The Third Charles E. Odegaard Lecture, Presented at the Sixth National Conference on Primary Health Care Acces, Colonial Williamsburg, Virginia, March 1996 

Presented by: Mark E. Clasen, MD, Ph.D., Wright State University, Dayton, Ohio:

Mark E. Clasen, MD, Ph.D., Wright State University, Dayton, Ohio

While I recognized the controversial nature of this title, I chose it anyway because it captured most closely the few thoughts that I may put forth regarding this concept. I suppose one could ask the question, how can one be culturally incompetent? Rather, we are considering the “oughts and shoulds” in our yearning for a society that has healthcare as a right, and not a privilege.

The American Academy of Family Physicians, and our constituent chapters, has put forth the noble idea that all Americans should have their own physician- a physician who knows them and their families, whose values and culture lies in the midst of their family units. Taking the concept of the genogram, or the family organ as Jack Rodnick whimsically mused about, and moving its concept beyond the psychosocial data base into the realm of family mythology. Personally, I think the genogram is a powerful tool.

When the genogram is considered at the level of family mythology, we can approach the health belief systems that guide many of our personal decisions in matters of health and illness. These belief systems also guide our notions of adherence with medical authority, or with the teachings and beckonings of health providers.

An entire hour could be devoted to issues of compliance or adherence; yet, we as healthcare professionals know that most compliance occurs in the milieu of a trusting relationship that is culturally competent. In this major thrust, that creating a real change in behavior, occurs best when the message is negotiated in one’s own language, articulated with the proper mixture of science, theology, and always love. There is little doubt that a culturally competent care giver is more valuable than the high priest of technology who possesses 100% knowledge to heal, but who lacks the human translation about how to heal.

Does the title of this presentation suggest that our medical school graduates are inadequately prepared to deal with a diverse population? Does the title imply that interpersonal skills are not fully developed or as finely honed as they should be by graduation? Does it imply that 20th century physicians have been egocentric, dogmatic creature and practitioners of the art? Does it imply that 20th century physicians have not made tremendous strides in conquering disease and delaying premature death? The title was not selected to caste blame, shame, or dispersions on 20th century medical education, it was selected to look forward into the 21st century- pondering the questions about what knowledge, skills, and attitudes are needed to equip the st century physician. What types of educational activities will prepare the medical student of the future to enter this profession, and what are the threats and promises of such a career?

To loosely paraphrase an old adage: “ a physician is frequently in error, but never in doubt.” For those in the audience who are not physicians, I want to assure you that ego strength is required to deal with pain and suffering, and demands a decisive, take charge approach, and is more egocentric than George Patton, especially when life and death matters hang in the balance.

As a consumer of healthcare, we prefer to be clients or customers when the issues are superficial; however, when the issues are weakness, being sick unto death, being rendered helpless, we more likely want to be a patient of a loving, caring physician who will guide us through the storm to the shoreline of restoration , health, and well-being.

We have accepted the culture of medicine that does not like “wimps” but strongly favors the direct approach, aggressive intervention, hard data, hard facts, “heal with steel,” and when in doubt cut it out. The culture of medicine is portrayed on the television series, “ER.” Notice all the language of medicine used to describe the culture of medicine: hard Science, hard facts, conquering the disease and aggressive intervention. I won’t comment on the term physician extender to describe physician assistants or advance practice nurses as part of the psychosexual language used to describe workers in US medical culture.

When my wife’s parents went to the radio-oncologist to enlist his help in addressing my mother-in-law’s inoperable lung cancer, they were asked the following question: Do you want the palliative dose or the curative dose of radiation? My mother in law is a fifth generation Texan, and my father-in-law grew up on the plains of Kansas, both are highly learned people, and how do you expect they answered that question? Suffice it to say that they did not opt for the palliative approach. Four years later, without a trace of cancer on bronchial biopsy, I would say they made the right decision. US medicine gives you the option for the palliative approach or the curative approach. It is the wimp factor versus aggressive intervention, and aggressive intervention wins.

Think of your own family. Rationing healthcare is good in concept, but now for my family. After all, managed care has brought us  coronary artery by-pass surgeries for $9000 in some markets, and the price is still falling. Major coronary artery plumbing jobs are becoming routine, and there is no doubt that carotid endarterectomies improve the potential to live life without stroke complications.

I presume many of you have become acquainted with Dossey’s book entitled “Healing Words.” For those who have not read this or seen the PBS series which devoted time to explore mind/body relationships, I will cite one study which was performed on patients in coronary care units. This was a double blind study with matched control groups and experimental groups. The groups which received prayer had significantly better outcomes than the group not prayed for. Despite the curative approach used by my mother-in-law’s oncologist, she received prayers from the Christian Medical Society and prayers offered from a variety of religious faiths.

There is a meditative tradition in almost every major religion: Buddhism, Christianity, Hinduism, Islam, and Judaism, and these major religions emerge from the same source of power (in my humble opinion).

There is healing in the words and traditions of these faiths because they are connected to the concept of a loving God as we know him or her to be. Ghandi  said,”I am a Hindu, I am a Christian, I am a Jew…Imperfect ourselves, we should be gentle to others.” The notion of healing words, meditation, soft intervention, and gentleness are the entrée to the next addition to the 21st culture of medicine.

There is no question that a pluralism of values which embraces the culture of US medicine will emerge in the next century. I am hoping that women entering medicine will not try to out Patton General Patton. I hope that entering students will already have an acquaintance with sorrow, grief, and human suffering.

Being a creature of the culture of medicine, one day I prescribed an antibiotic to a woman who was suffering from a moderate to severe pneumonitis. In the community health center where I was practicing, we had our own pharmacy. This prescription was costly and on our “use sparingly list.” I told this woman that I was giving her” Gorilla-cillin.” She looked at me and a tear came to her eye. I asked, “what is wrong?”

She replied, “You have cared for my mother better than any doctor ever has, but I thought you were different.” “Different,” I queried? Then she looked at me and asked, “are you calling me a Gorilla… A monkey? Do you think that I am too stupid to know the real name of the antibiotic?” I almost fainted. She cared enough to tell me that I was a culturally incompetent physician who was not sensitive to a racial connotation and too elitist to use the name Augmentin. I told her that now I could see my incompetence, and used the term only to imply the strength of the antibiotic and nothing else.

What I loved the most about working with the African American community in Houston was the dignity and wisdom of people who entrusted their health care in me. I had just enough culture competence to learn from this dear woman. When she understood what I had meant, and that I had meant no harm, our relationship grew even stronger. We brushed tears from our eyes, and I had gained more appreciation for cultural awareness and sensitivity.

In the same community health center, a very ill subset of diabetic patients were getting sicker. In this group hemoglobin A1C’s were climbing, and visual and extremity complications were worsening. The physician group asked our diabetic teaching nurse, Gloria O, to break out of her prescribed protocols, and render this group of patients intensive outpatient care. Listening to her counsel her patients in a new way, I heard her use language and imagery that I had never heard her use before.

With some patients she was gentle, and methodical- teaching life style modification. With others she talked about which dress she would wear when she attended their funeral. Ms. O was culturally competent and effective. By all parameters, this group became healthier. Here was a nurse practitioner who was more powerful therapeutically than a team of physicians. I learned a lot about the power of multi-disciplinary teams, and about cultural competence in changing behavior.

I could turn this into a personal confessional detailing the numerous mistakes that I have made regarding my own cultural naivety, so I will turn to other examples of cultural incompetence. I will relate the story of a second year resident who chased a patient through and out of the waiting area for wanting to discuss a termination of her pregnancy. As he yelled out scripture, the frightened patient ran out and never came back. When I attempted to counsel the resident, he quoted scripture to me. “Thou shall not kill.” I quoted back the first commandment: “ I am the Lord your God. You shall have no other gods before me.” – not even your best definition of me.

These stories illustrate examples of attitudinal incompetence, laced  with elitism, sexism, and intolerance. Gayle Stephens has pointed out wisely that practitioners of medicine’s shortcomings are not usually due to a lack of knowledge; rather, they are the result of character issues deep within. I have even heard the rumor that more reasoning abilities of medical students decline over the course of their medical education. Can this be so? Is a medical education destructive?

Many of us have been through a medical education, and have our own war stories to tell. Can the countless hours, sleepless nights, pimping, roundsmanship, and open harassment mold and inspire the culturally competent physician for the 21-st century? To be a physician for human beings, you must first be a human being. How does medical education care for the personhood of the medical student or resident? What is being done – other than Pelligrino –  to assist students as they poder ethical dilemmas? What is being done to foster true character building experiences which enable our students to encounter illness, evil, death, and violence and render hope, compassion, caring, and maybe even cure.

What will the 21st century be like in medical education? If we know the answers, we could begin our curricular revisions now. We know that our nation is aging, and that Gerontology and Geriatric Medicine begs for compassion in the curriculum. The racial mix of the nation is changing rapidly. We know the race, culture, and ethnicity are such that diversity can be used to make the US the most creative nation on earth. Stratification and separation may preclude us the rich blessings of our diverse heritage. We know that hatred and bigotry have evil roots and tentacles, and the politics of fear may prevail.

We have those that believe that the economic pie is only so large- that if somebody gets something, there is less to go around. This mentality exists among many physicians. The creation of wealth and capital is a concept missed somewhere in the education. We know that different languages will be spoken in this land. We know that HIV to be a sentinel event with other incurable conditions to follow.

And, the re-emergence of infectious diseases will tax our public health systems. We know that environmental pollution, chemical warfare, biologic warfare, and the disposal of nuclear waist will become more intense problems in the next century. We also know that racial disparities as expressed in mortality and morbidity rates largely disappear at the top of the economic scale.

At this conference, AJ Henley alluded to the fact that economic disparity and deprivation was more important to good health than access to healthcare. Correcting the economic problems would do more for the health of vulnerable and indigent people than medicine.

Many of us have an inkling that despite our total embracement of private medicine, a public sector will re-emerge as a dominant force in healthcare. The argument for the demise of managed healthcare is one that I won’t make here, but I predict it will happen. However, concepts of accountability, contracts for quality, and continuous quality improvement are here to stay in some form or another. Our students need strategies to incorporate these concepts into their own self-monitoring, self-measuring, and life- long educational strategies.

Evidence based medicine which Al Berg so eloquently described in Maui with the otitis media scenario and population medicine best articulated by capitated payment programs are examples of practicing in new ways. I remember Mark Babbitt articulated the futility of going room to room to room as the community became less healthy. I remember Mark learning about culturally competency when he prescribed  ampicillin to a migrant farm worker who lack refrigeration- because he was living in the car.

The day of the lone ranger, solo practitioner is over, and every small group practice in American is for sale. If solos are gone, then groups and intelligently crafted teams will be the future stage for the practice of medicine. Let us examine the future player.

One of the most enlightening experiences of teaching at a primary care medical school is that our strongest learning lab is the community. The teaching community is the most powerful ally that we have in teaching cultural competence. In Family Medicine our strongest teaching strategy is the teaching family. It is not the “Fam Scam” of the genogram; rather, it is the myriad of appropriate strategies that might be used in the context of this person’s family and health belief system.

In our department we lend teaching expertise to the advanced practice nursing curriculum as well as the physician assistant training program. We participate in the multi-professional course where medical students, nursing students, allied health students, and seminary students work and learn together. We learn cultural competence by learning from a diverse group of people.

Dr. Leroy, who, by the way, was recently  cited as one of America’s top 50 positive role models as a physician, teaches a course entitled “Economics, Society, and Medicine.” He welcomes our students during orientation. He tells them how he learned to be culturally appropriate and sensitive to the many people of the Appalachian culture whom he serves in his community health center. He even listens to and enjoys country western music, which was not the music in the home in which he grew up. In the first week of medical school, students begin their introduction to clinical medicine course, and the Department of Family Medicine has 20% of the curricular time of the first two years.

We have a teaching associates program and a curriculum that we brought to the national predoctoral meeting of the STFM in January 1995. In this program, non-MDs teach students the knowledge, skills, and attitudes needed to conduct a sensitive physical examination on both men and women. An OB resident from another school tried to tell one of our students that a group of feminists was teaching them an impractical approach. Our students were not intimidated because the patients gave them positive feedback. We believe our students do better in early cancer detection for rectal, prostate, breast, and pelvic cancers.

When we needed pediatric patients in order to teach our students the skills of physical examination of children, we were invited into a community elementary school so that our medical students could perform histories and physical examination on 5 and 6 year olds. What a thrilling experience for the medical students, and for the kids who enjoyed the rapport with the medical students. Incidentally, when I came to help precept the experience, a woman approached me and said, “Hello, I am a Community Health Advocate and I want to know how information derived from these examinations will be communicated to the parents and care-givers of these children.” Good question.

