About Coastal Research Group 2002

Historic source document from the Coastal Research Group local archive.

Coastal Research Group – About Coastal Research Group 2002 John E.

Midtling, MD, MS Medical College of Wisconsin: That was tremendous, Gayle.

Once again, some very provocative comments.

I think you got the peer review process.

If I had known you were going to use the red bull analogy, I would have invited a couple of my veterinary friends.

I think it's a very appropriate analogy.

We have some time for comments from the audience.

John Payne, MD, Stanislaus Medical Center, Modesto, California: I believe many of us are, at this point, ready to be bullfighters.

We are, however, specialists in personal medicine which by nature makes us sort of peace loving individuals who don't have the aggressive swagger that it appears to take to take on the big red bull's keepers.

Have you any suggestions for us timid sorts?

Stephens: I think as far as family practice is concerned, which is the pasture that I have been tending most of the last 25 years, I think we have been entirely too preoccupied with legitimacy, with what that big red bull thinks.

And we have projected a lot of thoughts into that big red bull.

We think the bull is dangerous.

The bull thinks we are paranoid, that we're hard to get along with.

My dean tells me that the family practice faculty are the most contentious and difficult faculty he has to deal with.

But I think we can give up a little bit now of this obsessive need for legitimacy.

We have proved that we can enter the doors of academia, that we can teach.

We have demonstrated that with what opportunities we have had.

And I would like to see us relax a little bit about making ourselves always agreeable and acceptable to the medical school, which is the worst part of this big red bull.

If you want to know the worst part of the medical school, it's the basic science departments.

That's where the bull is really bad.

These are protected, silent opponents and perpetuators of high-tech medicine operating very effectively and unobserved in those two pre-clinical years where they set the tone of what is truth, and what counts as knowledge, and what the students believe, and what makes them contemptuous of low-tech medicine because the basic scientists are contemptuous of low-tech medicine.

They don't know anything about it!

But they are the gyroscope, they are the ballast that makes the medical school incapable of changing.

And so one of the thoughts that I am having is how can we loosen up a little bit our frantic clutching of the medical school for legitimacy.

Can we not get some legitimacy from doing our work?

I know there is some reality here in doing what the school says you have to do to get promoted and all of that.

But I am ready to quit doing seven somersaults every time the Dean says to do two.

So I would like to see us loosen up and relax in that particular part of bullfighting.

I think that's where a lot of the action takes place.

There are some very real battles within organized medicine.

For instance, there are more than a hundred self-designated specialties that have nothing to do with the American Board of Medical Specialties.

More than a hundred self-designated specialties, which means that fragmentation is out of control.

It has been out of control but it's even more out of control.

Each of those self-designated specialties probably holds us in contempt in one way or another unless we provide them with a number of patients.

I'm not going to send my patients to this headache specialist.

I don't think headaches is a specialty, self-designated or not.

I guess maybe it's a change of attitude on my part that 25 years ago I couldn't wait to get into the medical school.

I screwed up my whole life in order to be a faculty member and I wish I hadn't.

It wasn't worth it.

Gene (Rusty) Kallenberg, M.D., Washington, D.C.: I thought your quite extraordinary comments and parable linked well with Dave Sundwall's suggestion.

It seems to me that the chief source of our credibility is the other half of the doctor/patient relationship and has been for the past 30 years, and was in my father's generation when he was a GP.

It seems to me that in the rush to get into the medical school, that we have, in a sense, turned away from a political base of support.

It's going to take very strong people to attack the bull.

I find that in our medical center it's the clinical subspecialists that are even more malevolent than the basic scientists because they have giant incomes to protect.

And the basic scientists are more like the lay patient in the sense that when they need medical help, they don't know what the hell they're doing, just like a patient doesn't frequently.

My questions is — would it not be appropriate to create larger political alliances in three directions: 1) with the nursing profession and the other people who are committed to taking care of patients and have been for 30 or 40 years or hundreds of years; 2) with other primary care physicians without sacrificing our principles and understanding that we probably do it best and better than any of the other so-called "primary care" clinicians; 3) with the poor people — the people in the rural zones of the country out of which family medicine grew on literally through state legislatures in the late 60's and 70's.

Now we have a whole new urban population of equally underserved folks.

It seems to me that it would be a terrific political alliance that would just wipe out the bull.

Stephens: I couldn't agree with you more.

I am going to have the opportunity to say that to the American Academy of Family Physicians next Friday because I have a chance to speak to the state officers' convention.

I am going to address this issue of numbers and alliances.

I think without doubt the 41,000 members of the American Academy of Family Physicians are a pretty impotent lot for the task at hand.

We should ally ourselves with a number of groups.

We started off — as the membership of the Society of Teachers of Family Medicine would suggest — with allying ourselves with non-physicians, with other health professions.

I think we've taken a step back away from that.

We started off with ambitions about family nurse practitioners and other nurse specialists.

