TIME health

Changing the Face of Medical Education in the U.S.

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Zocalo Public Square is a not-for-profit Ideas Exchange that blends live events and humanities journalism.

We have a focus on wellness, prevention, chronic disease management, and finding ways to deliver health care in the most cost-effective setting

The United States spends more money on health care than any other country in the world. So how does Costa Rica outperform the United States in every measure of health of its population?

Costa Rica is healthier because its government spends more money than ours does on prevention and wellness.

In our country, we have left vast segments of the population without affordable care and we do not focus on wellness or chronic disease management. We don’t consistently control the glucose levels in diabetics and, consequently, too many go blind or lose a limb. Too often, hypertension goes untreated until the patient has a stroke or kidney disease. Then, all too often, these individuals go on medical disability with far more societal expense than the cost of the original health management.

Sadly, it has become the American way to leave many chronic diseases untreated until they become emergency situations at exorbitant cost to the U.S. healthcare system. For many patients, this care is too late to prevent life-changing disabilities and an early death.

When people ask me why we started the UC Riverside School of Medicine last year – the first new public medical school on the West Coast in more than four decades – I talk about the need for well-trained doctors here in inland Southern California. But we also wanted to demonstrate that a health care system that rewards keeping people healthy is better than one which rewards not treating people until they become terribly ill.

As we build this school, we have a focus on wellness, prevention, chronic disease management, and finding ways to deliver health care in the most cost-effective setting, which is what American health care needs.

We also teach a team approach to medicine—another necessary direction for our health care system. If you have a relatively minor problem, your doctor might refer you to a nurse practitioner or physician assistant for follow-up. This kind of team care makes financial and clinical sense, particularly since we have such a national shortage of primary care doctors. The good news: Even among physicians, the team approach, or medical home model, is gaining ground, with the Affordable Care Act accelerating change.

For all the talk about the lack of health insurance in this country, we don’t often discuss the other side of the problem – the fact that many Americans get more care than they need. You may have heard advertisements that you should have your wife or mother get a total body scan for Mother’s Day, because it will find cancer or heart disease. There is no evidence that this screening is a good idea. But in the U.S., we often encourage people to do things that have no proven benefit, and our churches or community centers sponsor these activities.

For all these reasons, we must shift the focus of health care to prevention. Two of the most profitable prescription drugs in the U.S., according to some sources, are those that reduce blood cholesterol and prevent blood clots—both symptoms of coronary heart disease, a largely preventable condition. Shouldn’t we be spending at least as much on prevention as we do on prescriptions? Closely connected to prevention is wellness. So many of our health problems in the United States are self-inflicted, because we smoke, eat too much, and don’t exercise. Doctors need to “prescribe” effective smoking cessation programs, proper diets and exercise as an integral part of care.

One way to accomplish this shift is to teach it to future doctors. At UC Riverside, we are supplementing the traditional medical school curriculum with training in the delivery of preventive care and in outpatient settings. Our approach is three-pronged..

First, we work with local schools and students to increase access to medical school through programs that stimulate an interest in medicine and help disadvantaged students become competitive applicants for admission to medical school or other professional health education programs. These activities start with students at even younger than middle school age, because that is when students begin to formulate ideas about what they want to be when they grow up. We focus on students from Inland Southern California because students who live here now will be among those best equipped to provide medical care to our increasingly diverse patient population. Doctors who share their patients’ cultural and economic backgrounds are better at influencing their health behaviors.

Second, we recruit our medical students specifically with a focus on increasing the number of physicians in Inland Southern California in primary care and short-supply specialties. Our region has just 40 primary care physicians per 100,000 people—far below the 60 to 80 recommended—and a shortage in nearly every kind of medical specialty. Students who have been heavily involved in service such as the Peace Corps, or who are engaged in community-based causes, are more likely to go into primary care specialties and practice in their hometowns.

Then, we teach our medical students an innovative curriculum. For instance, the Longitudinal Ambulatory Care Experience, called LACE for short, replaces the traditional “shadowing” preceptorship, where students follow around different physicians. Instead, our students participate in an a three-year continuity-of-care primary care experience that includes a sustained mentor-mentee relationship with a single community-based primary care physician. In this experience, they “follow” a panel of patients and gain an in-depth understanding of the importance of primary care, prevention and wellness. Our approach also includes community-based research that grounds medical students in public health issues such as the social determinants of health, smoking cessation, early identification of pre-diabetic patients, weight loss management and the use of mammograms to detect breast cancer.

