the positive impact of patient involvement on health outcomes. This, together with the plethora of information available on the Internet, mandates that ambulatory care managers become serious about involving patients as partners in the care they receive. When I see my diabetics, for example, I try to convince them they can improve their diabetes care if they come to understand that I am their assistant. I am available to provide them with information and therapeutic suggestions on changes in their insulin. Ideally, I would like to teach them enough so that they can make the vast majority of clinical decisions on their own. In summary, the challenge that we face in ambulatory care is patient empowerment within the framework that we are available whenever there is something askew in their care. As a final example, I recently saw a patient who had gone the night before to the emergency room with abdominal pain. She said she felt no better. She asked me, "Dr. Goldfield, don't you think that I might have appendicitis?" After examining her, I decided that I'd done a good job training my patient to view me as her assistant and partner. She was right. I sent her back to the emergency room less than 12 hours after she'd been sent home and she was operated on that night.

Over the next few years, consumers will not only demand greater involvement in their health care but we will be able to provide better information tailor-made for the specific patient. We will be able to measure the costs and quality of episodes of outpatient care with much greater precision than is currently possible. This information will be of interest to both patients and physicians alike.

Maxwell Drain has provided us with an excellent summary and set of articles that demonstrates the vitality of the patient/customer movement.