These Community Health Advocates were trained in our Center for Healthy Communities, a project led by Cheryl Maurana, and resulted in the empowerment of community advocates who are not afraid to say to a powerful figure in medicine – just a minute, how is this experience going to help our community.  One little boy who was examined by my group of students had a blood pressure of 1388/88. At age 5 ½, this may have been his first access to a comprehensive pediatric examination. Another child had a raging otitis media, while another appeared to have a urinary tract infection.

When our first year students needed patients to interview during their medical interviewing course, a cadre of older hospital volunteers became our willing patients.  Students, patients, and faculty all found the experience authentic, significant, and important. Objective structured clinical examinations (OSCEs) are useful and a powerful device for assessment. But the teaching community has more to offer than scripted scenarios. The HIV, the geriatric, and the human sexuality selectives all use community patients and a host of non-MD teaching personnel. How could we teach geriatrics without Marshall Kapp’s insight into the legal issues of competence and aging? How could we teach community health without the faculty diversity found within that department?

Lest you think that we are soft science haven, I can also cite our trauma service which handles major trauma and has statistics which are half the national morbidity and mortality rates. Directors across the country rate our students as good as and better than graduates from other institutions.

What’s the secret at the Wright State University School of Medicine? Part of it is in the admissions process and the values that stand behind that process. With a 40 to 1 applicant to acceptance ratio, we could fall into the trap of being a mainstream medical school. We look for the student who has the academic base, then we look further. The key is to find the student that has had substantial involvement with community over a long period.

In this look, we seek students who have become acquainted with human suffering and who have made a connection with people who suffer, and who continue their involvement with people in these communities. We also find a racial mix of students who reflect the racial composition of our geographic area of western Ohio. Without students who reflect our community, we could not be evolving into a leading school in producing culturally competent physicians.

Last fall, Carole Bland and Michael Rosenthal assisted all the schools of Ohio when they became visiting faculty at our statewide conference on changing admissions practices of the seven Ohio medical schools. We are looking to change the mix of candidates likely to enter primary care versus specialty care medicine. The conference provided research data that suggests that the medical classes can be manipulated at the front end.

I still have trouble convincing our own admissions committee that we should seek students with science and math GPAs  around 3.5, because those with a GPA higher than 3.75 are more in love with science than with people. Listen to what your own committees would say to the notion of lowering standards, especially when the non-cognitive attributes of the culturally competent physician are still so ill-defined and foreign to the current culture of medical education as well as US medicine.

The emergence of the culturally competent physician also includes in-depth training in medical cultural anthropology and language skills that go beyond medical Spanish or the meager attempts at using a translator. Cross cultural/cross racial advanced doctor-patient communication skills are imperative, and the place to learn these skills is early in the medical education process.

Dr. Leroy has told me that he likes the students to take his course early, before their medical education has jaded them, and the current acculturation process of medical education has taken the wonderment of people out of the equation.  I believe that medical cultural anthropology is more intense and needed than is biochemistry. Memorizing the Kreb cycle for the 7th time does little to wipe tears away from people who need relief from pain and suffering.

The WSU School of Medicine model starts with admissions values, continues with the powerful presence of Family Medicine throughout all years of the curriculum, involves many non-MD educators, and an invested teaching community.

The will to create the conditions for the emergence of the culturally competent physician is an intricate process, and is different at each institution. The team concept of medicine of the future requires excellence in interpersonal and intraprofessional communication abilities. Much of this is driven by personal values and the institutional values that comprise the medical school of tomorrow.

A model that resembles the priestly model of care may be relevant here. The priestly model  involves the concepts of teaching, suffering, and celebrating. Teaching involves patient education and behavioral change. Suffering involves the intimate acquaintance with sorrow, grief, loss, anger, and failure. Celebrating is the essential ingredient for renewal and inspiration found in healing, care, comfort, and cure.

Are we telling our students to celebrate and dance? Do we dance with them? Are we distanced from sorrow and suffering? Have we taught in such a way that behavior changes and outcomes improve? Are we the role models of the culturally competent physician? Are we skilled in low tech, high touch medicine? Are we competent to stand with our patients through the threats and promises of technology and for the omnipresent aggressive approach which promises cure rather than palliation?

As John Mitling has taught us through his eloquent research, a family physician in every count in America means less cost and an improvement in morbidity and mortality statistics. Can this model be so wonderful? I believe the potential for all medical specialties lie in the renewal and transformation of the culture of American medicine that must begin in our medical schools. I have given several examples of what is meant by cultural competence, and have cited our early beginnings at our institution to create the culturally competent physician.

Can this interface between high technology, clinical excellence, and cultural competence occur? Of course, it can and should. Cultural competence is the attitudinal soul of the transformation of the culture of US medicine. Rather than the oak tree which stands fast in the storm, the strength of the future practitioner is that of a willow tree: many branches, the ability to change shape as conditions change, and a tree that can withstand storm and wind. It is the blending of soft and hard sciences, with faculty role models to help US medical students cope with suffering, teach new ways, and to celebrate always.

After all, there will come a time when lions and lambs will graze together, every tear will be wiped away, and there will be no more death. The promise of the parousia is no more or less possible than the cultural transformation of medicine, and the obvious impact this transformation will have on issues of access to health care.

Monday, April 16, 2012

6:30 AM – 8:00 AM Working breakfast in preassigned groups, Avocet Restaurant (conference registrants only) 

8:15 AM – 12:00 PM First Plenary session

8:15 AM Welcome   

      Jay W. Lee, MD; Memorial Hospital Long Beach (California)

8:20 AM Opening Statement of First Plenary Session by Session Moderator:

     Marc E. Babitz, MD; Utah Department of Health

8:25 AM First Roundtable: “Realities and Illusions:  A Discussion National Health Policy, PPACA and Health Care Insurance Reform 2011-2012” 

     Joshua Freeman, MD, University of Kansas, Kansas City

     David Sundwall, MD, University of Utah, Salt Lake City

     Hector Flores, MD, White Memorial Medical Center, Los Angeles

9:00 AM Audience Questions and Comments:

     Lead Question: Cynthia Olsen, MD

9:10 AM Special Presentation: The Primary Care Crisis 

     John P. Geyman, MD, University of Washington, Emeritus, Friday, Harbor, Washington

9:35 AM Audience Questions and Comments: 

    Lead Question: Richard Clover, MD

9:45 AM: Second Special Presentation: “Reconceptualizing the Primary Care Relationship”

     Joseph E. Scherger, MD, MPH

10:10 AM Audience Questions and Comments

    Lead Question: Perry A. Pugno, MD

10:20 AM Break

10:30 AM The 22nd G. Gayle Stephens Lecture

     To Be Announced

11:00 AM Audience Questions and Comments

    Lead Question: Charles Q. North, MD

11:10 Thought Provocateur #1: Caribbean Medical School Graduates and Regional Primary Care Needs

     Peter Broderick, MD, Valley Consortium for Medical Education, Modesto, California

11:30 Lead Question: Jimmy Hara, MD

11:35  Realities and Illusions: Plenary Roundtable and Discussion by the Conference as a Whole on the Days’ Themes: 

     Mark E. Clasen, MD, Ph.D., Wright State University

     Allan Wilke, MD, Ross University, Dominica, West Indies

12:00 Adjournment

Stephen W. Cobb, MD, Medical Director, Exempla Physician Network, Denver

Stephen W. Cobb, MD; Exempla Healthcare, Denver

Good morning.  I’m Steve Cobb from Denver. It’s good to be here. Three years ago I gave up running the family medicine residency at Saint Joseph Hospital in Denver. Now I run our group practice, which has doubled in size in two years. I wonder if that’s happening in your markets too. Hospitals are buying up practices. I met a colleague who’s on the same career path as me. It’s the 90s all over again! It’s a different world!

I will present a different perspective on the potential impact of PPACA. Saint Joseph Hospital takes care of the underserved in Denver, now that the University of Colorado no longer serves them. There’s no one left in Denver but St Joseph Hospital to care for that population. Only last year, the hospital got Disproportionate Share Hospital [DSH] money for the first time.

Denver is very different than Hector’s situation in Los Angeles  [see 22nd National Conference: How Will it Work? PPACA and the Community-based Teaching Hospital (Part 1, Flores)]. Saint Joseph Hospital is very much a partner with the Kaiser system in providing care, 80% of the admissions at our hospital are Kaiser patients.

Competition between Denver’s hospital systems

I will describe the three hospital cartels in the Denver market. I use the word “market”, even though I think that’s a bad word in this group. I don’t want to see any stones thrown at me up here, but I think that it might be instructive to hear this.

Mt story will tell how PPACA has provided pressure for cartels to collaborate with one another. The resulting collaboration is affecting the Saint Joseph family medicine residency.

The company I work for is Exempla. We have three hospitals in Denver. If I don’t show you geography none of this is going to make any sense, so I have to use pictures for my story.

Locations of Exempla's Three Denver Hospitals

Our three hospitals employ physicians whose practices support the mission of the hospital. That’s why those practices exist.

We have three major cartels in our market. The first, HealthOne is the Hospital Corporation of America [HCA] by another name. There is a a community partnership with HCA that makes them feel better about being a “for profit” entity, but it’s still just part of HCA. The corporation hosts two family medicine residencies in Denver.

The second cartel, Centura, is a marriage between the Adventist and the Catholic hospitals. They have six Denver hospitals and six “mountain” hospitals as well, with one family medicine residency in Denver and one in Colorado Springs.

The third, Exempla, is the weaker player in town, but I believe being the underdog is a good thing. We are Catholic sponsored [the Sisters of Charity of Leavenworth Health System]. We have a family medicine residency in Denver and our parent company owns one in Grand Junction.

Just to show you are we are the weaker member, below is a map of the geographical reach of the Centura network:

These hospital systems do not like each other. They do not like to collaborate. They do not trust each other. They don’t like to share data.

Medicaid Funding of Cooperative Efforts between Family Medicine Residency Programs

However, the family medicine residencies collaborate with each other, even though we fight over the medical students we recruit to Colorado.

So why do the family medicine residencies collaborate in Colorado? We collaborate because we have leveraged Medicaid money that funds a state commission that was established in 1977 so that we could build a primary care workforce in Colorado.

From this nucleus there is a history of nine family medicine residency directors working with commissioners appointed by the Governor to ensure Colorado has primary care physicians throughout the state. That has proved to be very important. We’ll discuss the commission more fully later.

At our hospital we have four 104 residents in four physician specialties. In the family medicine residency clinic we have 18,000 visits a year, of which 44% are self pay (in our hospital and that means no pay, since patient don’t pay for their care). The Sisters of Charity pay. They very intentionally operate a charity system that funds a lot of health care – at least the primary care.

What we think will happen after PPACA is fully implemented, is that our “self pay” percentage will go down by half and will be converted into Medicaid at some point in time. We think it’s important to be prepared for that.

Collaborative Efforts to Implement Patient-Centered Medical Home Principles

All nine family medicine residencies in Colorado applied for and received a grant from the Colorado Health Foundation, an HCA subsidiary.  HCA, a competitor, is giving us and its other competitors money to implement patient-centered medical home principles in the nine Colorado family medicine residencies. The residency programs are all at various stages in their development and face various struggles.

The goal is to get everyone’s residency program recognized by NCQA [National Committee for Quality Assurance] as a patient-centered medical home, and eligible for the contracts associated with tha designation. The residency in Fort Collins does very well financially and they probably will get some nice commercial contracts out of being a patient centered medical home recognized. At Saint Joe’s we probably won’t get any such contracts.

Medicaid-funded accountable care organizations

Our state Medicaid agency is creating accountable care collaborative organizations. I’ll describe how we’re going to participate in those. We will be developing new competencies for residents, like we do for students. We have to think about what kind of doctor that we will need to produce to be successful in the patient-centered medical home model.

What will this mean for a residency program that historically has produced docs that when they finish can go to work in a Kaiser system and be successful, but also can go out into rural America and be successful? Is that going to change? I think it will.

The Colorado Patient-centered Medical Home Initiative

Colorado’s patient-centered medical home initiative, although funded by the Colorado Health Foundation, will be administered by the University of Colorado and the Colorado Association of Family Medicine Residencies.

Here is what will happen at Saint Joe’s. Now our residents will all complete two quality improvement projects a year based on their patient practice populations. They will have to demonstrate health improvement in their practice population. This they will be required to do in addition to their ICU rotations and their continuity OB clinics.