We try to remove the powerful financial incentive for medical students to choose the highest paying specialties in order to pay off educational loans. We do this with “mission” scholarships that cover tuition in all four years of our medical school. This type of scholarship provides an incentive for students to go into primary care and the shortest-supply specialties and to remain in Inland Southern California for at least five years following medical school education and residency training. If the recipients practice outside of the region or go into another field of practice before the end of those five years, the scholarships become repayable loans.

Third, we are creating new residency training opportunities in our region to capitalize on the strong propensity for physicians to practice in the geographic location where they finish their post-M.D. training. Responding to our region’s most critical shortages, we are concentrating the programs on primary care specialties like family medicine, general internal medicine, and general pediatrics, as well as the short-supply specialties of general surgery, psychiatry, and OB/GYN. We are also developing a loan-repayment program for residents linked to practice in our region.

Ultimately, we hope our ideas for how to change health care will succeed and be adopted by others. It might take 30 years, but we believe what we are doing at the UC Riverside School of Medicine will change the face of medical education in the U.S.

G. Richard Olds is vice chancellor of health affairs and the founding dean of the UC Riverside School of Medicine. He wrote this for Zocalo Public Square. Zocalo Public Square is a not-for-profit Ideas Exchange that blends live events and humanities journalism.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME portfolio

Matt Black Is TIME’s Pick for Instagram Photographer of the Year 2014

The Californian photographer has spent the last year putting poverty on the map using Instagram

For many of his Instagram followers, Matt Black is a newcomer. He joined the photo-sharing app in December of 2013 to chart, through a series of gritty and deeply personal black-and-white photographs, the physical terrain of economic inequality in his native Central Valley of California, home to three of the five poorest metropolitan areas in the U.S.

“The Central Valley is this kind of vast unknown zone,” Black says. “These towns, these communities are right in the heart of the richest state in the richest country in the world. It’s halfway between Hollywood and Silicon Valley, and yet, you still have conditions like these,” where poor communities are left with bad roads, dirty water, crummy schools and polluted air.

Black’s work might be new to Instagram, but the 44-year-old photographer has spent more than 20 years exploring issues of migration, farming and the environment in the area. That was never his intention, though. “When I first started in photography, my goal was to get out of the Central Valley,” he says. “But it quickly became clear to me that if I had a significant thing to say, it would be about the place I’m from.”

Over 100 years, migration, farm labor and poverty have shaped the region, he says. “These are the places that actually produce what feeds the nation, and the irony is that we’re so dependent on these communities for food and yet rarely do people take time to actually look at them and understand what the challenges are, what these folks are facing — what their lives are like.”

Black’s Geography of Poverty project is designed to address these issues. “People should care because we’re all implicated in this system,” he says. “What we pay at the supermarket is what eventually goes to the farms and goes to the farm laborers. We’re all connected. So, [if] I can lift that veil and make that connection between what we eat, the choices we make, and how that impacts real people — communities — that’s the role I can play.”

The best way to do so, Black explains, was by using the unlikeliest of platforms for a photographer who developed his visual identity at a regional newspaper where black-and-white fiber paper prints were the norm.

There’s no doubt that Black is an unconventional choice for Instagram Photographer of the Year. For one thing, he doesn’t always uses an iPhone to shoot the images he posts on his feed – “It’s a mixture of iPhone and a Sony RX 100 camera,” he says, “but it seems like the convention is: if you’re upfront about it, then you’re not cheating, so I’ve been upfront about it.” Second, he’s not a prolific user. In the year since he joined the photo-sharing network, he’s posted 73 images – an average of one photograph every five days. That’s because he doesn’t look at Instagram as a daily journal. “I want each image to contribute and advance this portrait that I’m building, and if I feel like the images that I shot don’t meet that standard, then I don’t publish that day. I’ll wait until the next time.”

For him, Instagram’s appeal resides in its mapping feature – which allows photographers to add geographic coordinates to their images. “Maps are fantastic,” says Black. “They [offer] a complementary augmentation of reality. Photography and maps are similar: they’re born out of the same idea of describing a place for another person to engage with. And, they are right there, together, on that same platform. Without this map, I would not be on Instagram.”

The mapping feature might have attracted Black to Instagram, but the newfound freedom and sense of community is what kept him on the photo-sharing app. “I started Geography of Poverty with 20 followers. I had no clue if people would even understand what this was, and [I didn’t know] whether or not people would want to engage with me over these issues.”

To his surprise, Black found that Instagram users valued substance, engaging with the photographer and his work. “That’s reflected in the comments,” he says. “It’s interesting because in my other work, which are long-term photo essays, I’d spend one or two years trying to tell a story, and people wouldn’t have an opportunity to respond. It was top-down. On Instagram, it’s an unfolding, ongoing narrative, and people engage with that in a new way. It’s something they choose to receive. People take it in. People receive the work in a more intimate way. It’s right there, close to them. You don’t get that same reaction from a gallery show or from a book.”

