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2019 CRG Audio Recording

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(audience chattering)

[15 repeated non-speech markers omitted]

I'm really glad you're here.

(audience chattering)

[2 repeated non-speech markers omitted]

Testing, testing.

(audience chattering)

I'm late, I'm late for a very important date.

I'm late, I'm late.

Okay, you guys, we're gonna get started again.

Please take your places, your allotted spots.

(audience chattering)

Our next presentation is a theme panel

on healthcare experiences

in medically underserved geographic areas.

Our first presenter is Dr. Gomez from UCSF in Fresno.

And Dr. North from UNM, University of New Mexico.

(audience chattering)

– Hi everybody, I'm Ivan Gomez, I'm at UCSF Fresno.

I was the residency director there

for about 12 years and three years ago,

I decided to take the slightly less busy job

of department chief and I became the director

of the statewide AHEC about the same time, so who knew?

So I'm talking a little bit about healthcare experiences

in medically underserved geographic areas,

talk a little bit about what we do at UCSF Fresno

and also with the AHEC program in California.

So like a lot of the programs you've heard today,

pretty much do some kind of programs

that address things throughout the spectrum

from high school through residency

and postgraduate training.

I won't talk too much about LACMERS

as Latino Center for Medical Education and Research

that's based at UCSF Fresno.

Suffice it to say their doctor's academy has been in place

under leadership of Katherine Flores there for,

oh gosh, over 20 to 25 years now

and we're starting to see dividends on that.

We've had several junior high and high school students

that have come through that program

that are actually now practicing primary care physicians

and mainly in family medicine and pediatrics,

so it's been a great program.

The AHEC, which is one of the hats that I wear,

mainly focuses on health profession student training,

PAs, nurse practitioners, undergraduates, pharmacy students

and it builds upon existing programs that exist statewide.

You heard one of them yesterday

based at the Scripps program,

so one of our high performing centers there for sure.

The AHEC Scholars Program is a curriculum

that we've developed, you'll hear more about that.

Statewide across the 13 centers that we have,

we train about 13,000 learners per year in some respect.

We touch 13,000 people and the unique thing

about California's AHEC is the vast majority

of the student education takes place

within the community health center system.

Most recently, in fact, just a couple of months ago,

UCSF Fresno received LCME accreditation

for regional medical school campus

in the Central Valley of California,

which is a long time in coming.

And with that comes a reboot

of the San Joaquin Valley Prime Program,

which is designed to expand the number of students

that do the majority of their training

within the Central Valley.

And then of course we have our GME programs.

So in California, like I mentioned,

the AHEC there really bases its sites

within medically underserved areas,

largely within community health centers

and health consortium networks.

It's a unique model of the Californian

that most of our learner base really comes

from the ground up in terms of where they're trained.

Couple of examples of things that we're doing in Fresno.

Central Valley AHEC, one of our sites partnered

with a local FQHC to start a HRSA-based

teaching health center in West Fresno.

It serves a very underserved area.

PA residency's been developed in Fresno

and we provide support through this,

through the AHEC program to some of our partners

in different parts of the state.

And the AHEC scholars curriculum,

which I mentioned earlier,

this is actually a federally mandated program.

It was designed to improve academic community partnerships.

In California, we feel we have that down pretty well.

And so what we've done is we've designed curriculum

to increase the knowledge on social determinants of health

and provide increased community engagement opportunities

with a required community project

that allow these AHEC scholars

that participate longitudinally

to work with their AHEC center sites.

This is kind of the breakdown

of where our sites are based today.

Like I said, most of them are based in community clinics.

We have one that's based in independent 501c

at the central coast.

And then we have now three that are based

within family medicine residency programs across the state.

San Joaquin Valley Prime.

So this was recently renamed the UCSF San Joaquin Valley Prime.

The idea here is really to ensure that the majority

of students that are trained in the medical school program

are based at UCSF Fresno,

really to increase their exposure to the valley.

Ultimately, the plan is to expand from 12 students

to 50 students per year.

That gives me no small degree of heartburn

in terms of trying to find bandwidth

to actually train all these students.

I still have spots to train residents.

The three campuses UC Davis, San Francisco and Merced

are all combining together to really kind of form

a unique curriculum that's focused

on the needs of the Central Valley.

This is kind of a visual that kind of describes the progress.

San Joaquin Valley Prime is coming in right here.

It's in black because I'm dreading it over here in 2021.

And then as far as our residency program here,

the department here, basically we've developed

some additional relationships with other teaching sites

to be able to handle this bandwidth.

One thing that we've done to really kind of tease in

our community health center partners

is really kind of give them a stepwise level of engagement.

Almost all community health centers do some kind of

outward community program, mobile health clinics,

health fairs and so forth.

And even at this level, giving medical students

that degree of involvement while they're in Fresno

provide an opportunity for them to become more engaged

with what's happening in the community.

Second level for those that are kind of ready for it

would be to base medical students continuity clinics

within the health center.

So one unique thing about UCSF,

recently they converted their curriculum

to a longitudinal curriculum.

So basically their pediatrics rotation experience,

for example, instead of being over a one month period

is stretched over like every Monday afternoon for six months

and so on with other areas.

Family medicine, we've been able to secure that as a

one day every other week for the duration of medical school.

So they'll actually get a training experience

in family medicine for four years.

And then ultimately with some of the great work

that's being done at the California Primary Care Association

then identifying potential sites for residency development

as well.

So the idea here is the kind of hope and potential here

is that we have medical students actually come to Fresno,

work in a community health center.

They usually start seeing patients about 18 months in

that they see patients through three and a half

or 30 months.

So two and a half years of medical student training,

hopefully they'll stay in Fresno for their residency training,

do another three years of continuity training.

And in discussion with our program and our dean,

we've come up with a plan to help fit a secondary

continuity of care site for those medical students.

So if there are San Joaquin Valley Prime students

come and do a continuity experience in a clinic

and then stay on as a residence in our program,

they'll be able to continue to see the panel of patients

in that clinic.

And so potentially by the time they finish training,

they may have had a panel of patients for five and a half

years, which is a great potential for those community

health center sites.

This kind of is a visual of kind of showing to some of the

CEOs of the community health center sites that we're working

at, the cloud here represents kind of the pie in the sky.

But we all like them to eventually get to from new brand

new medical students coming up to being able to have

practices faculty within their sites.

Just real briefly, our family medicine program,

over 400 graduates now, about a third,

a little more than a third are still practicing within

the Central Valley, which has been great.

We work with a lot of different partners and the list is

ever expanding, a hundred percent of our training takes

place within underserved sites and community health centers.

In 2017, we were approved to expand 16 residents per year.

We're currently in the progress of expanding to 15 per year

because of funding, which would make us,

I think would tie us to be the biggest program

in California.

That's all I have.

(audience applauds)

– So we're gonna change slides here.

I'd just like to point out that I'm from New Mexico,

which is part of the United States of America.

(audience laughs)

New Mexico is the fifth largest state in the union

and we are a member of the union,

reunion members I guess.

So we have about two million people and if you took all

the people in New Mexico and distributed them evenly

throughout the state, they would all be socially isolated

along the way.

(audience laughs)

– Just to give you an idea how large the state is.

I'm Chuck North, I'm a family doctor and a human being.

I know that's redundant.

I grew up in Seattle, Washington, did my residency

in Minnesota, went to medical school in Pittsburgh

and then started in Indian Health in 1977.

I graduated from the Indian Health Service and retired

after 31 and a quarter years after being the chief

medical officer in Rockville in 2008.

This is my fun retirement job working

at the University of New Mexico where I'm a professor

of family and community medicine, the vice chair

of the department and the senior medical director

for patient centered medical home

and the primary care practices.

And what I'm gonna do today is talk to you

about some pipeline programs.

So my office is actually right next to diversity, equity

and inclusion and we have a pipeline.

We don't start at the first prenatal visit,

which Hector said they do in Los Angeles,

but we do start in elementary and middle school

with pipeline programs to encourage underrepresented

minority and rural students to go into medicine.

First of all, to study science and then to go into medicine.

So we have pipelines all the way through the college level

for medicine and pharmacy and science.

So we are a majority minority state,

I think one of four now, including Hawaii.

We're growing a diverse health workforce.

We've reached out to about 350 students a year

and over the last six or seven years,

we've touched about 2,000 student lives

through the pipeline programs.

Okay, now I'm gonna talk about four different programs.

That was one.

The second one is the BAMD program.

Now a lot of schools have had BAMD programs

for a long time where you take students out of high school

and they're accelerated programs.

Brown University had one that I was familiar with

when I was a resident.

I was actually on the faculty at Brown University

when I lived on the Hopi Reservation.

I had a faculty appointment.

I went there once to run the Boston Marathon

and use the parking place and I met the people.

It was really cool.

So they have a different kind of BAMD program.

We have one that is a partnership program

between the undergraduate school,

School of Arts and Science.

It's BA, not a BS degree.

The program is designed to help alleviate

the physician shortage in rural New Mexico,

particularly in underserved urban areas.

It expanded the medical school class from 75 to 100.

And it's 103 or so.

It just depends on how many people make it through on time.

We admit a broadly diverse class of 28 now,

so we can get 25 at the other end, high school seniors.

So I was on the BAMD admissions committee

after I retired, I was like 61 years old

and I was interviewing 17 year olds

that just learned how to drive, had braces and acne.

And they hadn't developed their personality even yet.

So it's really interesting to interview 17 year olds

who want to become doctors.

But a few of them that I interviewed got in.

One of them now is a radiology resident of all things.

She had two children, one as an undergrad,

and I went to her graduation.

She had one in medical school.

She had a very supportive husband.

Father died, which is why she went into medicine

'cause he had cancer when she started.

And it was really, really interesting

to watch this young lady develop.

She's from a rural part of New Mexico.

And I don't know what she's gonna do,

but it shows you the affirmative action part of the program.

I think we often add an extra layer of responsibility

to underrepresented minority and rural students

saying they have to go back and practice

with their people in their small town.

But some of them just want to get

the hell out of the small town,

the Indian reservation, the barrio, the ghetto,

and become like the white male physicians

they see at the university.

So I think it's good that she did that for her.

But the BAMD program has 13 cohorts now,

four undergraduate, four school of medicine,

and five have graduated, excuse me.

The largest proportion of the group is Hispanic,

which is not surprising in New Mexico.

The second largest is non-Hispanic whites,

and then American Indian and Asian and Pacific Islanders.

Vietnamese are listed separately

with African Americans and only 4%.

We have over probably around seven to 10,000 Vietnamese

people in Albuquerque, which isn't obvious

to people who don't live there.

So the graduates now will have

the 100th graduate of the program this year.

They're three times more likely to match

in family medicine, and 14 of the BAMD students

have completed their residencies

and 10 are now practicing in New Mexico.

The new class coming in, 20 of 28 are rural,

and 75% of the students are underrepresented

minority students.

Okay, that's program two.

Program three is the rural and urban underserved program,

or RUP, we call it.

It's an innovative four year medical school program

for students who are matriculated in school,

and they start in their first year.

A lot of students come in very idealistic, right?

And then we beat it out of them,

and they do something else,

and they become cynical and burned out.

So this tries to capture students

who are at the height of their ethical

and social responsibility, and provide them experiences

that will inspire them to continue

in their idealistic pathway.

So we mentor these students, and we provide opportunities

for them to work in communities that they desire

to work in when they start medical school.

If you look at the ethnicity, it's about even between

Hispanic and non-Hispanic.

14 Asian and five Native American students,

43% are not rural, 29% are,

and 42% are disadvantaged financially.

So this is the result of the match this year,

for the, we think they're all gonna go

where they're headed right now,

but things can change between now and the end of June.

So eight in Family Medicine, three in OB,

two in Psychiatry, one Peds, one going into an MPH program.

Okay, that was the third program.