We are tracking referrals and doing followup, which in the past was not done in this practice. There is intentional, continuous quality improvement in place. Never before were those words uttered in this program. We will have completed implementing EPIQ [Evidence-based Practice for Improving Quality]  in a few weeks. Our patients, who are 44% self pay/no pay patients, are really going to access their charts electronically.  You can imagine that it is a big deal for this population. It’s important that someone is there during the entire period of change, and we’ll be there throughout this process.

The Challenges of Care Management

Those of us who run residency programs all know that team-based care is one of the most difficult administrative challenges. We’re all part-time doctors in that practice, and there is a lot of discontinuity, no matter what our values and principles are. For these reasons, we’ve implemented nurse practitioner-run teams of care and we all work with them. That’s been very successful.

What’s not going well? 1) Care management! Nobody knows how to do it in our program. We don’t know how to fund it.  It’s very difficult to do for the population that we serve, even if you have money. 2) Population management! It is also very, very difficult to manage patients in this situation by registry for a lot of reasons. 3) Self-care! The facilitation of self-care is not going well. These are all resources that we don’t have. No matter how much we ask for the resources, the hospital doesn’t have it either.

We’re on the difficult journey that we hope leads to an effectively operating patient-centered medical home. The other eight residencies have similar struggles.

Medicaid Accountable Care Collaborative Program

The enactment of PPACA has, I believe, increased interest in a separate initiative, the Medicaid Accountable Care Collaborative Program.  There are three elements to this collaborative program: 1) Primary care docs providing patient-centered medical homes, 2) regional care collaborative care organizations which will be important,  and  3) comparative statewide data. A data analytics coordinator position has been established, to enable providers have be able to compare how they are performing with others.

Colorado is still divided into seven regions. In Denver County, where Saint Joe’s is, the Saint Joseph Hospital family medicine residency will be participating in a patient-centered medical home. You get a $4 member per month management fee, but all you have to do in this contract is say yes, I’m committed to patient-centered medical home principles and I commit to work with the regional care collaborative organization. That, at the present time is all you have to commit to. Nobody’s measuring anything. On top of your management fee, you get fee-for-service reimbursement.

What’s interesting though is that in region six (Denver) a contract to create a collaborative care organization was awarded to what’s called the Colorado Community Health Association – a collaboration between the IPA to which all of our primary care doctors in Exempla belong as do those of Centura, a competitive hospital system. Through this collaboration we jointly will address the care of the Medicaid population.

Hector alluded to the cartels in Los Angeles, where there are also emerging Accountable Care Organizations [ACOs] that are comprised of IPAs and competitor hospital systems and residency programs. These cartels are going to try to work together to try to do something that might be helpful for the Medicaid population. Why are the IPAs and hospitals doing that? I think, because they want practice experience, so that when commercial products come along they will have some competency to do this work. Maybe the motivation isn’t pure, but the side effect is that the Medicaid population may get better care.

Developing Residency Faculty Competencies for Quality Assurance 

What probably is more important in the current situation than focusing on resident competencies is the need for better faculty competencies. Our residents have competency, even now, in some of these quality improvement tools. Our faculty doesn’t really know how to manage care. It’s not something that they’ve done.

For this reason, I hired two of my former residents to work in our system. Six months after I hired them, one described three PDSA [Plan-Do-Study-Act] healthcare improvement cycles she has already done in her clinic, where she’s working to make various things better. Up until about five years ago, I didn’t know what a PDSA was. I am really proud of her.

Learning how to be NCQA recognized and what all that means; participating in mandatory Medicare quality initiatives like PQRS [Physician Quality Reporting System] –  are competencies that are new for our residency.  Beyond that, there is a whole new science for patient safety that we’re now teaching in the residency.

This is a very granular picture of the big changes that are occuring in one residency because of PPACA.

A Potential Unintended Consequence of PPACA in Denver

If we ever are going to get the resources to do population management at Saint Joe’s, it’s going to come from collaborating with the Kaiser system. Saint Joseph Hospital doesn’t have the money, but Kaiser does. Kaiser ends up with about half of our graduates every year. They’re very invested in those doctors being competent in population management. So Kaiser is interested in taking over the residency program all together.

Kaiser’s interest in our residency, heightened because of the changes PPACA will bring to health care delvery, may very well affect our rural medicine mission. I’m very proud to tell you that two years ago the family medicine residency program established an OB fellowship and our first graduate completed 120 C-sections. That matters to me. I spent my first five years in practice in rural Oklahoma taking care of Native Americans. My passion is rural medicine.

If Kaiser were to run our program, this is what I think would happen. Kaiser doesn’t really care if family medicine doctors deliver babies, or if they’re competent to work in ICUs, or whether they can do their own C-sections. The program that I built based on my personality and my belief of what a family doc should be won’t continue.

I think we’ll probably end up with an exposure rather than a mastery experience in obstetrics. I think the obstetrical fellowship will go away. Maybe that’s the right thing to do with the program, but these might be the unintended consequences of the impact of PPACA on our little community hospital residency.

I will conclude my story with this picture of Saint Joe’s.

Saint Joseph Hospital Denver with Kaiser Hospital in Background

We have two towers. (There’s a story behind that.)  In the background, right behind Saint Joe’s, is the Kaiser building. That’s how connected we are to them down in Denver.

These are my comments.

ABSTRACT

The authors assessed that the economic impact of closing a family medicine residency and outpatient center in Dayton, Ohio, has cost this community $17,451,000 annually. This cost is the sum of loss of revenue from graduate medical education (GME) Medicare payments to a teaching hospital with residencies, and the absorbed costs from increases in emergency department (ED) visits. The authors argue the displacement of a cost-effective family medicine health center and residency placed an economic burden on an area ill-equipped to absorb and afford it, and this impacted negatively on the health of a community.

BACKGROUND

The greater Dayton, Ohio, area once enjoyed the benefits of a 500+ bed teaching hospital, St. Elizabeth Medical Center, and its integrated family medicine health center (Hopeland) and residency program. For 122 years, St. Elizabeth Medical Center, and for 30 years, Hopeland, served as medical homes for thousands of greater Dayton area families considered as either “urban poor” or as “high risk.”

The St. Elizabeth Family Medicine Residency Program was established in the early 1970’s. This family medicine residency had slots for 12 residents in each of the three training years. Each of its 36 enrollees comprised a diverse and talented group of physicians in-training at a site that quickly earned a reputation for providing premier training in urban family medicine. Archival records indicate more than 270 family physicians completed their residency at St. Elizabeth. This program produced physicians with patient-centered training, which augmented the health and quality-of-life of the greater Dayton area.

This family medicine residency was also well known for encouraging many physicians to establish practices in underserved settings throughout Ohio and the nation. However, in 2000 the hospital abruptly closed and the Hopeland health center was slated for accelerated contraction and closure when the negotiations for a suitable buyer for both the hospital and its ambulatory center broke down.

During the 1990s, the St. Elizabeth Medical Center and Hopeland began to experience financial difficulties. Two of many causes for these difficulties involved poor cash flow from billing practices and an ever growing burden of uncompensated care for the poorest and most vulnerable citizens of Dayton. Consequently, the religious order that managed the hospital and health center decided to sell both.

For several months in 1999 and the first six months of the year 2000, the residency, health center, and community were informed that a for-profit buyer was conducting due diligence analysis and that a quick sale was expected. Relying on this information, a new class of physicians was recruited into the St. Elizabeth Family Medicine residency.

What became a surprise, however, was that negotiations for this sale collapsed in July 2000. While business, community, and civic leaders were interested in saving the hospital, the community was not given the opportunity to make a counter-proposal, and on July 13, 2000, it was announced that the hospital would close in 60 days. The hospital did close on September 13, 2000, but its ambulatory facility did not.

The 12 newly recruited first year family medicine residents and many second and third year residents were able to transfer into other residencies leaving a handful of second and third year residents and some Wright State University School of Medicine, Department of Family Medicine, faculty members behind to wind down the family medicine practice.

The residency program closed completely in 2002, leaving the greater Dayton community to ponder the enormous loss felt among generations of families who relied on this health center for the 122 years of its existence. St. Elizabeth employees were also distraught not only at their job loss, but at their loss of being passionate supporters of the St. Elizabeth mission to care for the poor and underserved. Similarly, Wright State family medicine faculty and 36 residents and their families were distraught, because they too believed in St. Elizabeth’s mission—never believing the hospital, health center, and residency program would be closed so quickly.

The closing of the St. Elizabeth medical complex has raised the question: “What economic perturbations or burdens did the closure of the St. Elizabeth Medical Center and Hopeland bring to the greater Dayton community?”

THE PROPOSAL 

In order to answer the above question, three assumptions were made: (a) the closure of the St. Elizabeth Emergency Center and Hopeland clinic resulted in increased emergency department visits at other Dayton sites; (b) the increase in emergency department visits would immediately emanate from the 40,000 people who annually visited the St. Elizabeth emergency department, as well as incrementally from the 30,000 who annually visited the Hopeland Family Medicine Center; and (c) since 42 capped Graduate Medical Education positions would be lost to the Dayton area permanently, it was proposed to determine whether or not this represented an economic burden to the greater Dayton community.

METHODS

To estimate the financial burden resulting from the loss of a family medicine residency, the authors:

(a) reviewed details of the due diligence documents used by the potential buyers considering purchase of the St. Elizabeth hospital and Hopeland. These documents contained data pertaining to reviews and audits of the federal medical education support payments from Medicare, clinical revenues and expenses, and all personnel costs—including resident and faculty salaries.

Because the “burden of suffering” among users of the St. Elizabeth hospital and Hopeland was large, the residency program received a large hospital disproportionate share (DSH) payment; that plus the combined federal medical education support from Medicare to St. Elizabeth hospital created a total full-time equivalent or FTE revenue stream of $160,000 per resident. (Note: Hopeland itself operated at a loss of $750,000/year, but because of the service revenue and the influx of Medicare dollars, a small surplus for the institution was generated.)

(b) analyzed emergency department (ED) visits throughout the greater Dayton area using data from the Greater Dayton Area Hospital Association (GDAHA). Their data is used by all Dayton area hospitals because of its accuracy and acceptance by area hospitals. The Wright State University College of Science and Mathematics provided statistical assistance analyzing and comparing area ED visits in different years.

Ohio Hospital Association data was used to calculate the average cost of an ED visit in both Montgomery and neighboring Greene counties. This was done to calculate: (a) the average cost of an ED visit which did not result in an admission and (b) the average cost of an ED visit resulting in an admission.

FINDINGS 

(a) When the Dayton community lost all 42 GME slots, this loss in revenue totaled $6,720,000/year. When balanced budget reduction formulae were applied to this amount for the years 2000-2005, the Dayton community had lost $4,805,000 each year without having receipt of federal medical education support from Medicare.

(b) Emergency department usage in the Dayton area had been rather constant from 1990 until July 2000. After 2000 when a significant “safety net of care” was lost and access to culturally appropriate care became constricted, that baseline abruptly curved upward. (Table 1)

Emergency room usage in Dayton, Ohio and surrounding counties

What this suggested to the authors is that without primary, secondary, and tertiary preventive care, through the presence of a family medicine model of comprehensive care, former Hopeland patients became sicker and then sought medical care from area Emergency Departments.

The slopes of ED usage between the years prior to the hospital closure (1998-2000) and those after the closure (2001-2003) differ significantly—and were calculated using GDAHA data. The estimated slope for 1998-2000 was not significantly different than zero (P=0.45). The estimated slope for 2001-2003 was marginally significantly different than zero (P=0.0583). The tests for determining if these two slopes differ significantly is statistically significant (P=0.0091).

These data support the hypothesis that Dayton area emergency department visits were relatively stable in the years prior to 2000, but have increased significantly during the years 2001-2003. In fact, they increased at a rate of about 9,000 visits per year. This slope led the authors to predict an increase of 9,000 more ED visits would occur in 2003 over those in 2002. In fact, GDAHA reports there actually were 19,316 more ED visits in Dayton during 2003. Using the actual figure of 19,316 makes the slope line following the Hopeland closure even more significant (P=0.009). By the year 2004, the slope flattens out. (Table I)

(c) The ED visits by former Hopeland patients not only resulted in greater numbers of area ED admissions, but they were more expensive visits than typical non-admission visits. For this study, however, the authors did not mix the visits resulting in admissions with those that did not. Instead, the authors considered all the ED excess visits “non-admissions”—knowing that the average cost of these non-admissions was $788.

This yielded a very conservative price tag for the aggregate value of these additional visits. By the end of 2004, an additional 17,000 ED visits, as tracked by GDAHA, were being made to Dayton area EDs, presumably driven by the closure of Hopeland.