This, he adds, offers “a fantastic opportunity for photographers to have an independent voice. There are hundreds of millions of people on Instagram wanting to engage with photography. If you’re a photographer working on these issues for so long, how can you not want to reach those people?”

Matt Black is a freelance photographer based in California. Follow him on Instagram @mattblack_blackmatt. In 2013, David Guttenfelder was TIME’s Instagram Photographer of the Year.

Phil Bicker, who edited this photo essay, is a Senior Photo Editor at TIME.

Olivier Laurent is the editor of TIME LightBox. Follow him on Twitter and Instagram @olivierclaurent

TIME motherhood

YouTube CEO: America Needs Paid Maternity Leave

Vanity Fair New Establishment Summit - Day 2
Youtube CEO Susan Wojcicki speak onstage during "Who Owns Your Screen?" at the Vanity Fair New Establishment Summit on October 9, 2014 in San Francisco, California. (Kimberly White--Getty Images for Vanity Fair) Kimberly White—Getty Images for Vanity Fair

It's not just good for women, it's good for business

YouTube CEO Susan Wojcicki wrote an op-ed in the Wall Street Journal Wednesday reminding everyone that paid maternity leave isn’t just good for women, it’s good for business.

She cited a 2011 survey from California’s Center for Economic and Policy Research that found that, after California implemented paid leave, 91% of businesses said the policy had either a positive effect on profitability, or no effect at all. Wojcicki, who was the first Google employee to go on maternity leave and now runs YouTube, which is owned by Google, says she’s seen this firsthand:

That last point is one we’ve seen at Google. When we increased paid maternity leave to 18 from 12 weeks in 2007, the rate at which new moms left Google fell by 50%. (We also increased paternity leave to 12 weeks from seven, as we know that also has a positive effect on families and our business.) Mothers were able to take the time they needed to bond with their babies and return to their jobs feeling confident and ready. And it’s much better for Google’s bottom line—to avoid costly turnover, and to retain the valued expertise, skills and perspective of our employees who are mothers.

Best of all, mothers come back to the workforce with new insights. I know from experience that being a mother gave me a broader sense of purpose, more compassion and a better ability to prioritize and get things done efficiently. It also helped me understand the specific needs and concerns of mothers, who make most household spending decisions and control more than $2 trillion of purchasing power in the U.S.

As Wojcicki notes, paid maternity leave can reduce risk of post-partum depression, keep babies healthy, and encourage mothers to stay in the workplace, yet only 12% of private workers and 5% of low-income workers in the U.S. have access to these benefits. Every other developed nation in the world has government-mandated paid maternity leave, and when the UN‘s International Labor Organization surveyed the maternity leave policies of 185 nations, the U.S. was one of two countries that don’t guarantee paid maternity leave. Papua New Guinea is the other.

She wants America to get cracking on paid maternity leave, stat.

[WSJ]

TIME health

How Obamacare Has Changed My Hospital

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So far in 2014, we have brought almost 7,500 new patients into primary care facilitating better preventative health and chronic disease management

The holidays are a convenient time to take stock of our blessings and opportunities, and to consider the challenges we have overcome in the previous year. As I reflect back, I have many things to be thankful for: good health, a supportive, healthy family, colleagues I enjoy and respect, and a job that I love.

This year, the Affordable Care Act (ACA) had a profound and rapid change on my professional life as a physician who works in an institution that forms part of California’s safety net for those in need. I’m the chief medical officer for San Mateo Medical Center, the county hospital and affiliated clinics in San Mateo County. I also provide primary care in one of our outpatient clinics.

As a result of the ACA, many patients we serve in our county became newly eligible for Medi-Cal, California’s Medicaid program. With this transition, they were offered far more choices: They had access to services that were previously unavailable, such as dental services and expanded mental health services. And, instead of having to travel to our specialty clinic in the middle of the county, they could be referred to “private” specialists in their own communities. Far from luxuries, these new choices will help promote preventative care and early disease intervention; patients who in the past might have delayed a gallbladder or hernia surgery (and ended up in the emergency department with pain) can get prompt treatment with their new Medi-Cal coverage.

Before the ACA, most of our patients were either uninsured or were enrolled in a county program that only covered services at our institution; they could not seek care elsewhere. So more choice for patients means more pressure on us; as patients become eligible for Medi-Cal, they may now choose to leave our organization to seek care elsewhere. I will try to avoid clichés as I write this, but there is one that is especially appropriate here: “pressure makes diamonds.” I am seeing a spectacular gem being built around me here in San Mateo, far from flawless but beautiful nonetheless.