More recently there has been the thought that we should ally ourselves with primary care internists and pediatricians.

I know Dr.

Odegaard is working hard on that but that still is an upward mobility for us.

I would like for us to look at the 30,000 doctors of osteopathy, the 30,000 osteopaths with whom we might come together in some coalitions for political purposes.

I think it's very unlikely that the AAFP is going to give me two seconds on this.

But I am going to say it, that there is no hope by the year 2000.

By my best estimates, the AAFP will have about 50,000 members.

If we keep recruiting first year residents at a 65% rate, it's going to be a hell of a lot less than that.

That may be the largest last man's club left in the world unless something is done.

Because the way they count their membership, you would get the impression that there are 65,000.

But it's not.

They're closer to 41,000 and many of them are like me — they're old and lame and fat.

But there is a problem and I think politically you're right on target — that we need to find ways of allying ourselves with other groups, at least for the promotion of the primary care agenda — what I consider the low-tech agenda.

Thomas Brown, MD, Long Beach, California: You mentioned possible, and I think it's the probable or being proven, co-opting of family practice by the medical schools in terms of its leadership and its direction.

I have watched this for 23 years and it does seem to be quite interesting how that's all occurred.

The values of the medical schools and the systems that the medical school does demonstrate has definitely influenced, to a tremendous extent, the training of medical students and of residents, and I think, by this time, certainly the way they practice medicine out in the field.

I don't think that family medicine is ever going to get the power-base within the medical school to pay much attention.

However, the real power that I think family medicine can have is by really looking at its membership out in practice, understanding from them how they control the health care delivery system on behalf of their patients — the kind of rapport they establish with patients, the kind of referral systems that they use, and the way they manipulate the whole system in behalf of their patients as patient advocates, recognizing that that's an extremely powerful base — those patients — in part of the coalition building that you're talking about.

I wonder if you might comment on that.

Stephens: I certainly agree that the patients were a part of the reforms of the 1960's that got us a place at the federal trough.

I think, though, the patients are confused now about the doctors and they don't know whether we're family physicians, or whether we're family planners, or what we are.

What the public had in mind as a doctor close to them and accessible was not exactly what we produced.

Ed Pellegrino has written very persuasively about this, that we had an agenda that he calls "a mutation." We were trying to move away from the general practice model.

We have in our presence a person who served on the Millis Commission and a man who also has had personal conversations with Abraham Flexner, Charles Odegaard, who's got a lot of medical education history in his head and who has given a good portion of his life, as far as I know, to try to help us help the public.

When the Millis report said "primary physician," and that's where the word came from, they had in mind something a little bit different than what we started producing.

Is that not right, Charles?

We went a little overboard.

We promised a little too much.

We did what was interesting to us in the academic setting.

It's quite disheartening if you call most family practice departments at 4:00 p.m. on any afternoon, they're closed.

They're gone!

There may still be some people there working, but they're like the bank.

They shut their phones off at 5:00 p.m. while they're finishing up the load in the clinic.

I think we've expended some of our moral high ground that we had 25 years ago.

I don't know whether the people give a damn whether we survive or not.

That may be a harsh thing to say.

The people want somebody to survive, but I don't know whether they care whether it's us or not.

It might be somebody else who plays that role.

I am finding that when family physicians take on the airs of the academic institution, they are no more to be admired than any other.

I lose my interest in them almost immediately.

Patricia Chase, California Office of Statewide Health Planning and Development, Sacramento: I want to thank Dr.

Stephens particularly for his statement that all of us are underserved.

I think politically this is something that all of you should also utilize and that is to recognize that some very powerful groups, including business, including insurers, as well as including the well-insured middle class, are feeling underserved and would be very supportive if they were informed and had a clearer understanding of what primary care and family practice are all about.

I think it is terribly important that you as a group and as a specialty, if you choose to call it that, utilize this and talk about service for people other than the poor and the traditionally underserved.

Stephens: We need a preference for the poor.

Charles Odegaard, University of Washington, Seattle: First, I should make it very evident to everybody here, it they don't know it, that I am an alien breed outside the law.

I don't belong to any of these guilds that we're discussing this morning.

I come in from the outside as a citizen who became a member of what was called "The Citizens Commission on Graduate Medical Education." I think sometimes the origins of the Millis Commission are not fully understood.

We had been through a period of years of production in the medical schools of biologically specialized physicians following World War II.

By the early 60's when the Millis Commission was appointed, there was a real fissure developing within the membership of the American Medical Association.

So this Millis Commission was actually appointed by the AMA because of an internal fight which had developed between the many specialized biomedically oriented physicians produced by the medical schools in the post-World War II period and the old GP's.

Now even to this day, I think if you go to a meeting of STFM and to a meeting of SGIM, you will notice a difference in the distribution of gray heads.

There's an older generation in family medicine and a younger generation.

There is no older generation to speak of among the general internists.