The fourth one I wanna talk about is the IHS,

UNM Family Medicine Residency Program

that I started with Art Kaufman and Burt Umland in 1996.

We took our first residence.

We started it in '95, and first match was '96,

so it's at 23 years old now.

I think that's about how long I've been coming,

no, I've been coming to this for 26 years now.

So it was right after starting to come to Coastal Research.

So of this group, 27% of the residents who matched

in the IHS pathway for their residency are Native American,

which is, I think, higher than anywhere in the country,

excuse me, on any residency pathway.

And 64% of the residents who finished are working

in either Indian Health Service,

federally operated Indian Health Service site.

Tribally or Native Corporation operated sites

or urban Indian programs,

which are like community health centers for urban Indians,

like in San Francisco, Los Angeles, Denver, Seattle,

Minneapolis, and Albuquerque mostly.

So this is a picture of some of our graduates.

And that's it.

So I don't know if I finished on time close.

Neil said he had a very hard question

and he was gonna ask me,

so I'm dying to hear what it is.

And while he's coming up here, Neil,

I just wanted to say I had the opportunity

to meet the first Hopi Indian woman physician

as an intern in University of New Mexico

in the IHS pathway.

And I told her that I started a scholarship program there

on the reservation after one of our hospital workers

died of colon cancer before we did screening

and we raised 15 to $20,000 to give scholarships

so students could finish their undergraduate training

in radiation technology or whatever.

And she goes, oh, he was my uncle,

but I never met him

'cause he died six months before I was born.

Then she went back to the reservation,

looked up her birth certificate and I delivered her.

So to your point earlier,

that was really satisfying for me.

I love to tell that story.

And we had the first doctor from the Pima Tribe graduate

and join our faculty this year, Charity Bishop.

So it's really gratifying to see especially young women

making their way into family medicine from their tribes.

Neil?

– Neil Paul Fox, lead question guy.

So thank you very much for showing us different models

of how to approach these underserved populations.

So my question is, we're family medicine docs

and there seems to be a little bit of a antithesis

with specialization, but over just this dialogue,

I've heard about geographically underserved,

rurally underserved, diversity, culturally underserved,

first nations underserved.

And we seem to have as family medicine as an organization,

then specialized in rural, global diversity

and so my question is from a appreciative inquiry,

which I learned in the last,

as an organization, is that a good thing?

Because there's a lot of overlap

and are we fighting each other over who's the boss

in rural and global health and so forth?

Or is it to our advantage to really talk more broadly,

especially when I look at the stats

of who actually ends up where with these pipelines?

So again, it's, are we specializing in underservedness

and then creating programs,

which may be an advantage or necessary,

or is it actually hurting us?

Question.

– Ivan, do you want to?

– Yeah, I guess it's kind of a little heretical,

but I think if anything, we've kind of de-specialized

and we're having to kind of reinvent this notion

of specializing in diversity and rural health.

I mean, what got me into rural medicine

was that we did everything and took care of everybody.

And it just seems like there's been, like you said,

a push to really kind of compartmentalize everything we do.

Certainly we see it in terms of our training,

where, you know, well, if you want to do inpatient care,

you got to be a hospitalist, you know.

If you want to do surgery,

you need to just go and be a surgeon, you know.

If you want to do outpatient procedures, you know,

there's economic and educational forces

that push people away from doing that.

So I kind of, not necessarily see it as something

that we're specializing,

just that we're kind of having to name it

something to come back to do what, you know,

what we should have been doing the whole time.

It's just mine.

– Yeah, I'd say, I think our hearts are speaking

rather than our minds, when we focus on these areas,

because our hearts go out to people that are suffering more.

And we see that in rural, underserved,

underrepresented minority, immigrant, refugee communities

that we focus on.

And I don't see the rest of the population suffering

that much, so they're going to get taken care of.

Anyhow, if we don't put our emphasis there.

And to be frank, that's where most of our graduates go.

They don't go to the rural, underserved,

and other communities that we're reaching out to.

– Make your questions and answers quickly.

– Quickly, okay, Shayla Serpis, Chula Vista.

Something you said struck me,

a cord similar to our recruitment process

of finding a good fit for the program and the community

and hoping that people will stay long-term

in underserved communities.

You mentioned how sometimes when individuals come

from those communities,

the idea of staying there is not always consistent.

And I have seen that, and particularly family members

who have this idea of success as being that ivory castle

or getting out of the community

and that conflicting feeling.

So I'm just wondering if you have more reflections

from your experiences on that.

– Well, I think the most effective way

to get people into rural areas is to take students

from rural areas.

So reaching out to help with their educational attainment

early on so they can be competitive in college

and get into medical school is really important.

There's a feminization of the workforce.

My experience is that women would much rather be near

their families than men would because they have children

and they want their mothers to help out.

And they want to be near their sisters

and the rest of their extended family.

So I think it's even more important to reach out

to grow your own from the seeds of success

in those communities and nurture them along

the educational pathway,

which starts probably at the first prenatal visit,

but certainly in elementary and middle and high school.

So we reach out to every high school in New Mexico

to build a bridge to this pathway for medical education.

– Great, good question.

Marianne, it's just an amazing presentation

and I want to take everything home with me.

My question actually does have to do with pipeline

and tracking and that as you start in high school

or middle school,

besides sort of a statistical spreadsheet tracking and such,

do you have touch points along the way

where you're keeping in touch with those students

through their journey or their undergraduate journey, et cetera,

to really do good tracking and such?

– Yeah, so the Doctors Academy program

that I briefly touched on,

so they have obviously various points

throughout the high school contact that they meet with them,

but they routinely connect with them

at least once or twice a year.

They're invited back as Doctors Alumni,

Doctors Academy Alumni,

to come and talk to students like from their own school.

So they not only kind of keep in touch with them

by kind of surveying them and calling them,

but also by inviting them back to continue to participate

in the process so that the kids

from these underserved schools can say,

hey, look, this person went to my school, I can do that.

– Yes, and this is a list of everybody

who finished the IHS residency.

It's 49 long, including the three people

finishing this year, so we keep touch.

And Warren Heffern is doing this for our entire residency.

So yeah, I think that's a really important point.

So we use our alumni network to do that too.

Very similar to what Ivan said, thanks.

(audience applauds)

– Next, I'd like to invite the panel,

Dr. Prislin, Hickson, McKenna,

to talk about reflections on choosing

family medicine as a specialty.

(audience chattering)

– So about a week and a half, 10 days ago,

I got an email from Bill.

(laughing)

And he said, are you gonna be there on Thursday morning?

And I said, stupid me, I said, yeah,

I'll be there Thursday morning.

There's nothing more challenging

than being at the tail end of a conference.

So we appreciate that all of you are still here with us.

And as you can see, we're gonna give

the most important presentation of the conference.

So, by way of disclosure,

well, do we have anything to disclose?

No disclosures.

Okay, here we go, let's see.

Nope, that wasn't it.

(audience chattering)

This side, got it.

All right, so we are, after all, in Hawaii,

and we wanna follow the traditions of Hawaii.

So the first part of our presentation

is gonna be one of oral narratives.

Marianne, do you wanna start us off?

– Sure, thank you all.

And I realized after hearing these beautiful stories

this morning, the presentations from Ohio,

that just the presentation that just ended,

it made me rethink a little bit.

Is this not working?

Oh, a bit closer.

Is this better?

Okay, thanks.

It made me think a little bit differently

about my own journey and how some of these

creative initiatives that were presented today

in certain ways in my own career 30 years ago

probably influenced my journey into family medicine.

So I'll try to highlight that and in a way

endorse some of these fantastic programs

that we heard about this morning.

So similarly, I heard from Bill and at first I thought,

oh, I hope this doesn't mean it's an end of my career

reflection and so I'm just gonna give a disclaimer

that it's not, even though I've had the privilege

of being an active family physician and teacher for 30 years.

And probably like many of us, my story is one

of caring about people, maybe not quite knowing

the pathway right at the beginning.

I'm a series of opportunities that were presented

and I was lucky to be involved in and then a mentorship.

I won't go back to my candy striper days.

I know somebody mentioned that yesterday

but I did have that as well and graduated from college

in 1976 and really wasn't quite sure what direction

I was gonna go, thought about public health,

I thought about physical therapy, I just wasn't sure.

I had grown up in a family really without any physicians

and was told, you know, if you're a girl

and you might wanna have family and really being a doctor

might not work in that pathway.

So I actually worked in a lab at the Salk Institute.

I started volunteering at the Beach Area Community Clinic

which was a free clinic in the Beach Area of San Diego

and their mission statement was healthcare is a right,

not a privilege and I thought, okay, you know,

I'm starting to feel that I'm maybe with my people

and I was volunteering in the women's clinic

doing pregnancy testing, talking with women

about their health and thought, you know,

I'm gonna give this a try.

I'm gonna take the MCATs and apply to medical school

and I was fortunate enough to get into UCI School of Medicine

and I thought I was going in with family medicine

as my path although OB did tempt me at certain moments

and after the first quarter of a pretty traditional

med school curriculum, I thought, okay, this is fine

but I need to find something more

and I thought about volunteering.

I was gonna go find a community clinic

in Orange County and volunteer

and then I got, again, one of these initiatives.

I got a flyer in my mailbox from Mary Elizabeth Roth

who probably some of you know, pretty strong-minded

family physician, woman faculty who was going to

try a pilot project where you could apply

and be connected with a family medicine resident

in a community clinic and start your longitudinal experience

and I did just that and had almost a three-year experience

in the community clinic of Orange County

which was just a beautiful, beautiful experience.

It was right in the immigrant neighborhood of Santa Ana

at that time, Tacos Uropán across the street and Fa,

you know, down the next block

and just a great mix of patients

and I still remember my resident mentors, Debbie Satterfield,

Tom Bent and Louis Lelous who were very active at that time

and then I went on to UCSD for residency

and there I came across Bill Norcross

as my program director and, you know,

he really exhibited the fact that you needed to be smart

to be in family medicine,

intellectual integrity was very important

and he really emphasized counterculture too.

He loved our group of the communist counterculture

as he called us and I realized that, you know,

again, this was probably a Song Brown initiative

or something that led us in our second year of residency

to have a continuity clinic

at the Santa Seder Health Center

and there I came across Louis Lelous again.

He had gone there from residency and anyway,

these initiatives, you know,

kept community medicine alive,

it kept my love of family medicine alive

and then really has come full circle in my career

in being able to, you know, work again with Santa Sedero

and UCSD and our local community partners

to establish the residency program

and to be able to be there, you know,

with such fantastic colleagues

and these long-term relationships with patients.

I've really been fortunate, I think,

to continue to practice a very full spectrum

of family medicine, inpatient, OB, longitudinal care.

It's really beautiful and I, just thinking back a little bit,

just two more brief comments,

I was thinking back to yesterday,

how fortunate I was to be attending a state school,

I think Dr. Don Frey said yesterday, you know,

look at how the cost, the price of education has changed.

I went to, I spent $600 a year in fees

to go to medical school and, you know,

had a little bit of debt for living

and paid that off as a resident, you know,

and I think that gave me a lot of freedom,

freedom of choice of where to practice.

I've actually been employed my entire medical career

and I know some people are lamenting that direction,

but again, I actually feel like it gave me some choices

financially, my expectations remained, I think, reasonable.

And lastly, we meet every year, these amazing students,

you heard them described earlier today

that are, you know, dedicated to patients of the community

that are coming into our residency program

and being trained, you know, both in the community aspect,

but also in a very broad spectrum of family medicine

and just one concern that comes up

and this was discussed at our program

at Dr.'s meeting in Kansas City last weekend

is are we training our young physicians,

our young family physicians for careers

that they might not be able to find

and that does sadden me, especially reflecting

on what a marvelous experience, you know,

and fulfilling experience my own career has been, so.

Thank you.

– Jeff.

– That's a beautiful story, thank you.