Competition has forced us to confront some difficult questions, such as: What is the role of the safety net in this new era when many more people are insured? Why should we, as an institution, continue to exist? Thankfully the answers to these questions came fairly easily.

As an integrated health system, we offer a range of services from outpatient to emergency services to inpatient to long-term care; we offer a distinct advantage over the traditional fragmented health care system. Embedded in the San Mateo County Health System, we can work with our colleagues in Adult and Aging Services, Family Health Services, and Public Health to better meet all the psychosocial needs of our patients. For example, our partnership with the county’s Behavioral Health and Recovery Services has allowed us to embed behavioral health experts in our primary care clinics so that they can better address the mental health needs of our patients; this partnership also expands our ability to refer patients with drug and alcohol problems.

As our patients have moved to Medi-Cal, the ACA has brought our institution some new funding. But we realize that this will be short-lived; many of the new programs of the ACA are funded by reductions to other parts of the safety net. Such pressure is not new; safety net programs are often short of resources, forcing adjustments and redesigns. But the ACA ramps up this pressure on us to innovate, to find ways to do things cheaper and more efficiently.

Fortunately, we had a head start. We began almost a decade ago by redesigning our primary care services and establishing team based care. The county implemented an electronic health record in our clinics long before there was a mandate to do so. The ACA, through its resetting of priorities and funding mechanisms, offers us an opportunity to build on this foundation. We have repurposed some staff roles and brought in new staff members with new skill sets. For example, we have staffers who are specially trained to extract information from electronic records to better manage chronic disease, and pharmacists have been added to some primary care teams to assist with medication management.

The ACA has facilitated new partnerships with other community provider, allowing us to focus on those services that we provide well while partnering to provide services that are best delivered by others. This is a transition from the past, when we were the provider of last resort, forced to provide as much as we could and living without the services we could not provide by ourselves.

One of our biggest investments has been in what we call our Lean transformation. Lean, based on the Toyota Production System, is a proven performance improvement methodology. Lean healthcare principles focus on increasing value by constantly improving quality and reducing defects and other wastes. Within the San Mateo County Health System, this transformation is being organized through our LEAP Institute. LEAP stands for Learn, Engage, Aspire, and Perfect (as a verb). As part of LEAP, we bring together teams that include line staff to observe and analyze our core processes – and then design new improved approaches that reduce waste and improve outcomes.

There is much work ahead, but much has already been accomplished. So far in 2014, we have brought almost 7,500 new patients into primary care facilitating better preventative health and chronic disease management. The majority of these patients are newly eligible for Medi-Cal. We have also seen a reduction of more than 20 percent in the number of patients leaving our Emergency Department without being seen due to long waits. We have seen an improvement in our performance on patient satisfaction surveys in a variety of areas including the Emergency and Inpatient Departments. And our pharmacy has reduced the time patients must wait for their prescriptions by about 75 percent. These are just a few of the gains. We look forward to many more.

Dr. Chester Kunnappilly is chief medical officer for San Mateo Medical Center, the county hospital and affiliated clinics in San Mateo County. He is board certified in Internal Medicine and also serves the organization as a primary care physician. He is a graduate of Dartmouth College and the University of Pennsylvania Perelman School of Medicine. He wrote this for Zocalo Public Square. Zocalo Public Square is a not-for-profit Ideas Exchange that blends live events and humanities journalism.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Know Right Now

Know Right Now: From California’s Pineapple Express to Another Shutdown Drama

Watch this week's #KnowRightNow to catch up on all the latest stories

The House passed a $1.1 trillion spending package late Thursday to ensure that the government will avoid another damaging shutdown. “This compromise proposal merits bipartisan support on Capitol Hill and hopefully will arrive on the President’s desk in the next few days, and if it does, he will sign it,” stated White House Press Secretary Josh Earnest.

A tropical storm called the Pineapple Express pummeled the Pacific Northwest on Thursday. In drought-stricken California, flooding and mudslides prompted rare school closures in the north of the state. Powerful winds knocked out power to more than 150,000 homes in Washington.

Gas prices hit a 4-year low this week, with the average price of gas in the United States sinking to $2.72 per gallon. That’s the lowest gas prices have been since November 2010. Prices are dropping due to higher North American oil production and less demand. New Mexico has the lowest gas prices at $2.38 per gallon, and San Francisco has the highest gas prices at $3.04 per gallon.