The 40,000 annual ED visits to the St. Elizabeth Medical Center spread quickly into the community upon the closure of the hospital and they did not factor into the area’s trend of experiencing an escalation in ED visits. Rather, it was the Hopeland patients who initially started the increase and, then as they got sicker and sicker, created a wave of new and increasing demand for ED services.

Thus, since a conservative cost for these visits would be $788 and since it can be estimated that an additional 17,000 visits occurred, a community burden for these additional ED visits would be 17,000 X $788 or $13,396,000. The 17,000 visits is the difference between the average visits to ED in the three years before and after closure of Hopeland.

Finally, the authors estimate the annual cost to the Dayton community by the year 2005 had risen to:

(a) $ 13,396,000 (excessive ED usage charges)

(b) $ 4,805,000 (loss of federal support from Medicare with the balanced budget act (BBA) formulae applied) and

(c) <$750,000> (Operating loss of the Hopeland Center, considered a gain in this scenario or $17,451,000)

In 1999 an average visit to Hopeland created a “cost” of $37/visit. In 2004, a visit to an area emergency department has an average “cost” of $788. This ratio is approximately 21:1

($788/37 = 21:1) and represents the excessive cost of an ED visit versus one made to Hopeland.

Discussion

Is such a large economic burden possible? Certainly, the loss of the GME slots is real, and the funds which followed each slot are real. The authors reduced these amounts to reflect the impact of the Balanced Budget Acts (BBA) over the various years since 2000. The additional ED visits are logical since there was little capacity to absorb the Hopeland patients into other Dayton area clinical settings.

The tables in this report argue that it is the expense of ED visits that are driving up area healthcare costs in Dayton, which could have been avoided by having care delivered at a well-established family medicine unit. This leads to speculation about the relationship between health care costs and the paucity of primary care in the USA, and especially whether or not patients should be directed to an urban family medicine training site, such as Hopeland, for much of the care they are currently seeking from ED departments. (Table 2)

National trends in emergency room use

The authors recognize that numerous confounding variables are operative in this analysis, the most important being the interactions between a chaotic health system and vulnerable people needing care from that system.

There is evidence that the number of visits to emergency departments is soaring nationwide (Table 2), as well as in Dayton, and ED departments are scrambling to meet new demands by increasing capacity.

Thus, it would behoove policy-makers and other healthcare decision makers to consider the alternative of a less costly and more effective family medicine model. The implication for America’s health care system is that a safety net, non-triage, comprehensive Family Medicine training and practice model is cost-effective and has great value.

In addition, it is a model whose real value lies in its ability to provide comprehensive and preventive care which results in non-events, i.e., fewer strokes, heart attacks, earlier detection of cancer, etc. For example, heart failure (HF) can be cost effectively managed in an ambulatory setting. When it is, it creates a reduction in the number of visits made to an emergency department, ultimately saving resources.

As an illustration, if heart failure had been treated at Hopeland, it would have generated a revenue stream of $75 per visit; if that same patient had visited a Dayton area ED, it would have generated a cost of $788; however, if that patient was subsequently admitted to a hospital, that original $75/visit becomes an average $19,000+ admission.

Finally, this commentary is a lament for the reality that a financial contribution to a community by one family medicine health center was considerable even by using conservative assumptions, and now it is gone. Unfortunately, the knowledge of this financial contribution has been done long after the Hopeland’s demise, and this knowledge cannot alter history or turn around the escalation in Dayton ED usage.

The perturbations set off by the closing of Hopeland did send people at risk to EDs. Five years later, the increase in ED usage appears to be flattening, but a higher ED baseline average number of yearly visits will likely become a new norm due to the turbulent dynamics of losing a major safety net family medicine center.

WHB: Nik, what influenced you to choose the profession of medicine? 

Nikitas J. Zervanos, MD; Lancaster General Hospital; Lancaster, Pennsylvania

NJZ:  I grew up in a Greek immigrant home in Reading, Pennsylvania. We lived on a very narrow street, called Pearl Street with only 25 homes on the block where I lived, half of which were inhabited by Greek immigrant families. Within several blocks from our home there were two general practitioners, both of whom made house calls, and not infrequently I would witness their visits into our neighborhood. They were highly respected and among the most honored people in our community, and that made quite an impression on me.

My father’s brother, Hippocrates, was a physician and practiced in the Island of Kos in Greece, where both my parents grew up. This is also the birth place of the 5th century BC Hippocrates. Four of my father’s first cousins, all born in Kos, were physicians and practiced in Kos, Athens, Rhodes and Kavalla. I also have many second cousins in Greece primarily on the island of Kos and in Athens who are physicians, and even one in Thessaloniki.

In 1865, my grandfather had completed one year of medical school at the University of Athens, but then switched to the school of Philologia (Letters/Humanities), and went on to teach in the Greek grammar schools in Alexandria, Egypt. In the mid-nineteenth century the Turks, who still occupied the Dodecanese Islands allowed the locals to re-establish their own school system. They invited my grandfather back to the island to oversee its development.

When I entered college, I majored and excelled in chemistry, and many of my peers were in the premed program. I was encouraged by one of my classmates to consider medicine as a career. It was only because I did not think it was financially possible to go to medical school, that this was not considered in the first place. But when I began talking about it within my family circle, I was advised by a relative to approach a Greek-American state legislator, to explore state assistance.

The legislator in fact told me that if I could get accepted into any one of the three Pennsylvania state supported schools, he would obtain a senatorial scholarship for me. I was accepted into all three and chose to go to the University of Pennsylvania, and for the next four years my tuition was taken care of. Once I decided on medicine as a career, I read a good many books on the history of medicine, and one book by Taylor Caldwell, entitled, “Dear and Glorious Physician,” a historical fictional account on the life St. Luke, made a great impression on me. So did everything I read about Sir William Osler.

WHB: Why did you choose Family Medicine?

NJZ:  I wanted to be like those general practitioners who I got to see in our Pearl Street neighborhood. These doctors had made a huge positive difference in the lives of so many people from the youngest to the oldest and especially on these families, or at least so it seemed.

I also assumed that if one sought to become a physician, it would be either like these two general practitioners or a surgeon. When I entered the halls of my medical school, and got to know my classmates during that first year, I wasn’t surprised that nearly half of my freshman classmates wanted to become family doctors.

However, the socialization process of our medical education system took its toll on my classmates so that by the time I graduated there were no more than five of us that wished to pursue “general practice.”

Yet, the fundamental character of becoming a physician never changed regardless of specialty choice. After all, all of our role models were specialists and people many of us wished to emulate. They were simply impressively good physicians.

But it was also evident that the GP was not held in high esteem by our mentors, or at least so it seemed. By the 1950’s it was the general internist who was now viewed as the new primary care practitioner. It was no wonder that more of my classmates chose internal medicine as a career choice than any other specialty.

One of the most important political issues of the day while I was in medical school was what the policy makers in Washington and elsewhere were calling, “a crisis in the health care delivery system.” Indeed we medical students would often find ourselves gathered together to discuss the medical politics of the late fifties. The biggest issue was the doctor shortage, but it was also the declining number of general practitioners.

Many considered the GP the backbone of the health care system, especially in rural America. Moreover, there was also concern about the growing number of elderly who were also facing the issue of both access and availability. At the same time, another more pressing and perhaps even more critical issue was the rising cost of medical care, and that health care was no longer affordable by the vast majority of Americans, and especially among the elderly.

Although universal and even national health insurance was a pressing political issue following the war, it was strongly resisted by organized medicine, and during my medical school days it still was. The Democrats were again in power, and the rhetoric was growing. The AMA took what seemed an increasingly unpopular position to resist any kind of government health insurance or universal health care insurance.

I remember the confrontation of President Kennedy with the president of the AMA, which provoked much discussion among of all. The compromise seemed to center around insurance for the elderly (Medicare) and federal/state insurance programs (Medicaid) for the medically disadvantaged poor. What was also surfacing was a strong argument for a new kind of holistic-oriented specialist that would provide and coordinate comprehensive health care on a continuing basis.

The difference between the general practitioner and what was being advocated is the formation of a “discipline,” which both elevated the status of this kind of physician, and also assured that this physician would acquire the needed competency skills. I for one never deviated from that goal. What was now needed is the endorsement and support of the academic medical community.

WHB: Who were your mentors during the time you were deciding upon your career?

Diana and Nikitas Zervanos

NJZ: In medical school it was our chief of medicine at Penn, Dr. Francis Wood. He embodied all that was good about being a physician. He embodied “professionalism.” He was gracious and loved us as students as much as he displayed his love for the practice of medicine.

He had that wonderful magic that attracted people to him, whether it was with patients, colleagues, residents, or students.  He was our Sir William Osler, who by the way also graced the halls of my medical school in the late1880’s. He also had invited our class to his home early in our clinical years, and we were also very impressed with his wife, who I considered another role model for Diana and us married folk.

After medical school and while an intern at Lancaster General Hospital, I was strongly influenced by Dr Edward Kowaleski, a Lancaster County rural-based general practitioner who was then president of the Pennsylvania Academy of General Practitioners. He talked about the looming crisis being caused by the decline in the general practitioner.

Within a few years he was president-elect of the American Academy of General Practitioners and later after his tenure as Chairman of the board of the AAFP, was to become the Chair of the Department of Family Medicine at the University of Maryland. He was a dynamic, charismatic individual, with a powerful persuasive melodramatic voice. He was one impressive person who could make things happen. My interest in the medical politics of family medicine was ignited, if I wasn’t already feeling the flames.

During my internship I was drafted into the United States Army. A fellow intern and I got the idea that if we went to the U. S. Army’s assignment branch for the medical corps in Washington, D.C., we might be able to influence our assignment. It turns out that the only reason why the army even granted us an interview was that the medical corps was trying to recruit physicians to volunteer for the Green Berets with deployment to Vietnam.

Fortunately the colonel took a liking to us and was willing to accommodate my desire for the only US army medical corps slot in Greece and my friend who wanted to go to Germany. While in the army my commanding officer and his wife were also my patients. He was not a physician, but liked what and how I was conducting my “family practice” for him and his family and the troops.

When I commented about my concerns about what was happening back home regarding the above issues, he encouraged me to do something about it. I wrote to my medical school dean at Penn, and although Penn was not doing much regarding the issues relating to the creation of a new specialty, he was aware of what was happening at Harvard.

In 1964, even though I was in Greece, I stayed up to date with the editorials on the issues, which were well covered in the editorials of the AGP (American General Practice), JAMA, the NEJM and other ready available publications.

My dean was supportive regarding my expressed concerns and seemed glad that I had written to him. He encouraged me to write directly to Dr. Joel Alpert, the then new chief of the Family Health Care Program at Harvard Medical School. They had developed a new fellowship for general practitioners, graduates of internal medicine, and pediatric residency programs, who were contemplating an academic position of sorts in the newly proposed specialty of family medicine.

Joel Alpert was to become a key figure in my maturation as an academician and had a profound influence on my ultimate decision to become a young program director, after completing my fellowship.

Once in Lancaster, it was Dr. Thomas Hart, the new program director at York, who quickly became a close friend and wonderful mentor. He had a wonderful sense of humor with a Groucho Marx like mustache and very quick mind. He not helped guide me through those very first difficult years, but many others and would often find himself telling new program directors, “tell me what your problems are, and I will tell you where you are in your development.” And some other times, “tell me where you are in your program’s development, and I will tell you what you can anticipate.”

Another very important mentor was Dr. Ward O’Donnell, the chief of pathology at Lancaster General and the president-elect of the hospital when I was hired. We did not have a chief of staff at the time, but he served in that role during his tenure as president. Ward was convinced that the best way for the hospital to advance as a major medical force in the community was to develop a strong academic medical program.

Recognizing the hospital’s history as a highly respected community hospital with a rotating internship dating back more than fifty years, he was convinced that a residency program in the new specialty of family medicine made a great deal of sense. He knew LGH could do it well. LGH’s strengths included fiscally sound well run hospital under the able leadership of Paul G. Wedel, an established rotating internship, a general practice residency, and a new young breed of academically oriented physicians.

With Ward O’Donnell as a driving force, I received a call from our new Director of Medical Education, Dr. John Esbenshade, to determine if I might be interested. The other major players in bringing this about also included Dr. Ian Hodge, chief of urology, and the then president of the medical staff as well Mr. Wedel. Without Paul enthusiastically behind the idea, it would never have come to fruition. They all served as my mentors in those early years.

Once in my new role as Director, I also counted on a growing support system that included Dr. Tom Leaman, the new chair of family medicine at Penn State University at Hershey, Dr. Ed Kowaleski who was now president of the AAFP, but still practicing in Lancaster County, and a growing number of academicians at Temple University, which was to become our major medical school affiliate, but also people at my alma mater, and the rising luminary at Jefferson, Dr. Paul Brucker.