So Bill asked us to reflect a little bit

on our personal journey and, you know,

so it becomes sort of an N equals one experiment

and I, you know, I hope there'll be some lessons

in applicability we can draw from it.

So I thought for my first slide I'd use a high school

yearbook picture, no I'm just kidding, I won't do that to you.

So I consider myself an accidental doctor

and what I mean by that is I didn't have any doctors

in the family, it never occurred to me to be a doctor

and I sort of just went on my way.

I was mostly interested in playing jazz drums

and I thought that was probably the future

and, you know, it's always good to be a musician

in case this medical thing doesn't work out,

you know, you gotta have something.

So I found my way eventually into college

and I studied anthropology and, you know,

anthropology is really about human systems

and it's about communities, it's about understanding

family structures and, you know, I didn't know it

at the time but I was actually preparing myself

to be a family physician and after college

I had some chances to sort of apply that anthropology

and I began to do some international work

and I worked with a, somebody mentioned the Ugly American

book that had come out and there was a cross-cultural

training agency called the Business Council

for International Understanding and it was in Washington,

D.C., American University and I spent a few years

actually putting training programs together

for American business interests that were working

all overseas in terms of language and cultural orientation

and so on, so in that work I started traveling

all over the place and you just start to realize

what an incredible, wonderful, big world this is

and one thing led to another and I got a graduate degree

in international development which is really truly

the study of poverty and the alleviation of poverty

and international organizations and how they interact

towards that mission, so one thing leads to another

and I found myself in Southeast Asian refugee camps

really the last chapter of the Vietnam War

and this huge diaspora with movement of Laos

and Vietnamese and Khmer folks to the United States

and this was a fairly misguided state department program

that I was a part of trying to get folks ready

for this move to this large immigration,

so it was in some of these sort of camp settings

on the Thai Cambodian border in the Philippines

and so on and you see thousands of people

and it sort of works you over and I sort of thought,

gee, maybe I need some different tools in the kit

and the interesting thing I think about how life unfolds

is that there are these just unexpected experiences

so it turns out that there was a family medicine resident

in that refugee camp with her husband

and they were working there for a year

and she was from Brown and their program director

had let her go for a year and then she was gonna go back

and finish her final year of family medicine training

and I said to her, gee, how wonderful that you have

these tools and that you can do this amazing work

helping and serving people and she's very matter of fact,

she just looked at me and said, why don't you do it?

And that interaction, other side of the world,

really put something in my face

and I had never taken a science course in college

and I left the refugee camps, came back to the states

and put myself into night school

and found my way into medical school.

So I really think I am sort of an accidental doctor

in that way and then if you enter medical school

in this manner, the manner I did,

family medicine is just obvious.

You don't really need to be a pediatric cardiologist

in the middle of a refugee camp or whatever

and so all of the principles of family medicine

just really made sense to me and I have some,

I've had some very important mentors along the way

and I think all of us have

and I really just wanna call out Perry Punio

who I met when I had my residency training

in Sacramento many years ago

and Perry pushed me in a lot of different directions

and I ended up getting involved at the academy level

and so on and none of those things would have happened

without Perry and I know Perry's mentored many of you

in this room, I'm certain and has been a guiding light

for a lot of us but Perry, I just wanna thank you

and I've had some other mentors along the way

and maybe we don't take enough time

to thank the people whose shoulders we stand upon

so I just wanna say thank you Perry for all you've done

for me and many others over the years.

So I do have some enduring wisdom sort of reflections

on maybe what all of this means

and why people would choose family medicine as a career

but I think I'd like to hold them aside

and we'll let Mike tell his story

and we'll get back to them at the end.

– So my journey doesn't rank with theirs,

it's very simple, I was a biology major

and as a biology major at a University of California campus

there's really three options,

you can teach somewhere K through 12,

you can go on and get a PhD and do research

or you can go to medical school

and so I looked at those options and I thought,

gee, I just went through junior high school and high school,

I don't wanna do that again.

I spent some time working in a research lab

and I realized quickly that I didn't have the patients

to have 20 year outcomes so that left medical school.

Once I got to medical school, a light came on

and there was a golden epiphany,

only it wasn't the kind of epiphany that you hear about

in family medicine, my epiphany was

I love internal medicine and adults

but I don't wanna spend all day

taking care of chronic disease

and children are wonderful

but I wanna have some adult conversations

and I loved OB/GYN but I didn't want to perform

one operation on the gynecologic side

as a major component of my career.

Psychiatry was good except for

psychotic people made me nervous.

Surgery, I had two thumbs so that was something to overcome

so that left family medicine

and so what I would like to do

because this is after all

the conference on access to primary care

is rather I'm gonna take the liberty of changing the agenda

and we're in family medicine

so I wanna spend a couple minutes talking about

the hidden agenda which is why aren't we getting more

and I'm with apologies to my osteopathic colleagues,

we're gonna talk about allopathic schools

for a couple minutes and the reason we're gonna talk about

allopathic schools is this just came out this week.

One of my favorite sources, US News

or what used to be US News and World Report,

these are the health sciences campuses

that train the most graduates for primary care residencies

and I would point out to you these are the top 10 nationally

and eight of the top 10 are osteopathic institutions

so I think what we've got here

and I'm hoping that there'll be some dialogue

is that we've got an allopathic problem,

I don't know that we have an osteopathic problem.

This has nothing to do with the talk,

I just love this picture.

I would comment though that this may be the last time

that our country was really unified

and as Neil pointed out yesterday,

the oceans are getting warmer and we better figure out a way

and if we're talking about global health challenges,

we better figure out a way to get unified again

so that we can deal with that.

Okay, we won, we're in 124 of 134 allopathic schools

and this is from the AFP,

if you got their little bulletin on match day,

they said it marks a decade of growth for family medicine.

Way to go.

I looked on the internet for a cartoon

describing a ferric victory

and I got this from the 2016 primary campaign,

I think it's a wonderful shot.

So here's the problem, I mean here's the problem,

I think we live in a reductionist world.

This is our match data from UCI

and I picked emergency medicine

because emergency medicine along with family medicine

are two of the more recent specialties approved

in the latter half of the 20th century

and you may ask me a bit later

why there's a couple of anomalous years

where family medicine did reasonably well

but we have a class size of about 100, give or take.

19 students out of 100 going into emergency medicine.

All right, so here's the detail.

Family medicine, our fill rate overall was 93%

which was, if you don't count preliminary positions,

we were pretty much the lowest.

Our allopathic fill rate was 39%.

If you look at emergency medicine,

they filled at 98.8%

and allopathic fill rate was about 65%.

So why do students do what they do?

I think the first thing is scope of practice.

I mean we all like to do what we enjoy doing

and what we're good at.

People that like to work with their hands

and are good at it, they choose surgery.

I think, I still think and I've spent a lot of time

over the years talking to students

that students choose specialties based on

where their interests and their aptitudes lie.

I think there's a big piece of pragmatism

and we'll come back to that in a moment.

And then I think the final component is,

for lack of a better word, I would call it evangelism

and that's where critical experiences, role models,

mentors come into play.

So let's just compare family medicine

to emergency medicine here.

And I've got some things that I think

are in terms of scope of practice.

We've got some things in terms of the pragmatism.

And so our specialties are similar in a lot of ways.

The one big difference, of course,

is that there's no continuity in emergency medicine,

although some of my colleagues would argue about that

in terms of a lot of return visits

when it's your court of last resort.

But you look at what's going on,

and this is from Medscape surveys.

I mean, if you're me and you're looking at scope of practice,

well, gee, only two thirds of our graduates

are doing pediatrics now.

Only 10% are doing obstetrics.

The number of procedures that family physicians do

has dwindled considerably.

Look at the work hours.

You know, 51 hours, we were talking about this this morning,

you know, back when things were tough

and we all worked 110 hours a week,

and our residencies wasn't so bad,

so 51 hours is pretty easy.

But look at our colleagues in emergency medicine.

That's the average work week, it's 32 hours a week.

Look at the salary discrepancy.

And then we had the information in terms of,

and I thought this was interesting

and talking about being happy at work,

being happy outside of work,

and the burnout numbers.

So the question is, where do we go from here?

Chip, you have some thoughts.

(laughing)

He's gonna answer all of our questions, by the way.

– So I worried about this talk a lot,

and because I know that lots of folks

have spent 30 years trying to figure out

how to kind of corral more people into family medicine,

and there've been Macy reports,

and Robert Graham Center articles,

and all sorts of things.

And I thought, you know, I needed to have the answer

this morning on the stage.

And so that worried me a little bit.

But fortunately, you know, at breakfast I reread the title,

and the title is Reflections.

It's not solutions, it's reflection.

So I think we can reflect,

and maybe I'd be a little bit off the hook

for having the answer.

So here are a couple reflections,

and hopefully we can get some dialogue.

So the first, we heard this morning

about how important strategy is, and that's really true.

And strategy has to be driven by core values.

And I think the challenge for us right now

is that the environment's changing very rapidly.

We need to be nimble, we need to be able to change and adapt.

But we also need to hang on dearly to our core values,

and to know what those are.

And to me, generalism is powerful,

and it's not always maybe welcome or recognized

in this sort of medical hierarchy,

but it's really powerful.

And it's a bit of our secret sauce,

and we can't let that go.

So that generalism, that way of thinking broadly,

is so important.

And if you look at leadership,

the folks who really have the ability

to be tremendous leaders very often

come from these generalist backgrounds.

And may also have studied humanities and other things.

I'm thinking of Sam, who we talked with last night.

He was telling me about comparative literature

and other things that really give you a base

from which to operate.

So I think our specialty has to really hang on

to the generalism piece.

I think being authentic is essential.

And I look at this person sitting next to me

in the work that she's done for 30 years,

and I, who I've just met at this conference,

and I think that any student or resident

that spent time with their clinic on the border

would say, "This is authentic.

"This is the real work."

And a certain subset of students

are gonna be drawn immediately to that.

And it's that authenticity of delivering the goods

where they're needed that we really need to hang on to.

I would say that counterculture is not only just okay,

it's necessary, and it's necessary

because the health system doesn't have it right yet.

And counterculture is about new ways of looking at things

and being willing to take some risks and make change.

So counterculture, which is part of our sort of birthright,

I think, in family medicine, we can't just let that go.

I'd also say that there's an intergenerational thing

going on right now, and I don't completely understand it,

but as I'm hiring new faculty members and so forth,

I'm really seeing that there's a very, very different

approach to work-life balance and other things.

And it's easy to say that we walked through

eight feet of snow to get to work or whatever it was,

and it was different back then.

And it's actually very important that we strip

some of that away and try to understand

what's going on intergenerationally

and how we can learn from the new generations

coming behind, 'cause they have a lot to teach us,

and they're gonna have to figure out some of this.

Along with the intergenerational pieces

of communication change, it's very profound,

and it has a lot to do with cell phones

and tweets and texts, and I remember the first time

I was on OB call, and I got up in the morning

and found out a baby had been delivered,

and an intern said, "Well, I sent you a 10."

I guess that meant 10 centimeters,

and I was supposed to get out of bed

and drive to the hospital, and so again,

obviously there's a little communication divide there,

and I'm trying to get with it.

I'm joking a little bit, but I think that

we do have to understand how patterns

of communication are changing, and if we think

of ourselves as professional communicators,

which as family doctors, we're supposed to both

sort of listen with two ears and talk with one mouth,

we need to get around this.

And the last is really around this leadership advocacy,

and I mentioned it earlier that generalism,

counterculture, and some of these pieces

really put us in a position where we should be

providing tremendous leadership to the

quite damaged healthcare system that we live in,

and I hope we can continue to do that.

So those are reflections.

So a couple of examples of things that I think work,

and then I'm trying to not take all the time.

