In a previous SpineLine¹, I commented rather critically on outpatient basis satisfaction measures actually decreased the quality of care and increased practitioner stress. Unfortunately, patient-based outcome measures are far from being the only stressors in our profession. Physician burnout leading to decreased quality of care, decreased patient safety and satisfaction, personnel turnover, and decreased productivity is certainly being influenced by health care quality measurement policy.² Current estimates of physician burnout nationwide are around 66%; in one particularly sobering study, Rosen et al have estimated that administrative burden has resulted in practitioners, particularly employed practitioners, spending less than 15% of their professional day and direct patient care.³ Another factor which has impacted practitioner well-being is the fact that over 70% of health care specialists are employed by hospitals or health systems. This has had an extremely negative effect, contributing to physician dissatisfaction and burnout via disruption of locus of control. This concept is based on an individual belief system regarding the causes of personal and professional experiences and the factors to which the individual attributes success or failure. Individuals with an internal locus of control attribute their successes to their own abilities and initiatives. Interestingly, those who develop an internal locus of control at the age of 10 have been shown to have lower levels of psychological stresses as adults. The concept of self-efficacy, a sense of self-sufficiency, and the belief that one is able to accomplish tasks and achieve goals, are crucial to the notion of a successful, functioning internal locus of control. Excessive regulatory burdens in the employed physician/practitioner model have tended to erode this internal locus, shifting it to the less effective and more distressing external locus of control with decreased self-sufficiency and a feeling that the individual is increasingly unable to function in a self-determining manner.⁴ In the last 20 years, multiple quality measures, each seemingly more burdensome than the last, have been instituted. The patient protection and affordable care act (2010), time performance metrics (such as value-based purchasing), Medicare access (2015), quality reporting, introduction of the merit-based incentive payment system (MIPS) and accountable care organizations (ACO's) proposed by the centers for Medicare and Medicaid services (CMS) have all increased the omnipresent bureaucratic and administrative burdens. A small number of groups have received $1.3 billion for developing these measures over the past 15 years. This has essentially provided incentives for larger institutions and industry to encourage more development of more measures which are rewarded by more financial contracts.⁵ Currently CMS has 2,266 quality metrics.⁶ The cost of this is overwhelming. One large academic center reported 108,000 person-hours devoted annually to report on 162 metrics.⁷ CMS has acknowledged that these quality metrics may be redundant and excessive. An attempt has been made to condense some metrics, in the form of the Meaningful Measures Initiative (2017). This has had some affect with 15% of the metrics removed in the first three years of the initiative. Much work remains to be done, however. Some authors5 suggest that implementation of metrics focused on clinician experience would be appropriate. Additionally, the quality metrics should have a finite quantitative limit, and undergo continuous assessment and improvement. One agency that may prove helpful in the streamlining process is the Agency for Healthcare Research and Quality, which has demonstrated the ability implementation of continuous assessment and improvement. Whether or not increased involvement of this particular agency will result in increasing consolidation of health care metrics remains to be seen. We should all certainly hope that it does. Moving on to our first issue with a new digital-only format, Zo Ghogawala’s President’s Message delivers a timely message on collaboration. Pedro et al, in a timely piece, discuss the shifting demographics of spinal cord injury (SCI). They note that with the aging population comes an increase in the mean age of SCI patients. As expected, the mechanism of injury are ground-level falls. They make a very cogent case for a multidisciplinary approach to these patients, emphasizing the utility of the frailty index. Somewhat surprisingly, the authors note that more aggressive care in certain syndromes, eg, central cord syndrome, may be appropriate in all age groups. Allison Waxler does her usual superb and succinct job reviewing 2024 CPT code changes and the Medicare physician fee schedule. In the Literature Review, Jabbouri and Grauer discuss a study comparing laminoplasty versus laminectomy; conclusions are somewhat surprising. Finally, Shahzad et al, present the results of a very important symposium at the recent Annual Meeting, Perception, and Awareness of Gender Representation in Spine Surgery. The results of this were disappointing and surprising, with most symposium participants not aware of the magnitude of many issues facing women in spine surgery. This is a must read, as awareness of this crucial issue will be the only way in which we can address it and correct the mistakes that have been made for many years. I am personally very pleased that this work will appear in this, the first digital issue. Hopefully, this will be a harbinger of progress.