One of my most important mentors was the Associate Dean for Continuing Medical Education at Temple University, Dr. Albert J. Finestone. In 1975 we began a national CME course in family medicine here in Lancaster, called the Temple University/LG Hospital Family Practice Review. I am still directing this course, now in its 37th year. It is conducted in the spring and fall and continues to attract more than 700 physicians a year.

Another very important mentor was my first associate, Dr. Henry Wentz. He was a general practitioner from the town of Strasburg just south of the city and several miles north of Quarryville. He was my attending on our so-called “ward service,” early on in my internship. He was smart, attentive, clinically astute, and a good and honest family doctor who I could look up to with admiration and pride.

He had us as guests in his home, and I was impressed with his wife Mary, who also helped him in his office practice, which by the way adjoined their lovely home. He and Mary raised two wonderful children and were involved in their little town and their church community. They made an indelible impression on Diana and me. We would have liked to emulate his practice, their life style, and community and hospital participation. I also thought what an added joy it would be to practice in Lancaster and here at LGH, be involved in teaching young interns, and serve to enhance the hospital’s medical education program.

When we began thinking of developing both a hospital practice and a rural practice, he was one member of our department who came forth and expressed his strong endorsement of the residency program and also suggested a practice location for a “model family practice unit” in Quarryville.

Of course, when I began to think of a director of such a center, I could not think of anyone better than Henry to help us achieve such an objective. Moreover, he was so highly respected by the members of the medical staff, that he could help sell the merits of the idea. He also happened to be the vice chair of our department.

When discussions took place regarding a center in the southern end of the county, it was Henry who first convinced Dr. Bare of its merits, and soon Dr. Bare became a strong advocate to establish the center in his town. Moreover, I was certain that if we could recruit Dr. Wentz to be the medical director of our new center, it would almost guarantee its success. When I was given the green light by Mr. Wedel to approach him, I immediately went to Henry and asked him to become my associate.

Although he was understandably hesitant, if for no other reason than his concerns over his practice, he decided that he could do this on a half time basis if we could convince Dr. Ivan Leaman who was then completing a general practice residency at LGH, to join him. Thankfully, Ivan agreed to do this, and Henry not only became my first associate, but continued in both a direct and indirect way to serve as my mentor. He remained in this role for several years until it became too much for him, and returned to full-time practice.

In the meantime, we continued to add outstanding individuals as associates, who served as faculty. The program now has more than fifteen fulltime family practice faculty and 5.5 ob-gyn faculty members. There have been very few of the faculty who joined the department who left over the years. One, John Randall, MD, became the chair of family medicine at Jefferson Medical College after Paul Brucker assumed the position of president of the university.

WHB: What was your educational preparation for becoming an academic family physician?

NJZ:  While an intern at Lancaster General Hospital, I considered doing a general practice residency, but I was disappointed in what was offered at LGH as it was more like another year of an internship. I looked at other programs, but they were not all that much different, so I decided to return to the Penn campus, and do a one year residency at the Philadelphia VA beginning in July 1963.

However, I got my draft notice in the early spring of 1963, so I postponed my year at the VA until after my tour of duty. In the meantime, while I in the military, as already noted I decided to explore the fellowship program at Harvard.

My correspondence with Dr. Alpert led to a formal application, and I submitted the required supporting documents. I was offered an interview after my discharge, and I was already committed to begin my internal medicine training at the Philadelphia VA to begin that March (1966), I was offered a fellowship to begin in July, 1967.

During the year that I was at the VA, the residency became formally integrated with the University of Pennsylvania. Dr. James Weingarten, the Chair of Medicine at Penn, and the overall director of both the VA and HUP residencies, encouraged me to stay another year before going to Boston.

This was also to include the opportunity to engage in a one year long weekly Balint seminar offered by Dr Bob Potash. I accepted the offer and completed a second year at Penn with Dr. Alpert’s blessing, which postponed my fellowship for another year to begin in July, 1968.

The first fellow in the Fellow in the Family Health Care Program was Dr Lynn Carmichael, a general practitioner from Coconut Grove, Florida. He completed his fellowship in 1964, and then went on to become the new Chair of Family Medicine at the University of Miami. Just as I think it did for Lynn, the fellowship set the stage for a number of us to enhance our roles in academic family medicine.

People like Drs. Tom Leaman and a couple of his associates participated in brief 3 and 6 month experiences in the program and then returned to Hershey. The program turned out to be good preparation for me for much of what I was going to end up doing at Lancaster was learned in this program including the development of our “Family Health Service,” which was modeled after the Family Health Care Program. While I was in my fellowship (1968-1969) the specialty of family medicine was officially established (February 1969).

Around the same time I had begun exploring various academic opportunities. The place I thought where I wanted to be was at Penn State University at Hershey, a brand new medical school where family medicine was to play a prominent role.  I interviewed with Tom Leaman, but they were looking for people with more practice experience.

Lancaster General Hospital; Lancaster, Pennsylvania

It was around the same time that I received a call from Dr. Esbenshade, the new DME at Lanaster General Hospital. He told me that Lancaster General was to create a new department that would need someone to direct the department’s new out-patient department with a community medical service and develop a residency in the new specialty of family medicine.

This suited my interests to the tee. What was also of interest that was our program was known as a community medical service, and what LGH wanted was what we were already doing at Harvard.

At the same time our program was picked to become one of the fifteen pilot family practice residency programs in America. As a fellow, it was fortuitous that I was part of all of this. I could not have been better prepared for what I was being asked to do. Moreover, it was also fortuitous that our program in Boston was developed at the time that Medicare and Medicaid was taking off.

WHB: “The family” and “the community” seem not to be regarded as relevant concepts by much of organized academic medicine. But both family and community are obviously important to you personally. Describe how the family and your community orientation affect you as a physician? 

NJZ:  Let’s face it, individuals come from families and people and families make up communities. Conceptually therefore there is a good bit of logic in caring for individual patients in the context of their families and the communities in which they live. Getting to know one’s patients in that context allows the physician to better care for the patient.

Therefore, when we started the program in 1969, we consciously chose the name “Family and Community Medicine”. Obviously, the family concept is integral to the specialty, and a concept that I came to value so highly back to the days growing up on Pearl Street in Reading.

The sixties was a time of change, and family medicine as a specialty was part of a new paradigm with its community focus to help solve America’s health care delivery issues.

Unfortunately, the family has been undergoing a break-down for some time and particularly evident throughout the sixties. Much of what we witnessed as to the ill-health of the community was the direct effect of the ruptured family structure.

In the light of all this, and what I thought was needed was to find within the new specialty we were about to create and develop was a breed of family physicians who would take a leading role to restore the health of the family and our communities.

Therefore the Lancaster program’s philosophy was to recruit physician leaders, who would be “Part of the Solution, and not Part of the Problem.” This slogan was on a banner on the wall right behind my desk. To support this notion we established a requirement that beginning in the second year we would require each resident to declare a community service project designed to make the community healthier.

One of the most pressing challenges in our community was the alcohol and now raging drug problem. Again we considered caring for the patient with an addiction best managed in the context of the family and community. It take a “village” to help restore people with addiction to be restored to health, so we embarked on finding ways to build a support team, and that might not include the patient’s biologic family.

Often times these victims come from seriously impaired dysfunctional families, let alone broken homes or broken neighborhoods. But we were going to try. We also accepted the fact that “family” doesn’t always mean that the person is married or still a member of his or her biologic family. It was increasingly common for patients to live as unmarried couples and in non-traditional family settings.

In the meantime, we have witnessed that many of the welfare programs put in place during the sixties had inadvertent consequences on the family unit. It is common, and increasingly so, to have many women today who wish to have a child out of wedlock in order to “earn” or acquire a welfare check. Sometimes it doesn’t even matter who the father is so long as the unwed mother can have a child to raise, which qualifies them for welfare assistance.

In 1969 we took on the addiction problem so seriously that we developed a unique addictive disease program that was to be integrated into the program’s new hospital-based “Family Health Service.” The addictive disease unit received federal, state, and local funding, and it included a “methadone clinic” and a “family counseling center.”

The patients enrolled in this program had to include a member of their family or intimate other. Together they were involved in the care process. They were seen in the family counseling center, which was made up by the patient’s family physician, nursing personnel, a social worker, psychologist, and a minister. The social worker, psychologist, or minister served as the patient’s personal counselor, but group therapy sessions were part of the program. It was amazing what we were able to do for addictive disease patients.

We soon were involved in the development of a half-way house and worked with the County’s various drug and alcohol task forces and other services to minimize incarceration. Although it was common in the beginning to admit patients for withdrawal, once the “Addictive Disease Program” was established that was rarely necessary.

The program grew quickly, and began to dominate the other resources of the residency program, and when the five year NIMH grant was exhausted, the program was taken over by the county’s offices of Mental Health and Retardation (MHMR). However, we did demonstrate that psycho-social issues can best be managed by addressing the pathology emanating from both the family and community.

Dr Zervanos (left) with family medicine residents (1972)

Having our residents taking on a community service project provided our residents the opportunities to test their leadership skills. To engage the community’s resources, we went to every agency in town, and met with their directors and discussed our new program. We asked them to offer our residents a meaningful role in their agency or program.

We explored different ways how our residents might help solve problems. This included tobacco consumption, radon exposure, and air pollution (Lung Association) to help prevent lung cancer; alcohol and drug addiction (Lancaster County office of Alcohol and Drug Abuse); teenage pregnancy (Childrens and Youth); homeless (Mission Center); health education (schools); etc.

Some residents served in an advisory role; others took on projects and others conducted studies, etc. A faculty person was given the task as advisor and coordinator. This aspect of the community medicine curriculum proved to be very successful. One example involved a resident, who did a rotation at Nazareth Hospital in Israel in his second year. When he returned, he decided to establish a foundation to help Nazareth Hospital, and before he graduated, he helped raise more than $50,000. Now the foundation raises millions each year.

Another example is a resident in the early seventies who was annoyed that some hospitals throughout the country, including our own, still allowed smoking, and in some cases still had cigarette vending machines. He worked with the Lung Association to send a letter to every hospital in the country, proposing that they change their policy if smoking was allowed in the hospital or if vending machines were still be used. We did not have statistics to determine what effect this had, but it we know from feedback received by the local Lung Association it was significant.

Of course today, it’s unheard of, and even employees can’t find a place to smoke at the General. Each year we recommend two or three residents for the AAFP Bristol Myers Squibb Family Medicine Leadership award. There are years when we have had 2 residents receive one of the 20 such awards that are given each year. The residents from the Lanaster General Hospital have received AAFP resident leadership awards than any other residency program in the country. 

WHB: How did you implement “family and community medicine” within Lancaster General and the rural communities in the geographic area it served?

NJZ:   One of the big issues that affected the development of the family medicine residency programs were the requirements that the Family Health Center had to care for a broad spectrum of socioeconomic groups; it could not be solely indigent care. However, we were not about to abandon our goal to develop a comprehensive health care program for the low income or medically indigent people of our community.

Part of the dilemma was that the medical staff insisted that the hospital-based unit was not to compete with the private practicing physicians, so to open up the practice to a wider socioeconomic spectrum created a challenge. We also realized that our hospital-based unit offering services to low income people who were now on medical assistance could attract maternity patients, a much needed group of patients for our residency program.

At the same time we were aware that the southern Lancaster County area was devoid of physicians. Three of the practicing physicians were over 65 and one wanted to retire, and there were only two others, both osteopathic physicians who did not utilize our hospital. The area was seriously underserved and there were several community leaders who were eager to get more physicians into their community, and showed interest in our proposal to place our center in Quarryville, which was the borough right in the center of the area.

Moreover, the chair of the department of “General Practice” was one of the three practicing GP’s who was over 65, and also welcomed the idea of placing our family practice center in his town. However, we had to convince Dr Thomas Johnson who was about to visit our program that the 15 miles distance was not going to be too far from the hospital.  At that time, the existing requirements of the Residency Review Committee on Family Medicine (RRC) limited the distance the “model unit” could be from the mother hospital to 15 minutes, not 15 miles (30 minutes).

It was our good fortune that Dr Thomas Johnson was who he was, for his opinion as to approval of a program weighed heavily on the Family Medicine Residency Review Committee. Moreover, Tom was advocate for programs that could demonstrate innovation. He insisted that at this stage of our development that the RRC needed to be flexible. He gave programs like the one we were proposing in Lancaster the opportunity to prove that their model could work.