So at the University of Hawaii,

we have something called an Imi Ho Ola program,

which takes young people from underserved backgrounds

who might not easily get into medical school,

and it gives them an additional year of training

where they're preaccepted into medical school,

and then they come for a year and they get

a lot of hard science and kind of a leg up

so that when they start the next year,

they're really ready to go.

And it's produced some tremendous individuals

and leaders in our state, in the medical profession,

and it's been a wonderful pathway for folks

that might not have made it to medical school otherwise.

And I know many of you have those sorts of programs.

We need to think about how to expand those.

Another one to keep an eye on is Jeff Borkin's program

at Brown, which is very interesting,

where they've created a master's degree

in primary care and population health,

and they've enrolled a third of their class in this program,

and it's now, I think, graduated its first class,

and they've generated a lot of general surgeons

and primary care docs, and that's a program to watch.

And the thing that's innovative about it

is not just that you get a master's degree,

and I think lots of us have tracks

and certificates and this and that,

but it's that this is not a little tweak around the edge.

This is saying a third of our folks

are gonna be sent this direction,

and that's very significant in medical education,

and so I think we gotta start to think,

can we, what are those sort of bold steps?

So I think these are examples of the programs

that we should start to look to and see if we can grow them

and then how they can help us.

But I guess I'd just like to go back

to our core values of generalism,

being authentic in the way we address needs

wherever they may be,

and I think that those elements are certainly,

will continue to be attractive to students.

– In some ways, this session might have been better placed

if it was the first session of the day today

because I think a lot of the other sessions

provided some of the answers.

I have a couple thoughts.

One of them is, I mentioned the scope of practice is changing

and has changed, and quite honestly,

I'm not sure that the territory that's been lost

by family medicine is ever going to be regained.

So I think there's something else we can do, though,

and that's redefine what a family physician is

and what scope of practice is.

And I heard a lot of that this morning,

and again, reaching out to vulnerable

and underserved populations.

That's a scope of practice.

I think addressing important issues of global health,

that's a scope of practice.

That's something that we can,

as we start to redefine family medicine,

we can think about.

I think about advocacy

and being the group that advocates

for a variety of populations, I think, is important.

I think thinking about how we can,

I'm not sure what to think about artificial intelligence,

but I do think that we better get on that bandwagon

and have some input in terms

of how that's gonna be deployed.

So that it becomes a tool that is useful

rather than a tool that drives us.

So I think there's lots of opportunities,

but I think we need to rethink about what it is

to be a family physician and what the content might be.

And then I think that, you know,

I didn't talk about evangelism.

I left that there,

'cause I think my colleagues talked about it pretty well.

I think that's key.

And that's part of that process of being there

and being heard.

And I see that I have a colleague over there

who wants to give me a wedgie.

So I did not mention mentorship,

but I would like to close this

by really recognizing four individuals

that have been critical to this conference.

And personally, really, really, really critical

to my career development.

And I'm gonna start with Nancy and Bill,

and we've heard what they've done with the conference,

but for me personally,

they've been friends through the years.

I came to California and was confronted immediately

with the prospect of having to face

the Song Brown Commission.

And starting with that and many other things,

Bill helped me navigate my way through that.

And as a consequence, became a trusted friend and advisor

for a lot of other issues.

And actually, I had the good fortune

of him spending some time with me

while I was chair at UC Irvine.

The second person, unfortunately, he just left,

but John Guymon, for me personally,

I ran into him when I was a second year resident in Portland

and he was down visiting our program.

And this big, powerful chair

of the Department of Family Medicine at the University

of Washington took the time to sit down

with a lowly second year family medicine resident.

And our paths crossed many times over the year

and John was always patient

and provided a lot of really, really pragmatic, practical,

and useful advice to me.

And the third person that I'd like to recognize

is Jack Rodnick.

Jack was a active participant in this conference series.

And, you know, it's fitting,

he had a special place in his heart for Kauai.

He and Judy and their family had a place up

on the North Shore of Kauai.

They loved coming here.

They loved coming to the conference.

Jack embraced life and embraced family medicine.

And he was, I think for many of us in California,

a tremendous mentor and role model.

And I know for me personally, I miss him desperately.

And, you know, having this conference end here

and thinking of Jack is particularly special.

– Thank you.

(audience applauding)

– We have time for one question, Don.

(laughing)

– Don Fry from Omaha, it always occurred to me

that if we were serious about increasing

the number of family physicians

in reference to what you said, Michael,

we would not open a single additional

allopathic medical school or medical school slot.

We would only open osteopathic schools

because they're the ones who are producing

the family physicians.

I say that at Creighton, the judges don't appreciate it,

but I continue to say it.

The other point is we're dealing

with a public perception issue that goes way back

and it hits our applicants way before they come

to medical school, way before, when they're kids.

And here's how I'll illustrate it.

I'm gonna ask you how you would deal with this.

There used to be a program for the younger people

in the room called the Beverly Hillbillies.

It was one of the dumbest programs ever on television.

And in the Beverly Hillbillies,

there was a recurrent recycled joke that went like this.

Jethro, who was 17 years old and in the sixth grade

at Beverly Hills High School, or excuse me, grade school,

would come home and he would make some brilliant observation

like two plus two is four.

In which case, his Uncle Jed would say,

"Hey, doggies, that boy's getting smarter every day."

And then Jethro Beaming would say,

"Yeah, Uncle Jed, when I grew up,

"I'm gonna be a brain surgeon."

And the audience would erupt with laughter.

I often wonder what would happen if Jethro had said,

"Yeah, Uncle Jed, when I grow up,

"I wanna be a board certified family physician

"and I wanna go back to Possum Trot, Tennessee

"and take care of all those poor folks back there."

Would there have been as much laughter?

Would there have been any laughter?

Would people have said, "Yeah, well, probably Jethro

"can do that."

That's a public perception that's deeply ingrained.

How do we counteract that?

How do we fight that?

– Could I help you get that out of my question?

– Go for it. – Go for it.

– So this is a little more, I'm sorry, Alan Wilkie comes here.

If I'm a medical student and family medicine

hasn't already chosen me,

the question I'm gonna be asking myself is,

what's in it for me?

– Your question is easier, I think,

than the first question, at least in my mind.

I may be simplistic, but, you know, again,

maybe we have something to learn

from our osteopathic colleagues.

I'd have to sit down and talk, but I would question

if we really want to be training more family physicians

than we need to get a different group of people

coming to medical school.

And I think that was so beautifully demonstrated

in the first presentation this morning.

Public perception is a really complicated thing.

And, you know, the other, my other take on public perception

is watch the nightly news and don't pay any attention to news

but pay attention to the commercials

and see what is being marketed.

And it's Keytruda and a variety of other things,

which is how contemporary medicine

is being presented to our public.

And when they do have medical stories on the nightly news,

you know, they're not about, you know,

how people went in to save the community.

They're about, you know, new data out on the utilization

of XYZ technology to treat, you know, disease number four.

And so there is a, if we're gonna go about changing that,

you know, then again, it's be there, be heard,

but then we've got to get into those channels

of communication.

I think a lot of what needs to happen is very different

than what any of us are trained to do.

So maybe one of the answers there is that we need to find

some strategic alliances with folks that are not clinicians

but work well in other worlds of communication

and then start to figure out different ways

to get messages out to the public.

– Thank you. – Yeah, thanks.

(audience applauding)

– I think we need to substitute Mark as well

be for Grey's Anatomy, personally.

So I'd like to invite Dr. Flinders, Punio and Babitz up

to reflect on this conference before it closes.

(indistinct chatter)

– No, and everyone has to stay.

– All right, you're on. – Okay.

– Good morning.

– No, I didn't.

I freeze in my shoes, I got sandals on.

So I brought my wool socks, my mountain socks.

– Good morning.

This should be brief.

I've got only 10 slides and provided I can maintain

the manual dexterity necessary to actually change a slide,

this should take under 10 minutes.

This talk could also be titled Loose Ends

and Enduring Questions.

This morning I want to reflect on some further contributions

to our enduring wisdom, make a single point

on the central issue of our current health reform debate

and revisit a lead question by one of our conference speakers.

And then close with a poem of 17 syllables.

First though, I want to thank Neil Palafox

for yesterday's Gayle Stevens lecture.

It was inspiring, it was courageous

and no one would have enjoyed it more

than Gayle Stevens himself.

I pushed it.

Not again.

All right, this guy gets mentioned anytime

wisdom is brought up in this group.

We're talking about the road ahead and what lies ahead,

what does family medicine should become?

This is from 2014 on the release

of the Family Medicine Future document.

If you want to know what should be the direction

of family medicine in the 21st century,

go back and read what we wrote in the 60s, 70s, 80s and 90s.

Now things change, but much wisdom endures

and that's why we're here.

Here's more enduring wisdom.

Don't give up on the reform ethos

and keep on the side of responsible change in education,

practice and social justice.

What is the next step?

Don McCann, one of the pioneers for the campaign

in support of single payer, past president of PNHP,

couldn't make it this year, health issues.

And so I asked him if there's anything he wanted me to say.

He gave me about six paragraphs, but it could be summarized

in this one sentence, beware of fake single payer.

Now the gentleman here on the left is not Don McCann,

but it could be, in fact is kind of a twin

when it comes to being an assiduous relentless reformer

campaigner for single payer.

This is the point that I want to make.

This is the overhead per capita, per year,

of an parenroly of private Medicare Advantage plans

versus traditional Medicare.

You see the difference?

For traditional Medicare, it's $147 annually per enrollee.

Is it any more expensive for privately financed Medicare?

Yeah, about 1,000% more, it's $1,400.

Now Kevin, fortunately, is gone and he is involved deeply

in the Medicare Advantage programs.

I belong to Medicare Advantage through Kaiser.

I get free gym because of the Silver Sneaker program,

and I'm doing well, but the taxpayer dollars

that are paying for that care are unfair to everyone else.

So when we talk about single payer,

we spent 30 years trying to advance the cause

and concept of single payer, and we finally got it

into the public dialogue.

After more work, we finally settled on a common vocabulary

that many people understand, Medicare for all.

It's simple, but now as in most movements,

the opposition has caught up and co-opted our own language,

confusing the public as well as Congress

with a myriad of counterfeit proposals

under the name of Medicare for all,

Medicare X, public option, et cetera, et cetera.

Most of these are nothing more than Trojan horses

from the private insurance industry.

Same corporate greed, same massive waste

under a different name.

There are currently nine bills before Congress

being bearing variations on the name of Medicare for all.

Seven of these are imposters.

Two are the real deal.

Saunders Bill in the Senate and Jayapal's Bill in the House,

for example, provide true Medicare administrative efficiency,

universal coverage, bulk purchasing,

and negotiated prices for drugs.

Our current and most urgent issue

is to educate the public and our legislators

and the policymakers.

The difference between true single payer

with all the benefits of traditional Medicare for all

and the profiteering imposters who

are exploiting through false labeling legislative proposals

called Medicare for all.

How's my time?

You're good.

All right.

In my last year of work before I retired,

I spent a lot of time in the archives and interviews

and stuff that I'd learned from Gail Stephens.

And I wrote commentaries on five of his most enduring essays.

These are the five that are included.

And I just want to make a comment on two of them.

Parable of the Big Red Bull, we know what it is.

It's the medical industrial complex.

But it's not just about high tech medicine.

It's also about another kind of breed, low tech,

or personal medicine.

It's a commitment in which one human being encounters

another human being in dialogue, in sincere conversation,

and takes personal responsibility for their care.

It's a labor intensive, non-procedural relationship

in caring.

It includes diagnosing, prescribing, repairing,

informing, advising, educating, and advocating.

It's a partnership.

Above all, it is personal.

And most of all, it requires listening.

Now, after my talk on Monday, Jim Herman asked the question,

Rick, all this thing about listening,

about being present, engaged in the present moment.

How do you pass that along?

How do you teach that?

How do you instruct it?

It ain't easy.