And lastly, on Wednesday, TIME Magazine chose the Ebola fighters as 2014’s Person of the Year. “They risked and persisted, sacrificed, and saved,” TIME editor Nancy Gibbs wrote.

TIME movies

Watch the Trailer for Dwayne Johnson’s Upcoming Earthquake Epic San Andreas

“Where will you be, who will you be with, when everything falls apart?”

The official trailer for Dwayne “the Rock” Johnson’s next film San Andreas is out: and it’s equal parts epic and terrifying.

Johnson posted the trailer on his Twitter account. It shows a massive earthquake laying waste to buildings, roads and dams across Los Angeles and San Francisco, between black screens bearing the words “Where will you be, who will you be with, when everything falls apart?”

The film is scheduled for release on May 29 next year, and also stars Paul Giammati, Archie Panjabi and Carla Gugino.

TIME 2016 Election

Meet the People Who Might Try to Replace Barbara Boxer

The list is long, but so far entirely speculative

If Democratic Sen. Barbara Boxer steps down at the end of this term—as many are speculating she will—it would be the first major shakeup in California congressional politics in years. With that in mind, Golden State political hopefuls are already jockeying for position to succeed her. To be sure, many of the names being floated will never rise much further than this list, but here are some of the people who may try to succeed her.

TIME justice

Chokehold-Death Protest Gets Violent in California

A protester flees as police officers try to disperse a crowd comprised largely of student demonstrators during a protest against police violence in the U.S., in Berkeley
A protester flees as police officers try to disperse a crowd comprised largely of student demonstrators during a protest against police violence in in Berkeley, Calif. Dec. 7, 2014. Noah Berger—Reuters

Across the nation, overwhelmingly peaceful demonstrations in solidarity with Eric Garner continued

(NEW YORK) — Mostly peaceful protests of a grand jury’s decision not to indict a white police officer in the chokehold death of an unarmed black man continued around the country, but authorities said a march in California turned violent when a splinter group smashed windows and threw objects at police.

A Berkeley police officer received hospital treatment for a dislocated shoulder after being hit with a sandbag, while another sustained minor injuries, police spokeswoman Jenn Coats said.

She said several businesses were looted and damaged when a splinter group broke off from the peaceful demonstration Saturday night, and officers attempting to get the crowd to disperse used smoke and tear gas. Protesters threw rocks, bricks, bottles, pipes and other objects at officers, and some squad cars were damaged.

At least six people had been arrested by the time the unrest ended early Sunday morning, Coats said.

Thousands of demonstrators have protested peacefully in New York and elsewhere since the announcement Wednesday that a grand jury declined to indict a white officer in the death of Eric Garner, a black man who gasped “I can’t breathe!” while being placed in a chokehold as he was being arrested for selling loose, untaxed cigarettes. The decision closely followed a Ferguson, Missouri, grand jury’s choice not to indict a white officer in the fatal shooting of Michael Brown, an unarmed black 18-year-old.

The scope of the demonstrations and the lack of violence were moving to Garner’s mother and widow, they said Saturday.

“It is just so awesome to see how the crowds are out there,” said Eric Garner’s mother, Gwen Carr, who added that she ended up stuck in her car after protests shut down traffic.

“I was just so proud of that crowd,” Carr said. “It just warmed my heart.”

Garner’s widow, Esaw Garner, said she saw demonstrators from her apartment window and told her son, “Look at all the love that your father’s getting.”

Officers have said the outcry over the grand jury decision has left them feeling betrayed and demonized by everyone from the president and the mayor to throngs of protesters who scream at them on the street.

“Police officers feel like they are being thrown under the bus,” said Patrick Lynch, president of the police union.

Garner’s family members joined the Rev. Al Sharpton later Saturday as Sharpton laid a wreath at the site on Staten Island where Garner died July 17 in a confrontation that started when police tried to arrest him.

An amateur video seen by millions showed Garner gasping, “I can’t breathe” during the fatal encounter.

“All we’re concerned about is justice from the police,” said Garner’s stepfather, Benjamin Carr, who wore a T-shirt with the words, “Enough is enough.”

Protests continued in New York City for a fourth day with several dozen people lying down on the floor of Grand Central Terminal and marching into stores in Times Square. There were no reports of arrests.

Protests have also been held in Philadelphia, Chicago, Miami, Las Vegas and a number of other cities.

In Seattle, several hundred people marched downtown to police headquarters Saturday. Authorities said a group then split off from the main protest and tried to get onto a roadway. Police say some protesters threw rocks at officers who blocked them from entering it. Seven were arrested.

Sharpton announced plans this week for a march in Washington, D.C., next Saturday to protest the killings of Garner, Brown and others and to press for change at the federal level.