The RRC gave us provisional approval, and hence we were allowed to establish our model unit in Quarryville, while providing our residents the three year continuity community medicine experience at the hospital based facility. Hence our predicament was converted to into a positive “innovative” idea.

We were able to prove that our residents could have two highly complementary practice experiences one in a rural-based “model family practice unit” caring for a wide spectrum of socioeconomic groups and the other a “community medicine” experience caring for a medically indigent population in the hospital-based urban setting.

The Walter Aument Family Health Center; Quarryville, PA in the 1970s

With the institution of Medicaid, the medically indigent were quickly identified, and perhaps not surprisingly, many more who qualified came out of the woodwork. Unfortunately too many physicians were dissatisfied with the reimbursement and were not anxious to add “new” patients who were on medical assistance, and that included maternity patients.

Again that created more opportunity for us and allowed us to quickly build our two practices. We called our new hospital based unit the “Family Health Service,” or if you will, a service in family health care, a take-off from the words that were used to describe our program in Boston, which was called the Family Health Care Program.

The residents would not begin their model unit experience until their second year when they would spend 2 to 4 half days per week in the new “Southern Lancaster County Family Health Center” in the borough of Quarryville, with a population of 2000 people in a drawing area of almost 300 square miles where more than 15,000 people lived.

In the meantime, the residents would continue to care for their patients in the Family Health Service one half day each week for the entire three years. Today the southern end of the county has doubled to more than 30,000 people.

To help the practice get started in Quarryville with full community support we capitalized on the benevolence of its community leaders and established a community advisory committee. They did much to assure the success of the center. What made some anxious was that the physicians who were caring for them were doctors in training.

However, we quickly pointed out prior to 1969, and even in many cases even then, a physician could be licensed in PA and set up practice following their internship. We pointed out that all our residents would have completed their internship by the time they began caring for patients, but in addition to that a senior faculty person with years of experience would be their preceptor or proctor and be available to provide immediate consultation and advice.

It did not take long to reassure the citizenry, and they soon were singing our praises, expressing appreciation for the excellent care that they were beginning to receive. Our practice grew very quickly.

WHB: Describe how the indigent community served by Lancaster General Hospital affect the character of its family medicine residency program? 

NJZ:   Our objective was to develop a family focused and community oriented health care delivery system, so the demographics of Lancaster City and County was important in our planning of the residency program as we proceeded to establish two very different family practice centers.

The various federal and state legislative initiatives incentivized community leaders, hospitals, and other new health care entities to reach out to the medically indigent and develop new programs to care for underserved populations.

We took it upon ourselves to learn not only who are patients were, but where and how they lived. At the time about twenty percent of the population of the city was medically indigent and an increasing number were Hispanic; today it is more than twenty-five percent. Most of these people would have ready access to the hospital-based Family Health Service, but this was not adequate.

A federally qualified community health center in the heart of the city’s southeast where the low income and highly concentrated medical indigent live was also established, and today it is staffed by several of our graduates. Its outstanding director is also a graduate.

The plaque for the Zervanos Center for Family Medicine Education

Historically going back to before the war years, the hospital established an outpatient clinic staffed by volunteer members of the medical staff, and for the most part, this clinic served the community’s medically indigent well. However, the care tended to be fragmented and too many health care issues went unattended.

So, with the establishment of the new Family Health Service, we gradually did away with all the specialty clinics, and were left with our faculty and residents. Over time, 85 or more percent of the patients’ needs could be met with residency program’s faculty and residents.

With the establishment of Medicare and Medicaid it was now possible to obtain consultation in most of the offices of our specialists; however, we did have some consultants that insisted that their clinics be retained, as they preferred to see their patients with the residents who were rotating on their service in the OPD.

Their clinics are viewed as a consultation service. This worked out surprisingly well, especially as the residency program grew. In some situations patients requiring surgery or highly technical services are sent to the nearby Hershey Medical Center, but most surgical procedures on the medically indigent are cared for by LGH doctors.

With four decades of experience and tens of thousands of graduates, what elements of the family medicine residency do you regard as unambiguously successful? Are there elements that you believe should have been constructed differently from the beginning? 

NJZ: The evidence we have as to our success is manifested in our graduates. They speak volumes. Of the more than 450 graduates of our residency program to date, less than three percent have changed their specialty and only one that I know of left medical practice all together.

Our graduates are changing the world for the better. I can think of hardly anyone that has disappointed me. I am proud to say many have become leaders within our specialty. Five that I know of have been chosen by their state chapters as the outstanding family physician of the year. More than a third of the graduates are practicing right here in Lancaster County, and their work is exemplary. That includes what they have accomplished in their individual practices as well as their contributions to the community at large.

Two thirds of our graduates are in communities of less than 30,000 people. The year that I retired as program director in 2002, a recruiter in New England called me, and she said to me that “I have been working in physician recruitment nearly as long as you have been a program director, and I have to tell you that when we have the opportunity to place a graduate from your program, we know from experience he or she is one of the best, and we have no trouble placing them almost anywhere they wish to go.”

Of course, our residency programs are constantly undergoing fine-tuning and change is inevitable, but fundamentally I would not change the overall structure of our program. I think the opportunity our residents have had to work in two different settings with two different socio-economic groups is a major strength of our program.

Moreover, I have been impressed when our residents are empowered and have been given the opportunity to exercise their leadership skills, as many have proven to be formidable.

Our residents have proven to be leaders as practitioners as well as in the academic family medicine community. More than ten have become program directors, one a dean, another a vice dean, two became chairs, and one a vice chair of family medicine, in medical schools, and many more have become full time academic faculty. Others have risen to become Vice Presidents for Academic Affairs or Chiefs of Staff of their hospitals.

Many are directors of large medical groups and one a top ranking officer of one of the major private health insurance plans. The current AAFP Division Director for Medical Education is one of our graduates. He was also president of the Association of Family Medicine Residency Directors as was one other of our graduates.

WHB: Are there things about the structure of the three-year residency that you would change now?

NJZ: Do we need a four year residency? I don’t think so. We have implemented a number of CAQ’s, and we still keep adding. We may wish to add another in Obstetrics. As I already mentioned the obstetrics curriculum needs to be revisited. The reality is that the vast majority of our graduates are not including obstetrics in their practices, and those that wish too often run into resistance from the ob-gyn community and hospital credentialing committees.

A CAQ would provide the added assurance that a family physician who wished to do full service obstetrics including surgical ob would satisfy more vigorous credentialing criteria. There are also changes taking place in the care of the hospitalized patient, with fewer family physicians caring for their hospitalized patient.

However, the development of the patient centered medical home concept is also addressing the changes taking place in our medical practices. Continuing medical education is extremely important, and I believe the American Board of Family Medicine with the Maintenance of Certification in Family Medicine has also reinforced additional ways to assure the public of that family physicians are keeping abreast of the latest developments in clinical practice and maintaining their competence skills in family medicine.

I still direct the Family Medicine Review Course for Temple University, and I can attest to the value of such ongoing continuing medical education as we receive constant positive feedback as to helping our physicians keeping current as well as helping them in preparation of their boards.

WHB: The latest health reform act was enacted under politically divisive circumstances? Are there elements that you are pleased have been enacted? Are there unintended consequences of the legislation that you predict will occur?

NJZ: I am very pleased that many more people will have adequate health insurance as health care has become so expensive that no one can get sick and expect to receive the care they need without it. I am also pleased with the assurance that no one with a major health problem will lose their health insurance, nor that someone with an existing health problem will be unable to obtain insurance.

Yet, one has to be realistic about our ability as taxpayers to pay for it. Moreover, our current debt problem seems so overwhelming that I am not sure where the money is going to come from to pay for this unless the American people are willing to experience an increased tax burden. Instead we are talking about how we might be able to reduce expenditures for health care. I don’t know how this is going to play out, but in the long run we have to find better ways to cut costs or lower the cost of delivering medical care.

There are many ideas that have been proposed, and we have to embrace those that will or at least might work. It doesn’t make sense to me for example why Medicare or Medicaid expenditures can be twice as high for the same demographic group of patients in one sector of the country vs. another.

Medical liability factors are another variable that can be controlled when there is the political will to change that.  Making the patient the center of how money is spent for medical care (medical savings account) is another idea that needs further exploration and experimentation.

Whatever is put in place, and whatever the good intentions might be, there are always unintended consequences and the potential for abuse. Both Consumers and Providers have learned to manipulate the system, but safeguards, or if you will, regulations (a hated term for many) can minimize that as well. I always thought that if there was an adequate or high enough co-payment that would reduce the overuse or abuse potentially.

I still believe that in any system, you have to give more responsibility to the patient as to how they use the system. Moreover, I have constantly preached that a physician should never order a pharmaceutical, laboratory test, or any other test, or procedure unless he or she knows the intervention will help and would cause minimal side effects.

Defensive medical practices, notwithstanding, we as physicians must be more fiscally responsible on how we influence the cost of medical care. We must teach our residents that we are stewards of the health care dollar as it is our professional responsibility. Patients who choose to use the ER should also know their out of pocket costs are going to be much higher.

I like the idea of being able to make evidence-based decisions, but that’s not always practical. Although I think the Electronic Health Record (EHR) has both positives and negatives, in my experience it takes longer to complete a medical record. Still there is a major advantage to have a lot of data at your fingertips, including easy access to consultation reports, lab, imaging, etc. There is little question that this increases quality of medical care, but it also takes time (increased cost) at each visit to want to read all these reports.

WHB: Are there elements of the health care reform legislation that you regret? 

NJZ: The Medicare and Medicaid legislation proved to be divisive. The leaders of organized medicine fought any kind of government insurance as they believed government intrusion in medicine will compromise the relationship between the doctor and the patient.

At the same time people inside and outside of medicine have argued that health care in a civilized society should be a right and not a privilege just as many believe that an education should is a right and not a privilege. And when health care becomes unaffordable for the vast percentage of its citizenry, especially among its non-working poor, government becomes the only resource to make it available.

However, it is also true that government and the growing third party system may interfere with what some physicians may think is in the best interest of the patient. In my opinion, however, this is very uncommon, and rarely compromises patient care in any serious fashion.

At the same time many people have benefitted from government health care insurance. Physicians’ incomes have increased and many people have received medical care services that would not have been possible otherwise.

Let’s face it, if one views Medicare and/or Medicaid or even insurance coverage from one’s employer as an entitlement, there can be abuse; and indeed, there have been abuses on both sides. Abuse or no abuse, health care costs have escalated, but it is astonishing that health care costs have reached such astronomical heights.

Even as a medical student (1958 to 1962), it was apparent that medical care was becoming increasingly more expensive. It is also a fact that “free” health care is abused. I witnessed this while in the military as some will go to the doctor even for frivolous reasons; they will ask for expensive tests or pharmaceuticals, and even insist on an antibiotic for their child’s cold; so long as they don’t have to pay.

There is also a difference on how doctors practice medicine if a patient has to pay out of pocket vs. if a third party will pay the bill. We witness this in the care of the Amish vs. those who have insurance at our center in Quarryville. Obviously I may be exaggerating to make a point. However, for good or bad reasoning, all would agree that costs are determined by who is footing the bill.

Still, I became an early advocate of government insurance, as a way to see to it that underserved people (the poor and elderly) could get the care they need. Now nearly all of us (99 %) can’t get the medical care we desire, let alone need, without health insurance.

Personally, I endorse universal health care, and I don’t object to an unipayer government subsidized health care delivery system. The simple fact is that I just can’t see how we can have an equitable and humane and effective health care system if people can’t access it because they don’t have insurance.

The challenge is to find a way to do this in the most intelligent, most thoughtful, most economical way possible, and without damaging the relationship the patient may have with their doctor or doctors. I think that’s possible, and frankly we just have to.

WHB: What is future of Family Medicine?

NJZ: Basic concepts of family medicine have not changed. Family Medicine is the specialty of primary care, and it is the backbone of our health care delivery system. It is the specialty that assures people holistic, continuous, and comprehensive health care. It means prevention and that includes primary prevention and even to a large extent secondary and tertiary prevention.

We work with our specialist colleagues to assure high levels of secondary and tertiary care. We pay attention to the psychological and sociological factors, and often to their spiritual nature as well for that too affects health outcomes. A sound doctor-patient relationship remains a most important component in assuring high quality primary care.

It is incumbent for all family physicians to understand that and to keep working to develop the best possible relationship with our patients so they can believe and trust in us and be assured of effective high quality care.

The Twenty-Third convocation of the National Conferences on Primary Health Care Access will be held April 16 through 18, 2012 (concluding at noon on April 18th) at the Park Hyatt Aviara Resort in Carlsbad, California. The theme of the conference is “Realities and Illusions”.