And I wasn't being flipped by saying,

it's sort of the zen moment, learning

to be in the here and now, which isn't something

you do with a pill, or a drug, or a one-week retreat.

I've been meditating for 50 years,

and I'm still working at it.

When I spoke with Gail, I realized

he had a reflective practice as well,

a personal reflective practice.

And whatever you do, the importance is being able to be

there with the patient.

Now, how do you do it?

You've got to find your own way.

But let me just give you a description of Gail's experience

of it.

In a 1992 interview with Lucy Candid–

did she ever come here?

Was Lucy ever at this conference?

She asked Gail, when you say engaged in your work,

I take it you mean seeing patients?

His reply, seeing patients, that's the words.

That's the work.

Everything else is tangential to that.

I've never been bored by, or disliked,

or dreaded seeing patients.

Seeing patients is always a new excitement to me every day.

I think about it every morning when I get up.

I never put my hand on the door of an examination room

that I don't feel some kind of new surge of wonder, perhaps

even reverence.

There is a sense in which you need to clear your head

and purify your thoughts before you go in to see a new patient.

That whole experience is multi-potentiality.

As soon as you open your mouth, you limit it in some way.

Something less is possible as soon as you say hello.

That's why it's reverent.

You'd like to go in there and not limit the possibility of what

can happen.

Now, it may turn out to be a purely routine and mundane

visit, at least the occasion for it.

But the patient is never routine or mundane.

I find it the most exciting human activity

there could possibly be.

I would pay to do it.

And one last, from William Carlos Williams,

another respected voice in American medicine.

He writes the same experience.

"So for me, the practice of medicine

has become the pursuit of a rare element, which

may appear at any time, any place, at a glance,

when the patient struggles to lay him herself or herself

before you.

We catch a glimpse of something from time

to time, which shows us that a presence has just

brushed past us, some rare thing.

And for a moment, we are dazzled.

The relationship between physician and patient,

if literally followed, leads to experience

which we barely deserve.

But it's there.

It's magnificent.

It fills my thoughts and reaches to the furthest limits

of our lives."

OK, and one last piece of wondering wisdom.

This one from Mac.

"Sometimes," he said this, I think I first heard it in 2016,

"it is the duty of a reform generation

not to implement radical change, but to keep

the flame of social reform alive."

And finally, some of you know, some of you don't.

I retired last year, after 40 years,

in the same job which I feel absolutely privileged

and fortunate to have done.

I love my work.

I still do, but I love what I'm doing now.

So as a parting shot, in the ancient San tradition

before retiring from the world, a teacher

was expected to compose a final poem in haiku form that

summarized the wisdom, if any, he or she

had gained in their lifetime.

And it was called the terminal haiku.

All right, haiku rules three lines, 17 syllables,

five, seven, and five.

So medicines like love, keep it personal, make it for everyone.

Thank you.

[APPLAUSE]

God, what a hard act to follow.

I have no slides.

It's called Reflections.

That translates to pontifications at this point.

But I have some thoughts.

And the title says Reflections on this conference.

But I think that a lot of what I'm about to say

really applies to the 30 years of conferences.

And I've been blessed to be involved with a lot of them.

In fact, I've been blessed on many levels

to spend time with people like Gail Stevens.

I remember John Guymon when he came to Davis as junior faculty.

I was a med student.

And I remember him coming to campus.

So the first observation I have, and I've

mentioned this to several people,

is one of the real blessings of this series

is our capacity for civil discourse.

We've mentioned it some, to see John Guymon and David Sunwall

at the same table, to listen to Josh Freeman and not beat him

up, and to really realize that the people here,

we've all drunk the Kool-Aid.

But we're not all family physicians.

This is a diverse group.

We have our behaviors.

We have educationalists.

We have finance people.

We have a general surgeon who's speaking

in favor of what we're doing.

We have a diversity of perspectives,

an extraordinarily broad diversity of perspectives.

And yet, we've had a civil discourse.

We've been able to articulate the common ground.

We've been able to share different perspectives that

provide us a wealth of opportunities.

And I think that's been one of the key strengths

of this conference and one of the things I will miss the most.

The second is that we've had the courage

to call a spade a spade and to raise issues

that we know are there.

We need to acknowledge them.

We know they're a problem, and we need to deal with it.

And there are things like the hidden curriculum,

the profiteering, and how much money has been sucked out

of the health care system that would go to patient care

but has gone to profit centers and investors and people

like that.

And that intellectual honesty, I think,

has been really important in these meetings.

The third point is that if you look

at all of these presentations, it's

like four days of TED Talks.

And here we've got 30 years of it.

There is an extreme amount of good work

that has been reported at these meetings.

There's a lot of people who have been laboring the fields

for a long time and have worked hard

over an extended period of time.

And an extraordinary amount of good work

has been done in family medicine, for family medicine,

but more importantly, for the people

we serve in family medicine, the general public.

And an awful lot of that good work

has been heard here and maybe nowhere else, which

I think is a tragedy.

And I think one of the blessings of the Coastal Resource Group

is that Bill has been capturing this information

on the website, transcribing it.

And there is a rich, rich resource of good information

that has been generated over these 30 years.

And I think that's a resource that some of us

are working really hard to try to make sure it gets preserved.

We've talked about enduring wisdom at this meeting.

But that enduring wisdom and things

that Gail Stephens and others have said over time,

that enduring wisdom is alive and well.

I think we've had the honesty to admit that it's evolving.

But there are still core components to it

that we all embrace, believe, live, and breathe every day.

And that feels really good.

And this meeting in particular, we've

talked a lot about culture.

And family medicine was called a counterculture.

But it is a culture.

And we in this room, despite our diversity and varying

viewpoints, we all have embraced that culture.

And to the extent that the people in this room,

and many who haven't been able to come to these meetings

but are out there laboring in the fields,

they have also embraced that culture.

And they show it through the love and the work

that they provide to our trainees, to our patients,

to our constituents, to our communities over time.

I believe that the students who matter see that.

They embrace it and will carry the torch forward.

And although there's a handful of us old timers

at this meeting, there's a number

of young folks who have drunk the Kool-Aid

and have the energy to run forward carrying the flame just

as fast as they can.

And it's one of the reasons I sleep well at night

is because I believe, I believe, I believe,

I believe that family medicine is so important that the public

will eventually wake up and recognize family medicine

and what we offer for what it is.

And that, too, is a blessing that I look forward to.

And I'm blessed to have a family physician taking

care of me and my family who has drunk the Kool-Aid, who

is willing to talk to us and find out who we are as people,

not just pieces of meat on an assembly line.

And family medicine is good for this nation,

good for the world, as we've seen in our global health

presentations.

And this meeting has captured so many different aspects

of the benefits of family medicine.

And I have to say, I am privileged to have

been involved with it.

Thanks.

Is there a doctor in the house?

I want a dramatic ending, but not like that.

So my enduring wisdom is I get to reflect on my 29 years

coming to this conference.

So thank you, Bill, and others.

And so what I want to say probably

is a summary of all the things that

have brought me to this point.

So I'm going to be reflecting on that.

I want to talk about something about history, something

about cliches, something about culture,

something about emotional intelligence,

something about being there, and then some thank yous.

So the first thing, you know, I'm

thinking back to all the conferences.

We started out with a concern about a shortage

of primary care physicians and pay inequity.

Have we solved that problem?

No.

We talked about the problem with federal funding

and not going to primary care.

Remember, early conferences, we need

to have an institute at NIH, a primary care institute.

Has that happened?

No.

We talked about the importance of preventive care

and public health, which I'm in now,

and how that is as important, or the slides have shown more

important than curative care.

When you look at what affects the health of a population,

it is not curative care.

It is public health preventive care, as well as

genetics and other things in their environment.

Have we solved that problem?

No.

And then comprehensive care, we've

talked a lot about what it means to be a family physician.

Comprehensive care, being with the patient.

Are we the primary providers in the nation?

Are we the ones who are leading the course, who

are, I don't know, making the most money

if you want to use that as a measure?

I don't take that as the measure, but no.

You know, it's our high-tech subspecialists,

who I like to refer to as partialists, who are still

leading the way in those areas.

So we haven't done that.

And our reimbursement systems in American health care

just reinforce that system.

So some of the problems we first heard

talked about 29 years ago, eh, you know, so-so.

So that's, is the cup half full or half empty?

I think it's probably still more than half full.

Some cliches that I want to sort of maybe

heard before we want to mention again, leave you with this.

Remember that most of our subspecialty colleagues

are partialists.

They only take care of a little piece of a person.

And when you remind patients of that,

they kind of look at you and they say, oh, yeah.

That's why they wouldn't answer my question about XYZ,

because they're just my liver doctor, my stomach doctor,

my knee doctor, et cetera, et cetera.

Remember that there are two kinds of physicians.

There are physicians who are just fascinated

by the presence of illness that happens

to occur in human beings.

And all our partially colleagues would fall into that area.

And then there are physicians who care about people

and their communities and where they live in their families.

And when those people happen, suffer

from maladies of one kind or another,

whether it's environmental, emotional, psychological,

physical, there are doctors who take care of them.

Well, that's why we've heard a lot about this meeting,

and I believe that's who we are.

And I'm very proud to be part of that group.

Another little cliche kind of thing

is, remember the little mantra I was taught years ago?

Patients don't care how much you know until they

know how much you care.

I demonstrated that in some of the talks this morning.

I think it's real important to remember.

I wanted to mention something called emotional intelligence.

How many know what emotional intelligence is?

Most of you know it.

We want to talk about politics.

We want to talk about changing systems.

You have to understand emotional intelligence.

How many times have you heard somebody say,

I presented reams of facts to these people.

I went to the legislature.

I testified.

I gave them all the data, and they still didn't vote my way.

Because you're trying to use academic intelligence

with other human beings who do not react to that.

I read a book recently.

It talked about emotional intelligence.

It was a great analogy.

They said emotional intelligence and academic intelligence

is like a man riding an elephant through the jungle.

The man on top who's driving is the academic intellectual

intelligence.

The elephant is the emotional intelligence.

The man can direct the elephant along a path

until one thing happens.

The elephant sees his favorite food over there.

And guess where they're going?

That's emotional intelligence.

I was at a hearing years ago, and I

have the great pleasure of testifying at our state

legislature in my current role.

But I was at a hearing a few years ago

where our office of the medical examiner

desperately needed to be able to hire at least one more

pathologist to kind of catch up with the back load.

And we had gingerly and delicately put in requests

for money, and had all the numbers

and how many cases we had, and how far we were back,

and what the national standard was.

And the committee looked at that, and they went, fine, yeah.

They were ready to go to the next thing

until a senator stood up and said, let me tell you a story.

I was on an airplane doing–

in fact, he was on a– it was actually a medical mission

he was part of.

He wasn't a physician in Central America,

and the plane crashed.

And everybody on the plane next step, he and another woman

perished.

He and the woman were rescued.

And he said, this woman was my neighbor,

and we were on this medical mission together.

And you know what really troubles me, told the committee,

is this woman had to wait two years for an autopsy report

so she could get benefits from her husband's death

on this plane crash.

The committee voted to fund two pathologists immediately.

That's emotional intelligence in action.

So now, when I'm counseling my staff in the health department,

I say, if you're going to go present this–

we call them building– you want to present money

to the state legislature?

I want to hear the story you're going to tell them,

because I don't want to just hear all the facts.

It's not going to work.

So if you want to make differences,

understand the emotional intelligence.

And a part of that is what you've heard over and over

in this– and I love the theme.

It's been here for 30 years.

And it was really emphasized this time.

It's kind of the theme of being there and being reflective.

There is no substitute.

I told you the story of my patient who died of cancer

and just wanted to hold my hand.

Boy, did I learn the lesson that day.

It's about being there.

Nobody else can do that.

You know, that's something we do, and we do it well.

We need to emphasize that and emphasize that.