 

TIME Environment

California’s Drought Is Now the Worst in 1,200 Years

California Drought Dries Up Bay Area Reservoirs
A car sits in dried and cracked earth of what was the bottom of the Almaden Reservoir on Jan. 28, 2014 in San Jose, Calif. Justin Sullivan—Getty Images

And it might not be ending anytime soon

California’s three years of low rainfall is the region’s worst drought in 1,200 years, according to a new study.

Record high temperatures combined with unusually low levels of precipitation have been the primary causes of the dry conditions, according to the study in the journal Geophysical Research Letters.

“It was a surprise,” study author Kevin Anchukaitis told the Los Angeles Times of the findings. “I don’t think we expected to see that at all.”

The drought has led to tremendous economic costs in the state, including an expected $2.2 billion and 17,000 farming jobs this year alone, according to a report from the University of California, Davis. It’s also expected to increase food prices across the country.

And the problem may not be going away soon. About 44% of three-year droughts last continue past their third year, according to the Times.

MONEY Travel

4 Shockingly Affordable Last-Minute Holiday Trips

Who says you have to celebrate at the homestead? This year, start a new tradition in one of these affordable getaways.

Are the usual holiday festivities feeling a little stale? This could be the perfect time to shake up your routine and celebrate the season with a much-deserved getaway. Yes, we know: Traveling at the tail end of the year is pricey. However, if you’re strategic about where and when you go, you might be surprised by just how low you can get that tab. Here you’ll find four festive trips, each with its own unique appeal. Though the destinations range from beach towns to ski meccas, they do have one thing in common: a reasonable price tag. Now that’s a gift.

 

 

  • San Juan, Puerto Rico

    This palm-lined beach in San Juan, Puerto Rico, could be your holiday vista.
    This palm-lined beach in San Juan, Puerto Rico, could be your holiday vista. Arco K. Kreder—First Light

    When to Go: Dec. 31-Jan. 7. San Juan remains relatively affordable throughout the year thanks to its airport, which has the cheapest average fares (per mile) of the 75 busiest hubs in the U.S., according to the Department of Transportation. In a recent search, flying from Chicago early on New Year’s Eve costs a manageable $550. Hotels are also affordable compared with many Caribbean hotspots. On Hotels.com, four-star properties in San Juan start at $206 a night during the first week of 2015, vs. $304 in Montego Bay, Jamaica, and $341 in Punta Cana in the Dominican Republic.

    What to Do: You can’t go wrong wandering the blue cobblestone streets of Old San Juan. Stop by the massive Castillo San Cristóbal fort ($5) and the Museo de Arte de Puerto Rico ($6), one of the Caribbean’s largest museums. On Calle del Cristo browse shops such as El Galpon, which sells authentic Panama hats (prices from $60).

    Next, head to Santurce, an up-and-coming area full of hip bars and eateries. “It’s always packed with locals,” says Ryan Ver Berkmoes, author of guidebook Lonely Planet Puerto Rico.

    Hit the beach at nearby Ocean Park and Condado. For less than $20, you can rent a chair, buy a couple of cold beers, and feast on empanadas sold by street vendors. For a wilder dose of nature, explore the hiking trails and waterfalls at El Yunque National Forest, an hour outside the city. A guided tour is $60, including transportation from San Juan.

    Interested in another good day trip? Try Playa Luquillo, the mile-long crescent of surf and sand about an hour east of San Juan. The beach here has a fun, social atmosphere and is known for its food vendors, says Ver Berkmoes. So grab a tasty fried snack and check out the scene.

    How to Celebrate: The city’s biggest New Year’s party, complete with fireworks, happens at the Puerto Rico Convention Center (discounted tickets are $65 on Gustazos.com). For something more low-key, head back to Santurce and its central square, ringed with open-air bars and cafés, to toast 2015 with a $3 piña colada.

    Jan. 6 is Día de Los Reyes, or Three Kings Day. Expect parades and festivals with food and live music (but keep in mind that some stores and restaurants will be closed).

    Where to Stay: In San Juan, Le Consulat is a great bargain in the Condado luxury district, where it’s surrounded by hotels charging upwards of $300 a night. At $127 for a double, you get free Wi-Fi, a simple, modern room, and an outdoor pool. For a bit of a splurge, Ver Berkmoes recommends spending a couple of nights at the Gallery Inn, where each room is decorated with art and antiques. Doubles start at $220 a night.