Th Park Hyatt Aviara Resort in Carlsbad, California

Background of the National Conferences on Primary Health Care Access

In 1990, a group of persons interested in family and community medicine, medical school reform, and advocacy for rural, inner city and other geographical areas of need, were invited to rural Wisconsin for the First National Conference on Primary Health Care Access. Since then, similar groups have been invited to assemble each Spring.

Over the years, many of the pioneers, key strategists, researchers and policy makers who have promoted the idea of community-responsive medical education have participated in one or more of the National Conferences. (Many have participated in 15 or more of the 22 conferences held through 2011.)

The National Conferences have continuity in the conference faculty from year to year. The conferences are limited to approximately 55 participants. Persons who enroll in the conference series are invited to renew their space in each subsequent conference. For additional information on the series of National Conferences, see: The Background of the National Conferences on Primary Health Care Access.

Continuing medical education prescribed units will be awarded. (For the CME awards of each of the previous National Conferences, see: CME Prescribed Credits for National Conferences on Primary Health Care Access.)

When the National Conferences began in 1990, there appeared to be a consensus among its participants that if legislation was enacted to increase access to primary health care, rural and underserved populations would be the principal beneficiaries of the reform.

A panoramic resort view from a Park Aviara room

That may yet prove to be the case, but many persons who strongly supported changes in national health care legislation have deep reservations about both the processes and the product of the legislation enacted in 2010.

Of course, enacting legislation at the federal level is only the first step in changing the way the health care system works. Not only do different sections of the comprehensive bill become operative at different times, almost every line of the legislation requires new regulations or revision of existing regulations.

Some (maybe much) of what the legislation requires will generate ongoing political debates, which often will be so divisive as to make the particular future policy stands of legislators and other policymakers (or even whom they may be) unpredictable at the present time.

Even so, there is much opportunity for constructive change, and those areas will be a central theme of the Twenty-Third National Conference.

Each of the National Conference sessions begins at 6:30 a.m. and is comprised of early morning breakout groups with assigned topics. (See an example of last year’s breakout session at 21st National Conference – Reports from Monday Breakout Sessions – April 12, 2010.

The Park Aviara - a Five Diamond Resort

Reports of succeeding days are found in the website’s archives for the months of April 2011 and subsequent months.)

All National Conference business ends at noon each day, permitting conferees to enjoy the surroundings of one of the world’s great destination areas for the remainder of that day with family or colleagues.

Information on the National Conference’s plenary sessions will be posted as they are announced.

The posting of the proceedings of previous National Conference plenary sessions relevant to the 23rd National will take place continuously.

This will include a series of presentations on Community-based Medical Education that are preparatory to discussions on this subject at the Carlsbad conference.

For information on the Twenty-Third National Conference, which is invitational, please contact coastalresearch@yahoo.com.

The Adjacent Lagoon and Bird Sanctuary

23rd National Conference Plenary Faculty (announced as of January 11, 2012)

Marc E. Babitz, MD, Utah Department of Health, Salt Lake City

Sally Bachofer, MD, University of New Mexico, Albuquerque

John Boltri, MD, Wayne State University, Detroit, Michigan

Peter Broderick, MD, Valley Family Medicine Residency Program, Modesto, California

Mary T. Coleman, MD, Ph.D., Louisiana State University, New Orleans

Hector Flores, MD, White Memorial Medical Center, Los Angeles

N. Benjamin Frederick, MD, Penn State Hershey Medical Center, Hershey, Pennsylvania

Joshua Freeman, MD, Kansas University Medical Center, Kansas City

John Geyman, MD, University of Washington Emeritus, Friday Harbor

Thomas Hansen, Creighton University, Omaha, Nebraska

Tim Henderson, MPH, George Mason University, Fairfax, Virginia

James Herman, MD, Pennsylvania State University/Hershey Medical Center, Hershey

Mitchell Kasovac, DO, A. T. Still University, Mesa, Arizona

Jay Lee, MD, Memorial Medical Center, Long Beach, California

Darryl Leong, MD, MPH, Care 1st Health Plan, Monterey Park, California

Gary LeRoy, MD, Wright State University, Dayton, Ohio

Don McCanne, MD, Physicians for a National Health Program, San Juan Capistrano, California

Charles Q. North, MD, MS, University of New Mexico, Albuquerque

Cynthia G. Olsen, MD, Wright State University, Dayton, Ohio

Perry A. Pugno, MD, MPH, American Academy of Family Physicians, Kansas City, Kansas

J. Jerry Rodos, DO, Midwestern University, Western Springs, Illinois

Joseph E. Scherger, MD, MPH, Eisenhower Hospital, Palm Springs, California

Frederic N. Schwartz, DO, A T Still University, Mesa, Arizona

David N. Sundwall, MD, University of Utah, Salt Lake City

Daniel Webster, MD, Michigan State University, Traverse City

Allan J. Wilke, MD, Ross University, New Brunswick, New Jersey

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Joseph Scherger, MD, MPH; Eisenhower Medical Center; Rancho Mirage, California

Doctors John Geyman and Joseph Scherger return to the faculty of the National Conferences on Primary Health Care Access, at the 23rd National Conference on Primary Health Care Access, to be held April 16-18 at the Park Hyatt Aviara in Carlsbad, California.

The first three hours of the 23rd National Conference will be devoted to overviews of the current issues surrounding 2010′s comprehensive and controversial health care legislation, the Patient Protection and Accountable Care Act (PPACA), to the nation’s seriously deficient primary health care system, and to promising new directions in primary care.

The first plenary panel, which will begin Monday, April 16 at 8:15 .m., will provide an update to the administration’s implementation plans, and to constitutional and political challenges raised against PPACA.

The first plenary panel will be followed by “Breaking Point”, Doctor John Geyman’s lucid analysis of the lack of preparedness of the nation’s current primary care system to meet even current challenges such as the increased prevalence of chronic disease and the aging of the population, without considering how PPACA might be fully implemented. Doctor Geyman is emeritus professor at the University of Washington, and author of seven books on health care policy that includes his latest on the primary care system [see Senior Fellow John Geyman’s New Book on Primary Care Crisis to be Featured at 23rd National Conference.] A reactor panel will follow Dr Geyman’s presentation.

Then, at 10:15 a.m., there will be a presentation entitled “The Future of Primary Care is Now!”  by Dr Joseph Scherger, Vice President of Primary Care and Academic Affairs at Eisenhower Medical Center in Rancho Mirage, California. A reactor panel will follow his presentation as well.

The 23rd National Conference is invitational, with registration strictly limited. For further information, contact coastalresearch@yahoo.com.

Joshua Freeman, MD; Kansas University Medical Center

The scheduled panelists are Joshua Freeman, MD of the Kansas University Medical Center (Kansas City), David Sundwall, MD of the University of Utah (Salt Lake City), and Hector Flores, MD of the White Memorial Medical Center in Los Angeles. Doctors Sundwall and Flores are Senior Fellows of the Coastal Research Group. Dr Freeman is a Fellow.

Last year Dr Freeman critiqued the PPACA legislation as the 2011 Stephens Lecturer. (See Proceedings of the 22nd National Conference: The 21st G. Gayle Stephens Lecture: Dr Joshua Freeman.) He is Chair of KUMC’s Department of Family Medicine and has been involved in issues of social justice and care to underserved populations throughout his career.

David Sundwall, MD, University of Utah

Dr Sundwall, who has served on a committee staff of the United States Senate, and has been served as Administrator of the United States Department of Health and Human Services Health Resources and Services Administration, and also as the Utah State Director of Health.

Dr Sundwall is currently on a national policy committee on  Medicaid and federally financed children’s health programs. (See Activities of the Fellows and Senior Fellows of the Coastal Research Group: Dr David Sundwall is Vice Chair of Federal Panel on Medicaid and CHIP Payment and Access.)

Dr Flores, who is nationally recognized as an expert on the provision of health care to disadvantaged communities, is one of the founders of the White Memorial Medical Center’s family medicine residency program in East Los Angeles. He has taken part in several federal committees and task forces relating to health care access.

Hector Flores, MD; White Memorial Medical Center, Los Angeles

Doctors Freeman, Flores and Sundwall will each speak to the issues and then will engage in an exchange first among themselves and with National Conference participants.

The National Conferences on Primary Health Care Access have taken place each Spring since April 1990. They are invitational conferences limited to around 50 persons. This is the third consecutive National Conference which has examined the efforts to develop and implement a comprehensive federal health care reform legislation.

Professionals interested in primary health care public policy who would be interested in receiving an invitation to the National Conferences should send an e-mail to coastalresearch@yahoo.com.

Plenary sessions concentrated on the student pipeline for the primary care workforce will take place on the second day of the 23rd National Conference on Primary Health Care Access (Tuesday, April 17, 2012) at the Park Hyatt Aviara Resort in Carlsbad, California

Perry A. Pugno, MD, MPH; American Academy of Family Physicians

Leading the principal session on student interest in primary care will be Doctor Perry Pugno, Vice President of the American Academy of Family Physicians (AAFP), who will examine student interest in family medicine careers, addressing the question as how student interest has changed over time.

Dr Pugno will describe the AAFP’s re-design of its strategic approach to student interest in response to new studies, new trends, and now new input from a diversity of stakeholders.

Dr Pugno asks: “Is there a “magic bullet” that will trigger the choice of family medicine as a specialty?” and answers “Probably not”.  But the use of a portfolio approach to address multiple factors and decision-points for individual medical students (or even pre-meds) can indeed make a difference in the pipeline for family medicine’s future.  Innovative residency training models, value-added curricula, and diverse training settings are only a few of the many approaches now beginning to demonstrate their favorable impact on student interest.

The presentation by Dr Pugno will be followed by a responder panel that will be announced soon.

The posting of the proceedings of this plenary session is part of a series of previous presentations on Community-based Medical Education that will be highlighted on this website. Such presentations are preparatory to discussions on this subject scheduled for the Twenty-third National Conference on Primary Health Care Access at the Park Hyatt Aviara Resort in Carlsbad, Caloifornia April 16-18, 2012. 

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From the Third Plenary Session of the 21st National Conference on Primary Health Care Access:

Robert Ross, MD, Oregon Health Sciences University/Cascades East Family Medicine, Klamath Falls (Moderator):  I’d like to welcome Dr. Daniel Webster, from Michigan State University, Traverse City, to give us our first topic of the morning, “Strategic Interventions in the State of Michigan”.

Daniel Webster, MD; Michigan State University, Traverse City

Daniel Webster, MD, Michigan State University, Traverse City: I’d been encouraged for many years by Doctors Bill Wadland, MD, George Smith, MD,  and Beth Burns, MD, who have all attended the National Conferences before, as has Dr Linda Garcia-Shelton. All have spoken very highly of them, so last year I attended a National Conference for the first time.

Introductory Comments

Officially, I’m a family physician who graduated from Northwestern University in 1979, attended Michigan State University (MSU)  College for Human Medicine, and then trained in a family medicine residency in Grand Rapids, Michigan.

I entered practice in a town called Traverse City and ran a family practice there for 14 years. Then in 1996 I left private practice to start a dually accredited (MD and DO) family practice residency.

I was director of that residency for 14 years. Dr Perry Pugno (Director of Education at the American Academy of Family Physicians and a Senior Fellow of the National Conferences) has been my mentor since 1995.

About two years ago, we started the seventh campus for MSU’s College of Human Medicine. I am the Assistant Dean in Traverse City for the MSU campus, my third career in the same town  - as family physician, residency director and now assistant dean.

I will speak about the consequences of Michigan’s strategic initiatives for medical student education. First, I will provide some general information about the growth in medical student education in the State of Michigan and then talk specifically about growth in the  College of Human Medicine (CHM). I’ll discuss some success stories and also some stories yet to be evaluated as success stories.

Earlier in the conference we talked about the Baby Boomers, This is a generation that we in Michigan are looking at too.   I’ll present this in little chronological steps going back to 2005, look at the present, 2010, and forward to 2015, as to what worked and what didn’t go so well.

Michigan’s Geography and its Medical Schools

When you look at the geography of the state of Michigan, you can see there is a lower peninsula and an upper peninsula.  News media reports sometimes forget the upper peninsula is actually part of Michigan. The upper peninsula is not a separate state.

I will give you some driving distances – Traverse City to Lansing,  the main campus of MSU CHM, is a three hour drive. To drive to Lansing for several hours of meetings, then return home to Traverse City is a good day’s journey. We have a campus in Marquette, eight hours away, as well. The other campuses are in Grand Rapids, Kalamazoo in Southwest Michigan, Flint and Saginaw.

The stakeholders in this effort are Wayne State University, University of Michigan and MSU.