And as we reminded from Gail Stevens,

to reflect on those things.

I've had time, as I've had to become a teacher of the things,

to reflect on my patient experiences

to relearn what I learned from those things, being there.

And last but not least, as the time runs late

and everybody wants to go, it's always

bad to be the last speaker.

Well, actually, the question person is the last speaker.

There's a lot of thank yous.

So first of all, thank you to Bill and Nancy

for 30 incredible years, 29 for me, for all the work.

This is not an easy job.

It's a lot of work to arrange all the things,

put everything together.

Nancy, thank you for coming in, because thank you to you too.

I want to thank the many members who

contributed to the wonderful gifts

we were able to buy to Bill and Nancy.

These were not inexpensive things that we got,

but there actually was some money left over.

And I gave Nancy a Visa gift card today

with the rest of the funds that we had from our account.

It might be enough to pay the freight to ship those things home,

Bill.

Thank you to Bill and Nancy.

I want to thank people who have come to this in the past.

You know, there are a lot of folks

that we think about.

Jack Rodnick was a good friend of mine, Marian Bishop.

I became a good friend of her when I was working for her.

A lot of people who came here in the past who we miss

and we want to remember, and I want to thank them.

Every one of us actually needs, should, wants to thank them.

They are the people on whose shoulders we stand,

as Chip said today.

This has made us who we are, and I'm grateful to them.

But at the same time, I have equal gratitude

for each one of you.

It's been such a pleasure to know you.

I mean, Chuck was my fellow in uniform

for many years at these meetings, and meeting John and Alan.

I could go through the names.

John Bolter with his incredible leadership and vision

and doing things the program.

I mean, go around the room and look at every one of you

and say, thank you for what you do,

and what a privilege for me to get to know you.

Neil, your incredible talk yesterday was just fabulous.

And picking up on Neil's talk, I want to remind us, number one,

we are voyagers.

We are voyagers on a path of reforming health,

one patient at a time, by being there.

And whether the rest of the world accepts that or not,

it doesn't make any difference.

Because the voyage we're on is important to you, to me,

and to that patient.

And if people can't see that, I'm sad, and I'm sorry.

That doesn't change the value.

We are voyagers, and we're on the voyage.

And again, to pick a little bit off of Neil's talk,

I actually had to ask him this morning.

I said, Neil, I'm just really curious,

after hearing your talk, how did the native Hawaiians react

to the movie Moana?

Disney does these movies.

And sometimes they don't go over very well with the people.

My wife and I went to visit China last year.

We asked people, how did you like Mulan?

They said, we loved it.

So Neil gave me an interesting explanation.

At first, he said the Hawaiians were very much resistant

to the idea, but they sort of slowly warmed over time

and came around to doing that.

Well, there's a line in one of the songs from there

that the grandmother sings, know who you are.

Be who you are.

The ocean chose you to be a family physician.

Be who you are.

Be on that voyage.

And again, I just want to express my gratitude.

It's been a great privilege to be at these meetings

and to get to know you and to appreciate what you do.

Thank you.

[APPLAUSE]

[END PLAYBACK]

Lee Burnett, Student Doctor Network.

First off, gentlemen, thank you.

What a fantastic way to close out these 30 years

with what you just had.

Rick, you spoke of the road ahead and enduring wisdom.

In that vein, I'd like to turn this question really back

to the audience.

Do we want this 30th conference to be the end,

to be the terminal haiku?

Or would we like this wisdom to endure?

So I'm curious, in show of hands,

who would like to see a 31st national conference?

[LAUGHTER]

It's unanimous.

Thank you.

Awesome.

[LAUGHTER]

That's enough more to say.

I think that says–

I think that says it all.

I think that's the end.

[LAUGHTER]

Any other questions or comments?

Bill?

Anybody dare and ask another question?

Where are the other things standing between them

and a pina colada, right?

[LAUGHTER]

William Burnett from the Coastal Research Group.

You have a question of me?

No, I was wondering if you wanted to make any comments.

Well, I do think that these 30 years, which I did want to state,

came out of the work that a number of us

did on the National Advisory Council of the National Health

Service Corps, where people like Mark Babbitts and Chuck North

and others were so important that we decided,

as the National Advisory Committee,

that we would counsel it, that we would go around the country

to see all of the experiences that were taking place.

And I think that that's what gave us the idea of doing this.

These particular conferences obviously

have taken more than Nancy and I can commit to in the future.

But it's a body of knowledge that

can be transformed in appropriate ways

into other mechanisms, including perhaps smaller conferences,

certainly including the spectacular presence

of the student doctor network, the studentdoctor.net,

and the other kinds of uses of media to get to students,

that there are a number of different ideas

that we will have that will be calling upon you

and that Lee Burnett and others will be connecting with you,

Laura Turner, and the like will be connecting with you

in the future.

So this need not be the end of the voyage.

It might be tacking in different directions here and there,

but I look forward to seeing whether there

are people that would like to continue

on the sorts of discourse and the sorts of activity.

And look forward to see what happens.

Thank you all.

Thank you.

[APPLAUSE]

And thank you, everyone.

Yes, one minute early.

OK.

Another thunderstorm.

It's a lot of work for your desires.

[SIDE CONVERSATION]

[2 repeated non-speech markers omitted]

Oh my god, your laptop's been stolen.

[SIDE CONVERSATION]

[1 repeated non-speech markers omitted]

Unintended Consequences of 1960s Health Reform

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The thing about introducing these folks is, of course, they don't need an introduction.

And if I did introduce them at the full depth, I'd take the entire time.

But I'll still introduce Phil briefly, noting that he was a Chancellor at UCSF,

Director of Institute for Health Policy Studies at UCSF, was Assistant Secretary twice,

both under Johnson and under Clinton.

And one of Phil's joking notes of how he should be introduced would be in part

to note that Pete was the smart son, Huey was the handsome one, and Phil was the dumb one.

And, well, you start to say, "Well, Phil's not that dumb."

But the fact that he'd go back to Washington a second time does give a little credence

to the fact that there may be a little dimwitted in this somewhere in there.

And so with that, Phil.

Peter, thanks for that insulting introduction.

Pete has really given a very good overview of the context within which policies were

developed at the time of the Miller's Commission when I was in Washington.

But prior to that, in the 1950s, we first had the report of the President's Commission

on the Health Needs of the Nation in 1952.

That was Truman's alternative to national health insurance.

And our father actually served as a member of that commission.

And many of the things we did in the '60s were described in that report.

There was then the Bain Jones report, a report to the Secretary on physician

and other health manpower issues.

And then there was the Bain report to the Surgeon General in 1959

so that by the early 1960s, there was a significant body of information

pulled together around the needs, particularly issues around physician supply,

physician shortage.

And the common view was not only with respect to specialization,

but in fact that there was a significant shortage of physicians in the country.

And it was within that sort of mindset that we began the policy activities in the '60s.

Also in the 1950s, President Eisenhower introduced or proposed legislation in 1956,

which included support not only for research facilities but for the building

of medical education facilities.

The legislation passed but without the medical education facilities.

Funding was there for research facilities as the money was flowing into the medical

schools for the support of research and was in the fact transforming the medical

schools, at least those that garnered the research dollars in the 1950s.

Also another factor, and Eisenhower did that again in '58.

Again, they expanded the research funding, research facilities funding,

but not funding for medical education facilities.

And the other factor in the '50s started in the '40s that was to impact on residency

training particularly was the Hillburton program, which resulted, of course,

in the modernization and the construction of many hospitals,

many of them in the suburbs, but not funding of public hospitals because they

received tax dollars from either local government or state government.

So then we began in the early '60s, Kennedy proposed legislation early on in 1963,

when the Miller's Commission was established.

Congress passed the first Health Professions Educational Assistance Act of the 1960s

in '63 in the fall, and over the course of the next five years,

progressive additions were made to that until 1968, and I'll say a little bit

more about that in a minute.

But also other things that were not intended, at least as they were being

considered, Medicare in particular, the debate on Medicare did not focus on

either civil rights or on graduate medical education, but in fact,

Medicare was to have a profound impact in both of those areas.

After Medicare was passed, very early on, we began to focus on the — because

Medicare policy simply reimbursed hospitals on a cost basis.

You incurred the cost, you got reimbursed for those costs, and included in those

costs were the cost of interns and residents and the cost of supervising

physicians.

And the — in addition, of course, the higher costs of patients in a teaching

hospital were also part of that reimbursement.

They were to become explicit in 1983 when the DRGs were added to the process,

and we really changed the way hospitals were paid.

But the — in the — in meetings we had and Bill Longmark at UCLA, who was then

chairman of the Council on Medical Education of the AMA, was one of the

really instrumental people in advising us on the development of those policies.

And the — there were both the policies that related — that influenced us,

the explicit policies on GME, but the policies that were — it might say

unintended, but had a major impact, of course, were the payments for physicians,

services, Part B of Medicare.

And there, because of the usual customary and reasonable payment method,

it was whatever you set your fees and what the fees were in the community were

basically what was paid.

And as the procedure-based specialists were used to charging more and did charge

more, and general practitioners in the main were not high chargers,

and particularly if they were in rural areas, so you had this very skewed system

of payment that over time made things progressively worse.

And it wasn't an intended effect of Medicare, but it certainly was an effect

of Medicare.

And many of the details — I mean, the Social Security Administration,

which was then administering the program, spelled out the broad policies

and left the details of implementation to the various Blue Cross plans,

which were the intermediaries for the hospitals, and mainly Blue Shield,

which were the carriers for physician payment.

And as a result, you had policies that differed from one part of the country

to another in terms of how this was implemented.

Medicaid, of course, was quite another matter, and it just was dramatic

in the early days of Medicare.

And Medicaid, the resources that were put in by the Federal Government

to the implementation of Medicare in contrast to Medicaid,

which was basically a welfare program administered through the welfare administration

in the Department of Health Education and Welfare, not through the Public Health Service,

not through Social Security.

Social Security didn't want to have anything to do with it.

Because it was a stigmatized population.

And Frank Land, who was a family physician — actually, general practitioner,

I think Frank was from Nebraska, was the first administrator of that program.

But that was a largely state-determined policies.

And as a result, did not have the same impact.

Now, with Medicare, another unintended consequence occurred in 1966

when it was very clear that the Civil Rights Act had to be applied to Medicare.

The courts had decided in 1964 about Hill Burton,

and any hospital that was to receive Hill Burton funds from that point on

had to be desegregated.

And the hospitals didn't believe it.

Most of the doctors didn't believe it.

But in fact, the President was absolutely firm on this issue.

It was a value-driven policy.

It wasn't a focus group.

There weren't polls taken.

And as a matter of fact, it was politically very detrimental to the Democratic Party

to desegregate the hospitals in every congressional district in the South.

But that is, in fact, what happened over a very short period of time

between February of 1966 and July.

And not only did this have a profound effect on those institutions,

when we began that process in some states like Mississippi,

only about 13 percent of the hospitals admitted black and white patients.

In other states, it was a much higher percentage.

But that process moved very, very quickly.

But more significant even, perhaps than the impact on the southern hospitals,

was the impact on residency programs in northern hospitals and southern hospitals.

There were fewer black residents in northern hospitals, lower percentages

than there were in the South.

Many southern hospitals that were desegregated had a larger numbers of black residents

in contrast to hospitals.

And well, that very quickly disappeared after the Civil Rights Act was passed.

And I think Lou Sullivan, actually, who later became the Secretary

of the Department of Health and Human Services,

was the first minority physician to intern at New York Hospital.

And so we saw a profound impact totally unintended by the Civil Rights Act

and Medicare.

And then, by the time I reached UCSF in 1969,

Clark Kerr had been President of the University until, as he said,

when he was removed from his position when Reagan was Governor,

he said he left the presidency as he came to the university,

fired with enthusiasm.