  • San Francisco

    Embarcadero, Ferry Building, San Francisco, CA.
    Skaters take a spin on the Embarcadero rink. Walter Bibikow—Getty Images

    When to Go: Dec. 19-26. Why not spend Christmas in the City by the Bay? The weather is temperate, most attractions are open, and hotel prices actually drop, says Chris McGinnis, a travel blogger for the San Francisco Chronicle. For instance, last year, rates at the city’s big convention hotels hit an annual low of $170 or less from Dec. 19 to 25, vs. a full-year average of $241, according to the visitors bureau. Plus, with the usual tourist hordes thinned, museums are less mobbed, and reservations at top restaurants are easy (or at least easier!) to snag. Flights, too, are reasonable this time of year. We found nonstop flights from Chicago starting at $305.

    What to Do: Skip touristy Fisherman’s Wharf and check out the futuristic de Young Museum ($10; closed on Dec. 25), which displays 27,000 works from the 17th to 20th centuries. Don’t miss the observation tower. It has stunning views of Golden Gate Park. Nearby, the California Academy of Sciences houses an aquarium, a planetarium, and a living rainforest dome ($35).

    The city is “brimming with sublime food,” says Michele Bigley, author of the Fodor’s San Francisco guide. In the buzzing Mission District, Bigley recommends La Taqueria for a behemoth burrito ($7) before catching a movie at the Roxie, one of the oldest theaters in the nation. Cap the night with a cocktail at Trick Dog, where drinks are named for local landmarks ($12).

    Visit the Ferry Plaza Farmers Market to see the NoCal bounty. “Occasionally you’ll spot famous chef Alice ­Waters shopping there,” says Anna Roth, food and drink editor of SFWeekly. In the same building, she recommends Hog Island Oyster Co. for seafood stew and, of course, oysters ($18 to $20).

    How to Celebrate: Through March, an art project using 25,000 LED lights will illuminate the cables of the Bay Bridge. Check it out from the amazing Top of the Mark bar on the 19th floor of the Intercontinental Mark Hopkins. For a more athletic option, glide over the city’s largest outdoor ice-skating rink, set along the waterfront on the Embarcadero ($14 with skates).

    On Christmas Eve, indulge in an old-school meal at the House of Prime Rib, a city institution. “During the holidays it’s all decked out,” says Roth. “You’ll spend $40 or so for an entrée, but at least the martinis are cheap!”

    Where to Stay: For a unique property in the heart of things, try the Herbert Hotel. Located just off Union Square, the Herbert has bright, sleek rooms (ask for one with a private bathroom) and hardwood floors. Doubles are $259 a night through Dec. 20 but drop to $155 Dec. 21–25. Prefer something with more of a neighborhood feel? The quaint San Remo Hotel offers rooms with windows from $99, though you will need to share one of several bathrooms.

  • Bacalar, Mexico

    Bacalar, Mexico
    The shallow waters of the Lagoon of Seven Colors Hugo Ortuño Suárez—Demotix/Corbis

    When to Go: Dec. 15-22. Mexico’s Yucatán Peninsula can get pretty busy at the end of the year. According to American Express Travel, Cancún is 2014’s most popular international destination for both Christmas and New Year’s. That appeal has some upsides—every major U.S. airline offers direct flights to Cancún. However, it also means crowds and, according to hotel researchers STR, a December average daily rate of $227.

    For holiday travelers, Bacalar is an escape from that tourist frenzy. This small town overlooking Laguna Bacalar, or the “Lagoon of the Seven Colors,” is 3½ hours from Cancún, and 35 minutes from Chetumal. During the holidays, ­Bacalar hotels ­average a manageable $123 on ­Hotels.com. To visit, fly into Cancún and rent a car (about $40 a day) or take the $55 bus. Flights tend to be cheaper earlier in December, says Zachary Rabinor, CEO of tour operator Journey Mexico; we found one for $414.

    What to Do: Tour Bacalar’s beautiful old Spanish fortress, Fuerte de San Felipe de Bacalar ($4, free on Sundays), originally built to protect the town against pirates. Later, hang with the locals at the town’s popular balneario (swimming facility); entry $2. The area is lined by small eateries and has plenty of thatched umbrellas where you can take a break from the Caribbean sun. Or, for just $1.50 an hour, rent a bike from Cocomoco rental shop and pedal along the bay. Obviously, you should be eating as many tacos as possible; the fish and shrimp options at La Playita are not to be missed (from $4).

    The town also makes a great base for exploring the Mayan ruins of Chacchoben ($4), a 45-minute drive away. The site, closed to the public until 2002, is home to stone structures dating to the year 800—some still showing signs of their original red paint. Mexico’s biggest cenote (a natural sinkhole), the 300-foot-deep Cenote Azul, is about a mile outside of town—the water is so clear you can see down to the sparkling-white sand floor. Entrance $1, life vests $3.