MSU has two medical schools on the same campus – CHM (allopathic), and the College of Osteopathic Medicine. Both are housed in East Lansing. The others are Wayne State in Detroit and the University of Michigan at Ann Arbor. These produced 581 students per year in total, as of 2005.

I alluded to the MSU CHM campuses. The allopathic four year campus is in East Lansing. The two year campuses (where specific students do their third and fourth years of medical school) are in Lansing, Kalamazoo, Flint, Saginaw, Marquette, Traverse City and Grand Rapids. MSU’s College of Osteopathic Medicine has their first two years in East Lansing as well. But then the students spread out and do the preceptorship model and the base hospital model, with the students going to approximately 17 hospitals in the state of Michigan. The University of Michigan’s activities are located mostly around Ann Arbor and Wayne State around Detroit.

In 2004-2005, there was a Michigan workforce study that showed that the ratio of primary care physicians to specialty care at that time was 34 to 66. 39% of physicians practicing in Michigan had attended a Michigan medical school, and 61% had completed a Michigan residency. Michigan ranked fourth in the United States of students in a public medical school. The study projected a State shortfall of 4500 physicians over all and a State shortfall of 600 Family Physicians.

These figures seemed low to me at that time. However, this drove some of the State’s medical schools to increase their enrollment sizes, which they were already in the process of doing. The study was revisited at in 2008. The percent of primary care to specialty care hadn’t changed. The study found that in 2008 almost 80% of the physicians were planning to maintain their current practice patterns or to increase their hours of practice.The study also that the female/male physician ratio was  50/50, and that, as in all other states, the population was aging.

Meanwhile, Michigan has its  economic problems, with an unemployment rate at almost 15% in April 2010. Because of severe shortfalls in the general fund for supporting medical education, these original stakeholders have been told to absorb state funding cuts of 23% over three years. Yet, there greater numbers of uninsured, who are increasingly seeking medical care in Emergency Rooms.

Currently, there are 1,051 graduate medical education (GME) positions in Michigan, with roughly one-third being in primary care medicine. Of these 317 primary care GME positions only 99 are in family medicine, comprising only 10% of Michigan’s GME positions.

The next slide clearly shows the impact of medical school expansion. In 2010, the total has increased from 2005′s 581 to 925 medical students per year. Through this increase of 344 medical school positions, Michigan’s physician workforce is being redesigned – although perhaps not for all the right reasons.

Only the University of Michigan stays at the same level, but Wayne State increases rapidly from 200 to 300 graduates. Michigan State’s CHM jumps from 106 to 200, opening one new campus and expanding the combined Midland-Saginaw campus. The College of Osteopathic Medicine (COM) has increased as well from 100 to 250. COM’s growth is towards Detroit, so they’ve entered the competitive market for clinical sites in Ann Arbor (home of the University of Michigan) and Detroit (home of Wayne State).

The next slide shows where the campuses are. Wayne State (labelled WSU) and Michigan (UM) are in the Southeast and MSU’s four year osteopathic medical school (COM) and College of Human Medicine (here, labelled CH) are on  the main campus in East Lansing.

But simultaneously, MSU’s CHM, is launching a four year campus.  Thus, MSU will have two four year campuses, one in Grand Rapids and one in Lansing. They’ll split the students equally between those two campuses in the first two years. The MSU CHM Dean, Marsha Rappley, MD, divides her time equally betwen the two campuses. (It’s an hour’s drive between them.)

Expansion of Community-Based Medical Education raining into New Areas

The students will then be distributed for the next two years to the other community campuses, and will either be assigned to Marquette, Traverse City, Kalamazoo, Flint, the combined campus of Saginaw-Midland, or they’ll stay in either East Lansing or Grand Rapids.  COM, I’ve already mentioned, is expanding to Southeast Michigan, towards Detroit.

Also in 2010 some new stakeholders have entered the scene. These include Western Michigan University, Central Michigan University, and Oakland University. Oakland University’s medical school in Oakland County (in the greater Detroit suburbs) is on board to start partnering with William Beaumont Hospital, admitting 50 medical students starting in Fall 2011.

I visited Central Michigan University in Mount Pleasant just a couple weeks ago. They will  have 100 students starting in 2012.  Western Michigan University (Kalamazoo) is planning for 50 students, although they don’t have a start date as of  yet.

Impending Shortage of Medical Student Preceptors

One of the concerns is that when you start adding more students and more medical schools, as you all know, you only have so many preceptors to go around. There is now competition in  Michigan for the development of training centers for all of these medical students. The map gets a little busier. We still have CHM and COM primarily in East Lansing, but CHM’s four year campus in Grand Rapids is added.

Two of these campuses – Grand Rapids and East Lansing – are providing identical services and an identical curriculum. Oakland University (OU) is in Rochester, and Central Michigan University is located in Mount Pleasant. Meanwhile, Western Michigan University is in Kalamazoo, one of our community campus sites. That creates some friction as well.

The problem with finding preceptorship sites is not so much the case in the Traverse City area, because we’re a brand new area for CHM. Although we have been a base hospital for the MSU College of Osteopathic Medicine, with regard to CHM, we have a lot of volunteer faculty that are eager to teach the students. But there is more competition for community preceptors in Kalamazoo and Saginaw and, obviously, in the Detroit area.

Faculty Development for Community Preceptors

All of the campuses, including ours, are engaged in faculty development programs for our preceptors. The last thing we want to do is ask somebody to teach and not help them with the skills they need to teach. The preceptors want that information.

MSU and Medical Education

Next, I will discuss MSU’s progress over the the last couple of years.

As the slide above indicates, MSU is a land grant institution in an auto producing state – an industry that has created some of our major current economic problems.

CHM is a college of Michigan State University, which is a land grant institution. CHM was founded in the 1960s and 1970s to encourage the training of primary care physicians. At one time we had 25% of our graduates going into family medicine. That has changed. Of the 46% entering primary care in 2010, only 9% went into family medicine.

41% remain in the state 43% entered primary care in 2008 and you can see the results down to 2010.

Sometimes it’s confusing as to which medical college you’re looking for, because they’re all in the same building.  (At MSU they say we have three medical colleges because they include the veterinary school.) There is no hospital on the MSU campus itself, although we have hospitals in each of our community sites.

The photograph is of East Fee Hall. When Dr Allan Wilke (a Senior Fellow of the Coastal Research Group) and I were undergrads, that was a dormitory. All of the COM’s offices used to be old dorm rooms.

That’s where we are now with the CHM – the school I’m associated with at this time. I was its residency director as well. We had a family practice residency network that had nine residencies located across the state.

These are the players in my culture right now. There’s a fair amount of friction because Central Michigan University is talking about expanding north, so they would be expanding into where my preceptors come from. We have Kalamazoo Western potentially starting a medical school, and if they do, MSU will pull out of Kalamazoo. Where those students will go, I’m not exactly sure, although I think some of them will end up in Traverse City.

Meanwhile, Saginaw and Midland have plans to combine into one campus as well.

All of the campuses have teaching hospitals, rather than having just one major academic teaching hospital. In Traverse City our teaching hospital, Munson Medical Center, is the hospital where I have had privileges for over 30 years.

This slide gives you a few statistics. Munson Medical Center is a major employer in the area. It currently is going through affiliation talks with Grand Rapids Spectrum Hospital. Whether that’s good or bad, I haven’t determined yet.

When we pose the question to our board as to why should we have a clinical campus in Traverse City, they cite that previous Michigan work-force study that I referred to. The board thought it was good for recruitment, retention and academic stimulation and provided an opportunity to meet rural health care needs. They thought it would help the institutional reputation, as well.

For the first two years – the year starting July 2009 and the coming year starting in July 2010 –  students had already been assigned to clinical campuses. For that reason, we had to recruit pilot students. We have six pilot students for the current year. Four of them are from California, two of them are from Michigan – actually one of them is from Traverse City, and she plans to go into primary care and stay in Traverse City. The four from California plan on going back to California.

Eight months later they’re still happy, and having a good time.

The slide below describes the Traverse City curriculum, which is similar to most medical school curricula, with basic science in the first year and problem-based learning in the second.

 Then in the third year, we have six clerkships, each that are eight weeks long, using the same curriculum across all clinical campuses.  Our campuses are based on a model called Regional Medical Campuses or Disseminated Medical Campuses. (The Canadians use the term “Fully Distributed Medical Campuses”).

Each campus has a clerkship director for each of these specialties and coordinating them is a lead clerkship director for each of these specialties.  This creates a network that delivers the same curriculum across all community campuses. We are fortunate in our family medicine programs to have the students for eight weeks. I take them myself, and am also the family medicine clerkship director in Traverse City.

In Traverse City, I place them in both the rural sites and in sites in Traverse City. They work in the hospital for a week. They are in the Traverse City Health Clinic, which is a free clinic, serving migrants and Native Americans. I try to expose them to all aspects of primary care, similar to Marquette, which does the same thing

The Marquette training site is fortunate to be located in the Upper Peninsula. It geographic situation and curriculum are similar to the rural sites used in the Minnesota program described yesterday by Doctor Macaran Baird. Both the Upper Peninsula and Minnesota rural students have 12 weeks of family medicine.

The Marquette site has a higher percentage going into family medicine, as well as a higher percentage of family docs staying in the Upper Peninsula. They also either go through the residency in Marquette or they go to another residency and return to the area.

(In this morning’s breakout session, Doctor Baird confirmed that the Minnesota data parallels our findings about those training in Michigan’s Upper Peninsula.)

Then in the fourth year we have four week required clerkships in advanced medicine or senior surgery, and then they choose their electives.

The CHM Longitudinal Curriculum

I’ve been in residency education for 14 years and I’ve only been in medical student education for about 16 months. So it’s taken me awhile to learn it. But what’s really nice about the CHM curriculum is the longitudinal component.

The curriculum includes gateway assessments, which are simulation labs, back in Lansing or Grand Rapids. Gateway assessments related to physical exams occur in the second and third years. There is also an Evidence-based Medicine gateway exam as well.

There’s a huge curriculum on professionalism included in our evaluation forms as well. Patient safety is a curriculum component, as is the ethics curriculum, and these subjects are integrated in the curriculum from the first year through the fourth year.

A new requirement is community service (which most of the students have been doing anyway, but now it’s an educational requirement, for a minimum of 40 hours over the four year curriculum. There is a research project in the third year as part of their Evidence-based Medicine curriculum.

To give you an example, our students are doing a medication error reduction research project, by means of a survey of pharmacies to see what rate of medication errors there are in prescription writing, whether from an electronic FAX, email or hand-written prescriptions.

For community service, we paired up with our local high school. The slide below shows one of our third year students, co-teaching anatomy and physiology. (I heard from several of you at this conference that this is being done at other medical schools also.)

Student Demographics, Tuition and Debt

This slide presents some of our demographics, with 66% of the students across all campuses coming from Michigan and 34% from out of state. The general distribution is as noted below, although the tuition is actually higher. Tuition is now up to about $30,000 a year for instate students, and closer to $60,000 per year for out of state students. I’ve been told it’s the highest tuition in the nation for a public institution.

One reason for the high tuition is that part of the tuition comes back to operate the medical school. When you have that many campuses, with that many levels of administration and that many requirements across the state, it’s not an inexpensive way to deliver medical education.

I’ve been told by the six students I have in Traverse City, that their average debt approaches $210,000 at this point.

Summary and Issues for Further Consideration

When considering the future needs of medical education in Michigan, we need more slots for primary care, specifically family medicine. We need something to help with loan repayment for students, just as do those of you from other states. We need some help with our insurance reimbursement for primary care. Hopefully, that is coming through the healthcare reform bill, although not until 2014.

You’ll find, as I did, students like their electronics. They want a practice that has electronic medical records. The generation of students we are teaching is looking for the quality of life (not that those of us who have been in practice for thirtysome years aren’t looking for it also). The students will want to limit their call. So those are all concerns we’re going to have to deal with.

Much of this increase in student medical education has occurred in a nonsystematic manner. Each school took it upon themselves to increase their medical school class size. The increase in CHM medical schools’ class size was driven by the desire of the Grand Rapids’ community to have their own four year medical school in partnership with MSU.

That’s why we have two parallel tracks, East Lansing and Grand Rapids, that are only 58 miles apart.The fact is that CMU, Western and Oakland are each developing medical schools with no workforce plan connected to the other three institutions speaks to that.

I’ve noticed in working with medical students is that when they come into medical school, they want to take care of the whole patient. They want to enjoy the practice of medicine, and they want to provide some value or trust to the culture of medicine. Myself, CHM, and all of us in this room just need to figure out how we can do that best. Thank you!