Dr. Pappas recalls the state of medicine during his residency in Boston. It was practiced on a much smaller, more regional scale than in today's world of managed care and enormous health insurance companies. Since his start in medicine, hospitals have shifted from being independent and serving all the needs of a region, to being part of a regional system, each hospital providing a part of the care needed by patients in the area. He recognizes that the central issues in the current healthcare structure are "how do we monitor quality, assure affordable access and provide reasonable economic reassurance for the physicians?". Focusing on primary care physicians, who he says are still the basis of healthcare delivery in spite of the increasing role of others such as nurse practitioners, Pappas offers three issues to keep in mind when trying to solve these healthcare problems. The first is Access, understood to mean that when a primary care physician requests further care for a patient, it is given promptly, and without question. Second is Information, meaning that while the patient is under the care of someone other than his primary physician, that his primary doctor be kept fully informed of his care, for the benefit of the patient's care and for his family's reassurance. The third point is Respect. He is referring to the respect that must be held between physicians, regardless of specialty or status, which is vital to a congruous healthcare system and good patient care.
Dr. Pappas suggests that an "integrated medical continuum" is the key to a successful medical structure. This system involves a hospital leadership triad, a larger administrative group representing all area hospitals, and continued education opportunities to benefit "patients, physicians, and management." Pappas sees that medical specialism has become too narrow and believes that such extreme specialization is fragmenting the medical profession. In order to combat the for-profit insurers, he says, physicians must "develop a collective offense and limit our porous specialty fragmented defense."