(Laughter)

But while he was President, he instituted policies

that we would now call affirmative action and that there was a profound change,

first of all, in the admission of minority students.

And in '69, we were recruiting black students from actually all over the country.

We had recruiters going out to recruit.

Within about three years, it was not only black students,

but women, and the whole place was transformed within a decade,

as has happened in most medical schools around the country.

Again, the Civil Rights Act, people didn't really think about this impact,

but it was to have a profound effect on medical education

and then on graduate medical education.

Well, in '68, the process of the health profession's educational assistance legislation,

that year we had the most comprehensive support for medical education

and other health professions, dentistry, pharmacy, veterinary medicine,

nursing, and provided not only grants for construction,

loans for students, scholarships for students,

but supports for medical education.

And the goal was to both increase enrollment and to increase the quality of education.

And there were grants specifically designed to support innovations in medical education.

And my deputy at that time for health manpower, Ed Rosinski,

who was a medical educator, Ed's training was not in medicine but in education,

was the principal person behind that idea that there needs to be,

from the federal government, supports for innovations in medical education.

It wasn't until 1971 that the federal government took a position on family practice.

Actually, in the '60s, we didn't take a position because there wasn't a board,

and we didn't want to say that the federal government should dictate to the profession

what it should be doing, although a number of general practitioners,

Amos Johnson, among them, were advocating to us that we do exactly that,

because they wanted to break down some of the barriers more quickly,

but I think that the way it went was really the right way.

Well, the family practice residence, we supported in '71, and as a result of that,

the numbers increased.

In '69, there were 30 family practice residencies.

By 1975, there were 219.

And by '77, all of the public medical schools had departments or divisions

of family medicine or family practice.

Only 50 percent of the private schools did that.

Now, the federal policies were, in a sense, permissive.

There were grants to be provided if you developed those programs.

Unlike, say, the Civil Rights Act, which was a regulatory and radical change,

in '79, the federal government expanded the funding beyond family medicine

to other primary care residencies, particularly general internal medicine

and pediatrics.

Now, by the 1980s, we were not talking about a shortage.

We were now talking about an oversupply.

We had doubled the enrollment in medical schools.

We had increased the numbers, as Pete said, from '85 to '125,

but doubled the output of the medical schools.

And we then had kind of a steady statement.

It's been a relatively steady state since then, but with a dramatic reduction

in federal direct support for medical education.

The research — support for research has continued, and the 800-pound gorilla,

of course, has been Medicare in terms of funding graduate medical education.

Now, unintended consequences, also with respect to federal manpower policies

from the Justice Department and the Labor Department.

Labor Department said in the '60s there's a health manpower shortage,

which then resulted in changes in the immigration laws, which resulted

in very significant increases in the numbers of foreign medical graduates,

now called International Medical Graduates in — in the residency programs.

Also, after Medicare, it's interesting that the number of residencies

in affiliated hospitals that were medical school-affiliated

went up from 48 percent in 1964-65 to 77 percent by 1970-71.

So in a five-year period, a dramatic shift in the affiliation

of residency programs with the medical schools.

Also, the number of foreign medical graduates, if you can believe in 1951,

there were only 1350 in residency programs in the United States.

That was 9 percent of the total.

By 1969, there were 11,000 — it was 32 percent of all the residents

in 69.

So that shift occurred, and it's been relatively steady since,

and although the numbers go up about 4 percent a year,

it is still a — the percentages haven't shifted as dramatically

as they did in those early Medicare days.

So when the hospitals could get the money to pay the residents,

they added residencies very, very rapidly.

And they continued to do that until this year.

The — I've mentioned the impact — the unintended impact

that Medicare had both on the GME policies and on the payment policies.

We could have the first slide.

Is there some way to flip that on?

It's that — oh, there's some — oh, here we go.

Here we've got it.

It's like a miracle.

Pete talked about these figures,

and this is just a recapitulation to see their dramatic effect.

And this is, I think, princely a Medicare effect.

If you look at the growth in clinical faculty,

we've had almost an eight-fold growth in clinical faculty since 1965.

The number of medical schools has doubled.

Since '85, the number of med students has hardly increased at all,

and we see, again, this huge increase in the residents

and even greater increase in the clinical faculty.

If we could have the next slide.

Then you look — Pete mentioned the revenues,

and you see the huge impact.

Where is the money coming from?

It's like Willie Sutton.

You know, he went where the — he robbed banks because that's where the money was.

Well, the medical schools added clinical faculty to generate the revenues,

which have now been the major factor in support of medical education.

We could have the next slide.

We notice here that in 6061, 36 percent of the revenues came from research,

basically from NIH.

Now, the money's increased still, but it's now only 18 percent.

Whereas clinical services, that includes faculty practice plans

and hospital and medical school programs of providing medical care,

now up to 48 percent.

You don't think that doesn't influence the policies of these institutions

where you are dependent then on the support of your educational enterprise

from your faculty practice revenues.

And, of course, in the — what some people would consider the good old days

when it was fee for service, and everything you did was a revenue generator,

now those become cost centers for many of these services.

We'll see what happens.

Now, we find that Medicare, like NIH, has now become the dominant federal policy

without being intended.

And, of course, medical — the Medicare policy for graduate medical education

until 1997, there was no federal policy except we'll support whatever the hospitals do.

And those residency training programs have continued to be dominated by service needs

and the interest of either the hospital or a clinical division head.

Again, the policy said we'll fund you for whatever you do.

We'll not only fund you with direct support for the resident

and the supervising physicians, we'll pay you a lot more for every patient you take care of,

even though it's been clear for years that the indirect medical education payments

were far in excess of what the actual costs were for those patients.

And you had incentives in states like New York because it was based on where we were in 1984,

they based the — these payments.

Monifior gets $200,000 per resident. Hospitals in Iowa get about $40,000.

Now, if that isn't an incentive and you wonder, well, why have the residents increased

in New York and Pennsylvania and New Jersey?

Well, it's a very clear, very perverse incentive.

Now, with the balanced budget act, for the first time, Congress has said

we're not going to fund any more residents.

We're going to put a cap on the number of residents.

And they also have given some incentives to New York to reduce the numbers,

and they have now passed that on.

They basically hold harmless for a five-year period if you reduce the number of residents.

And when we look at each of these areas, we see unintended consequences of the policies

on graduate medical education, on medical education.

And certainly, there's been no incentive in any of the federal policies with respect

except for these small discretionary grants out of the Bureau of Health Professions

to support the development of family medicine in the medical schools

or in residency training programs.

And you compare those dollars to the Medicare dollars to GME,

which trained huge numbers of physicians and specialties in excess of what the needs were.

There's been no focus on geriatrics or the needs of the elderly in funding of the GME programs in Medicare.

And now we have a movement with the balanced budget act to support managed care.

I mean, to move HICFA from being a payer to being a purchaser.

And I think we can anticipate unintended consequences of these policies as well.

And nobody is really looking at that.

The one thing they did in the balanced budget act, they said we're going to reduce your IME funding

over the next five years by about five and a half billion.

But we're going to take the money away from managed care plans, about four billion,

and give it to the teaching hospitals at 20% per year.

So they take it away with one hand and give it back with another.

There will be a modest reduction also in the payments for direct medical education

in an attempt to really slow down this constant growth.

And the only reason that happened this year is because the Republicans control Congress

and Senator Moynihan from New York isn't able to prevent that continued flow of funds

uninterrupted without any limit into the teaching hospitals in New York and New Jersey.

And Pennsylvania.

So we've had over the years, over the last now 40 years,

and going back to the context of Millis and the problems that they were addressing

as Pete said, we're still facing many of the same issues.

The federal policies, Hillburden, NIH certainly had no beneficial effects

on primary care, on the development of S, or on the development of family medicine,

either as an intellectual field or as a practicing specialty.

We have Medicare policies, which have now become the dominant policies.

Again, perverse and unintended effects.

The only policies that were really directed towards sort of a rational system

were the health professions, educational assistance funds.

We still have, you know, about $200 million maybe in the Bureau of Health Professions,

maybe 250, and Medicare has about $7.5 billion just to support a graduate medical education.

NIH is $11 billion, so it gives you some idea of where the incentives have been

in the federal government.

I think it's been a miracle to my mind that this has — family medicine has developed

to the extent that it has in the face of these very, very formidable not only obstacles

within the institutions, within the universities, but because of these financial incentives

that have flown from outside into those institutions to accomplish what's been accomplished

to date.

Am I any more optimistic about the future?

I would say I don't think so.

I mean, I think we have to look at the unintended consequences of managed care

and see if we can anticipate what those will be and try to move to get some more rational

policies, and maybe with Peter's help we can do that.

Thank you.

All right.

[ Applause ]

I'm astounded Phil.

That was ever so brief.

I appreciate this.

You've intimidated me.

Not likely.

Last, introducing Dr. Hewitt Lee.

Hewie's the past president of the Palo Alto Medical Clinic is the emeritus executive

director of the Palo Alto Medical Clinic, trustee of the Palo Alto Medical Foundation

professor at Stanford University.

As my dad noted, he's a surgeon.

At one point, he was, however, doing so many hemorrhoids that he was known as a vascular

surgeon, though he is a general surgeon by practice.

Hewie will give a perspective on the Miller's commission's impact on the real world

and practice, rather than the lofty ivory tower of the world of the Beltway.

[ Laughter ]

Lawyers are the real ones we want to do hemorrhoidectomies on.

[ Laughter ]

It's really an honor here as a specialist to talk to all of you primary care people

and particularly to follow these distinguished members of my own family.

As Pete just had a birthday, as he mentioned a couple of days ago,

and he's now older than Mickey Mouse.

[ Laughter ]

And he found on a trip to Italy last year that he was older than most of the monuments.

[ Laughter ]

So I've had that.

I've had three older brothers that were in med school.

We were all one year apart, and I learned from all these guys the easy way to get by everything.

They would tell me who the professors who graded easily were

and who the ones didn't require, you know, work very hard were,

the ones who didn't have eight o'clock classes and all those things.

So I had a much easier time getting through than they did.

I could just flow along and learn by their mistakes and accept,

toward the, each time I introduced, get introduced to a new professor,

he'd say, "Oh, my God, not another lead."

Well, that's what all you can say now, "Oh, my God, not another lead."

I had the pleasure of interning those days when there was still an internship at Western Reserve,

and Warren was the dean and the nurse was the president,

and these things were beginning to ferment at that time.

Then I came back, I had a residency at Stanford in San Francisco

in the old days of a surgical residency, you know, the final pay of the final year,

after six years was $150 a month, and went to the, and joined the Palo Alto Clinic in 1956.

And the, at that time, we were 70 physicians, and all but three were specialists.

We had three general practitioners at that time, and 67 specialists.

The, and concerned by the ever decreasing impact

of the general practitioner, my dad and his grandfather, said,

and he's quoted in the millis report as saying that we should build a monument

to the general practitioner, barium, and originate the concept of a personal physician.

And as you know, the, there's been some discussion this morning already,

the, what to call this new personal physician that, that was beginning to evolve

as a result of the millis report, and then the later creation or the very soon later creation

of the board of family practice was generalist, primary care physician, family,

physician, family provider, and so on.

And, and ultimately out of the distillate came the term family practitioner.

And, and with the, with the meaning had three additional years of training past an exam,

and this was occurring, began to occur at the time when there was really severe,

increasing fragmentation of the care.

And I think there's one of the problems with, with health care.

It's been its fragmentation, and Peter, I'm sure is, Peter Jr.,

I'm sure is faced with some of these complaints that there's no continuity of care.

The, it's all distributed amongst specialists who don't really know the other half.

And when you have a primary care physician controlling this, or guiding this,

or being the, the manager of this, there's going to be, I think, a major increase

in the general happiness of the, of the patient.