They are a product of much more recent developments in the medical schools, the original heretics.

As a medieval historian by background, I really do think it appropriate to use that word, "heretic" and "orthodox" in regard to medicine because it is as though we have a conflict in two religious systems.

There are mindsets here.

Their gray matter has to be dislodged.

It's not just bad habits that you see in what they do.

You got to figure out what's going on up here if you're going to effect changes in the way medicine operates in this nation in the near future.

So the Millis Commission chose the word "primary physician" because GP had become a dirty word to the more entrenched elements of specialized medicine then.

To get out from under this, we picked up the word "primary physician" simply not to have an argument over words and to get onto the substance.

As an outsider, I would like to say that I think you should be careful in assessing where you are in this process.

I can testify from the fact that I have reasons for watching this from 1963 on that there really is a shifting going on.

There is a heretical group within the "House of Medicine." The reason you can't ignore the medical schools is that the future generation is born there.

So it's all right to say you'll stay outside it if you're in the "old guard." You're not going to be in the "new guard." But if you're going to get into the new guard, you got to get inside the medical school, so you have to take on the big beast itself in order to finally win this battle for the American people in terms of having a more appropriate distribution of right kinds of health care providers.

I do think that one thing you can do is to infiltrate that castle.

One of the ways of getting there, I think, is by affiliation with the other primary care oriented groups — the general internists, the pediatricians.

I do know that some internists, maybe some pediatricians, were invited to come here.

I know of one in particular, Tom Inui, my recent colleague in some of these ventures, was very eager to come here.

He is a former president of STIM but he was not able to come to this meeting because of a prior commitment.

I do think that in the next meeting it would be helpful if you had with you here — I'm not talking about merger — I'm talking about collaboration with some other allies that I think would be helpful.

I'm sorry that there aren't general internists and pediatricians here in larger numbers because I think this has been an extraordinarily informative meeting about good things that are going on that have a potential for the future.

So I would hope that in your next meeting you would accept the fact that you need all the allies you can find in order to beat the great beast.

Some recent experiences have demonstrated that internists have developed some very real respect for aspects of primary care which could be learned by going to some of your specialized meetings.

I am thinking particularly of the Amelia Island experience.

I've gone to each of these meetings on some threat of giving me continued medical education.

But I have been honest enough to say that I'm not allowed to use it.

I do urge, as you look for your allies wherever you can find them because you got a big problem to beat.

I must say that it's a great pleasure for me to be here.

I'm here, I think, through the invitation that came from Gayle.

It was a great personal pleasure for me to hear Gayle, but I wasn't surprised by it because I heard him before in doing such a brilliant job.

Midtling: Thank you, Charles.

With that I think we will break off the discussion because some people have to make it to the airport.

I'll just offer a few comments.

Unfortunately, I don't think the change will come from the owners and the handlers of the big red bull.

The change will come from those who purchase services from the big red bull.

I hate to be cynical about the house of medicine but I think much of what Gayle has said is true and that the change will have to be external.

I am struck by the fact that two weeks ago I gave the keynote address at ADFM, the department chairs meeting, in Florida.

Following me on the podium was the president of the American Farm Bureau and following him was Tom Tocke, who is a congressman from rural Iowa who founded the Rural Health Caucus.

Both of them said, "You show us the way.

We know there has to be change.

You need to link up with us and we need to build a coalition of forced change in America.

I think that's one thing that I would like to see come out of this meeting.

To some extent, and I think this ties into what you were saying Charles, we're preaching to the choir and we're preaching to the converted.

I really think we do need to link up with general internal medicine.

I would like to see several leaders of general internal medicine come to this meeting because they tell me that they view us as being more similar to them than many of their subspecialty colleagues.

I think that for general pediatrics the same could be said.

But I think there are other coalitions.

Phyllis Kritek identified nursing.

I think there are coalitions outside of the health professions that we should be linking up with us — the Tom Tockes of the world, the American Farm Bureau people, and others — and as we move into future conferences, I would like to invite them.

I am struck by the success stories that were presented here the past three days.

It gives me a greater sense of hope than after last year's meeting when I went home somewhat depressed, actually.

I think we've seen some phenomenal success stories at the local level, at the state level, at the federal level.

I think, hopefully, the proceedings can be a vehicle by which some of these local success stories or demonstration projects can be disseminated throughout the country so that others can see what has worked at a regional level and maybe implement that.

Then maybe we can move toward a national system.

I really think we're dealing with a system that is probably going to make incremental change.

I think we need a few successes like the Oregon model, perhaps — maybe some of the things that Dave Sundwall was talking about which are really incremental piecemeal.

I think if we can develop some model demonstration projects, perhaps then we can show that these work and begin to move toward a more revolutionary change in the system.

Source file: Coastal Research Group/CRG/CRG OLD/CommunityBaseEd2.htm. Historic from local Coastal Research Group archive files during the DEV archive reorganization.