    How to Celebrate: Get in on the holiday spirit by checking out the town’s tree lighting. Then shop for locally made gifts at handicraft shops in the town center or near the entrance to the cenote. Also be sure to sample traditional Mexican Christmas goodies such as ponche (warm tropical-fruit punch stirred with cinnamon sticks), romeritos (sprigs of the romerito plant served with potatoes and mole), and bacalao (salted cod).

    Where to Stay: The recently opened Bacalar Lagoon Resort ($115) consists of seven spacious cabanas set on a freshwater lagoon; snorkeling gear is available gratis. Nearby Rancho Encantado is a great value at $125. The rooms have thatched roofs, air-conditioning, and cool tile floors. Guests can get an outdoor massage, kayak on the lagoon, or just kick back in one of the property’s many hammocks.

  • Keystone, Colo.

    Keystone, Colorado.
    Skiers take in the view of North Peak. Jack Affleck—Courtesy of Vail Resorts

    When to Go: Dec. 25-30. For a ski trip that doesn’t break the bank, Dan Sherman of Ski.com recommends Keystone, the most affordable of Colorado’s Vail Resorts properties. In late December, a single-day advance-purchase lift ticket at Keystone costs $99, compared with $129 at Vail or Beaver Creek. Plus, Keystone is just 90 minutes from Denver, allowing visitors to fly into a large airport with well-priced flights. Trim the cost of your airfare even further by flying on Christmas Day, when flights from Chicago start at $245, vs. $315 on the 24th.

    What to Do: Hit the mountain! Keystone offers an impressive mix of terrain, from “long-groomed cruisers” to the “trees and bumps of North Peak,” says Harold C. Jenkins, a travel agent at Corporate Vacations American Express Travel. The resort is also home to Colorado’s biggest night-skiing program, with the slopes open until 8 p.m. during the last week of the year. “Watching the sunset from the top of Dercum Mountain is spectacular,” says Sherman.

    Buy your lift tickets at least a week in advance; you’ll save up to 25% off same-day rates. Feeling a little rusty? Ski School lesson prices drop around 20% when you book two days ahead (about $130, though 2014 holiday prices are still being finalized). Kids 12 and under ski free, with none of the holiday blackouts you see at other resorts.

    For a break from the slopes, spend an afternoon in Breckenridge, a half-hour away. Grab ­coffee at local favorite Cuppa Joe and check out the stores and galleries in this former mining town.

    How to Celebrate: You’ve been burning calories, so go ahead and splurge on a nice meal. In the village, Ski Tip Lodge offers a four-course prix fixe ($75), with dessert served by the toasty fireplace. Or hop a gondola to Der Fondue Chessel, located at the top of North Peak. You’ll get a full Bavarian meal—including fondue, of course—for $59 a person.

    What time and place could be more appropriate for a sleigh ride? The resort offers hourlong rides that wind through Soda Creek Valley and include hot apple cider (adults, $30; kids, $20). Afterward, swing by Keystone Lodge to check out the model village carved out of chocolate.

    Where to Stay: Unlike most resorts, Keystone is just a ski area, with no standalone town. While that results in fewer off-mountain activities, it also means most lodging is just minutes from the slopes. A two-bedroom condo at the Gateway Mountain Lodge, a five-minute walk or free shuttle ride from the lifts, starts at $419 per night. (Compare that with a two-bedroom in Vail, which starts at about $900.)

    Prefer a standard hotel room? The Inn at Keystone ($235 a night for a double) is also walking distance from the slopes and has a rooftop hot tub with views of Keystone Valley.

  • What to Know Before You Go

    No matter where you’re going this season, these four air-travel strategies will save you time, money, and hassle.

    Check in the day before. Not only is online check-in your best chance at switching to a better seat (airlines release some prime spots 24 hours in advance), but if the flight is oversold, it reduces your chances of being bumped, says Wendy Perrin, travel advocate for TripAdvisor.com.

    Get in the fast lane. Planning to travel a lot in 2015 and beyond? Apply for TSA PreCheck, the program that allows you to go through expedited security lines without removing your shoes, coat, belt, or laptop. Membership costs $85 and lasts for five years.

    Load up on apps. Use your airline’s app to get the latest on your flight. MyTSA will update you on security wait times, and GateGuru is great for sussing out airport amenities.

    Bookmark flightstats.com. Canceled flight? Use this site to vet your options, says Perrin. Flightstats will show you which airports and planes are delayed so you can look for a route that works for you, rather than blindly accepting whatever the airline rep suggests.

     

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