I, I had the pleasure of being a delegate to the AMA at the time the millis report was

commissioned, and it was commissioned as, as you all know, by the AMA itself,

the Council on Medical Education, which has probably been the most significant committee

of the, of the AMA over the years.

The, and with the, is the general practitioner's status declining,

with the specialists getting the cream of hospital appointments,

the best and easiest hours, the most pay, and the greatest status.

It was no wonder, really, that, that their general practitioner was going

into a steady decline on a national basis in the United States.

With the, with the creation of the board and, and of family practice,

this was an incredible shot in the arm for the evolution

and, and beginning to pull people back into the field of general practice,

or now family practice.

And, and the mission as a comprehensive doctor,

a true primary physician, with equal educational rank

and status for the specialists, I think was, was really something incredibly important.

And a reversal of the specialization trend began,

of course there were other reasons for this, as Phil pointed out,

because sometimes that's where the money, money came from.

But, with the evolution of the board and the, and the two subsets of the board,

the competent special competence in geriatric medicine

and a special competence in family practice.

I mean, in sports medicine, each requiring additional training in those fields

allowed further enhancement of the primary care physician.

In the U.S. in 1900, there were 76 million people in the entire United States.

And we had 119,000 MDs, almost all male,

and there were 10,000 specialists at that time.

In 1975, there were 482,000 male and 30,

and, and 86,000 female physicians saw this major, major change degree

for a total of 568,000 doctors.

And, at this time, there were 37,000 male family practitioners.

And 7,000 female family practitioners, and general practitioners numbered 25,000.

So they had, the, the, the change had begun to occur.

The family practitioners beginning to ascend, and the general practitioner was beginning to disappear.

The, by 1996, there were 580,000 male and 157,000 female physicians.

Serving a population of 265 million in the United States.

So in less than a century, we'd gone up, you know, about 100 million people.

We had, at this time, there were now 47,000 male family practitioners,

15,000 female practitioners for a total of 62,000 family practitioners,

really labeled as such, and there were family, and, and general practitioners,

the ones basically without the board training, had dropped to 16,000.

It was still, it was a major turnaround, but it was still not enough.

In, in Palo Alto, now at the Pali Clinic, we now have 180 doctors,

and we have 33 family practitioners up from three in this, in the, in my,

just in, during my tenure there.

We have 45 internists, and we'd have only three general surgeons,

one vascular and one thoracic surgeon.

So you can see the balance is really very, very different from the national balance.

The, the Miller's Commission felt that their ideal place for a family practitioner was, was in a group practice.

And then he or she could utilize the, the specialized colleagues for their help in, in diagnosis and treatment,

and, and special procedures, and group practice would give the patient the advantages of continuing contact

with the physician who knows him well, and, and knows his medical history,

combined with access to the wider array of skills and facilities.

The, the, with these, there also has been an increased status of the family practitioner.

He, he or she now has boards.

The pay has become somewhat comparable.

They, at least in our institution, and, and they pass the exams.

They have, they need to re-certify every seven years, and they get two weeks off for education every year,

and all the time necessary to study for the, for the, the new or the review boards that they have to take.

They are staffing now.

Family practitioners are now staffing.

The urgent care facilities.

The female physicians are able to job share, which is a great plus for them.

We have sometimes two share, we have, we have about ten female doctors job sharing at the present time.

And they work in sports medicine and geriatrics.

And, and have an ever increasing load of patients who really love them for the comprehensive care that they're able to give,

without the fractionated care they were getting at the hands of the specialists.

The, the, it's really, I think, a major evolution from the lonely, isolated general practitioner, sleep deprived,

relatively poorly, poorly paid, to the, to, to the new family practitioner who has significant empowerment,

with management positions, and a marked increase in, in quality of life and lifestyle, and good pay.

And, and in the spirit and letter of the recommendations of Millis and those who followed him,

we now make provisions for, for these, for additional time off.

They have sabbaticals and vacations, things almost impossible for a, for the individual and solo practicing general practitioner.

The, the course is still a tremendous shortage nationally, and people like Pete have done a great deal to help that.

I mean to, to, to alleviate that by establishing a 17 residency programs in the Southern California area.

And that's pretty significant, isn't it 17 people that you've made?

>> Not I.

>> Well, you, you evolved, yeah.

>> You've watched.

>> Watch, oh yeah.

>> [LAUGH]

>> But there's been, there's been a real move, though, though, at Bill Fox would know that Stanford does not have any primary care,

any, any family practitioner program at its own university hospital.

The, and I think this still, I don't know if they have one at UC or not, so they have a family practitioner.

>> We just moved it out and put the, the in vitro fertilization group.

>> Yeah, let's.

>> [LAUGH]

>> That's, that's where the money is.

>> [LAUGH]

>> Well, we, we find, we find the, the knowledge and, and vitality and energy and intelligence.

And intelligence of the new family practitioners that we were able to recruit.

Just fantastic.

And they've been a wonderful addition to our institution now and we're, we're really delighted to see them.

And we'd like to see the increasing turnaround.

It's still pretty competitive in our recruiting for family practitioners.

The last surgeon we got, we had 70 applicants for one job.

And as you know, Stanford anesthesia last year turned out 13 anesthesia residents and

six of them couldn't get a job.

And three of them went to Kaiser as nurse anesthetist, even though they were MD anesthetist.

So, you know, this great glut of specialists that we have, we still keep cranking them out.

But we're, we're doing better on the others.

Well, it's been a great pleasure addressing you all and thank you for your attention.

>> [APPLAUSE]

You

CRG PHCA 02Apr1998 Unintended

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Transcript imported from the local CRG audio transcription files for human review. This is the same underlying transcript used for the related “Unintended Consequences of 1960s Health Reform” recording.

The thing about introducing these folks is, of course, they don't need an introduction.

And if I did introduce them at the full depth, I'd take the entire time.

But I'll still introduce Phil briefly, noting that he was a Chancellor at UCSF,

Director of Institute for Health Policy Studies at UCSF, was Assistant Secretary twice,

both under Johnson and under Clinton.

And one of Phil's joking notes of how he should be introduced would be in part

to note that Pete was the smart son, Huey was the handsome one, and Phil was the dumb one.

And, well, you start to say, "Well, Phil's not that dumb."

But the fact that he'd go back to Washington a second time does give a little credence

to the fact that there may be a little dimwitted in this somewhere in there.

And so with that, Phil.

Peter, thanks for that insulting introduction.

Pete has really given a very good overview of the context within which policies were

developed at the time of the Miller's Commission when I was in Washington.

But prior to that, in the 1950s, we first had the report of the President's Commission

on the Health Needs of the Nation in 1952.

That was Truman's alternative to national health insurance.

And our father actually served as a member of that commission.

And many of the things we did in the '60s were described in that report.

There was then the Bain Jones report, a report to the Secretary on physician

and other health manpower issues.

And then there was the Bain report to the Surgeon General in 1959

so that by the early 1960s, there was a significant body of information

pulled together around the needs, particularly issues around physician supply,

physician shortage.

And the common view was not only with respect to specialization,

but in fact that there was a significant shortage of physicians in the country.

And it was within that sort of mindset that we began the policy activities in the '60s.

Also in the 1950s, President Eisenhower introduced or proposed legislation in 1956,

which included support not only for research facilities but for the building

of medical education facilities.

The legislation passed but without the medical education facilities.

Funding was there for research facilities as the money was flowing into the medical

schools for the support of research and was in the fact transforming the medical

schools, at least those that garnered the research dollars in the 1950s.

Also another factor, and Eisenhower did that again in '58.

Again, they expanded the research funding, research facilities funding,

but not funding for medical education facilities.

And the other factor in the '50s started in the '40s that was to impact on residency

training particularly was the Hillburton program, which resulted, of course,

in the modernization and the construction of many hospitals,

many of them in the suburbs, but not funding of public hospitals because they

received tax dollars from either local government or state government.

So then we began in the early '60s, Kennedy proposed legislation early on in 1963,

when the Miller's Commission was established.

Congress passed the first Health Professions Educational Assistance Act of the 1960s

in '63 in the fall, and over the course of the next five years,

progressive additions were made to that until 1968, and I'll say a little bit

more about that in a minute.

But also other things that were not intended, at least as they were being

considered, Medicare in particular, the debate on Medicare did not focus on

either civil rights or on graduate medical education, but in fact,

Medicare was to have a profound impact in both of those areas.

After Medicare was passed, very early on, we began to focus on the — because

Medicare policy simply reimbursed hospitals on a cost basis.

You incurred the cost, you got reimbursed for those costs, and included in those

costs were the cost of interns and residents and the cost of supervising

physicians.

And the — in addition, of course, the higher costs of patients in a teaching

hospital were also part of that reimbursement.

They were to become explicit in 1983 when the DRGs were added to the process,

and we really changed the way hospitals were paid.

But the — in the — in meetings we had and Bill Longmark at UCLA, who was then

chairman of the Council on Medical Education of the AMA, was one of the

really instrumental people in advising us on the development of those policies.

And the — there were both the policies that related — that influenced us,

the explicit policies on GME, but the policies that were — it might say

unintended, but had a major impact, of course, were the payments for physicians,

services, Part B of Medicare.

And there, because of the usual customary and reasonable payment method,

it was whatever you set your fees and what the fees were in the community were

basically what was paid.

And as the procedure-based specialists were used to charging more and did charge

more, and general practitioners in the main were not high chargers,

and particularly if they were in rural areas, so you had this very skewed system

of payment that over time made things progressively worse.

And it wasn't an intended effect of Medicare, but it certainly was an effect

of Medicare.

And many of the details — I mean, the Social Security Administration,

which was then administering the program, spelled out the broad policies

and left the details of implementation to the various Blue Cross plans,

which were the intermediaries for the hospitals, and mainly Blue Shield,

which were the carriers for physician payment.

And as a result, you had policies that differed from one part of the country

to another in terms of how this was implemented.

Medicaid, of course, was quite another matter, and it just was dramatic

in the early days of Medicare.

And Medicaid, the resources that were put in by the Federal Government

to the implementation of Medicare in contrast to Medicaid,

which was basically a welfare program administered through the welfare administration

in the Department of Health Education and Welfare, not through the Public Health Service,

not through Social Security.

Social Security didn't want to have anything to do with it.

Because it was a stigmatized population.

And Frank Land, who was a family physician — actually, general practitioner,

I think Frank was from Nebraska, was the first administrator of that program.

But that was a largely state-determined policies.

And as a result, did not have the same impact.

Now, with Medicare, another unintended consequence occurred in 1966

when it was very clear that the Civil Rights Act had to be applied to Medicare.

The courts had decided in 1964 about Hill Burton,

and any hospital that was to receive Hill Burton funds from that point on

had to be desegregated.

And the hospitals didn't believe it.

Most of the doctors didn't believe it.

But in fact, the President was absolutely firm on this issue.

It was a value-driven policy.

It wasn't a focus group.

There weren't polls taken.

And as a matter of fact, it was politically very detrimental to the Democratic Party

to desegregate the hospitals in every congressional district in the South.

But that is, in fact, what happened over a very short period of time

between February of 1966 and July.

And not only did this have a profound effect on those institutions,

when we began that process in some states like Mississippi,

only about 13 percent of the hospitals admitted black and white patients.

In other states, it was a much higher percentage.

But that process moved very, very quickly.

But more significant even, perhaps than the impact on the southern hospitals,

was the impact on residency programs in northern hospitals and southern hospitals.

There were fewer black residents in northern hospitals, lower percentages

than there were in the South.

Many southern hospitals that were desegregated had a larger numbers of black residents

in contrast to hospitals.

And well, that very quickly disappeared after the Civil Rights Act was passed.

And I think Lou Sullivan, actually, who later became the Secretary

of the Department of Health and Human Services,

was the first minority physician to intern at New York Hospital.

And so we saw a profound impact totally unintended by the Civil Rights Act

and Medicare.

And then, by the time I reached UCSF in 1969,

Clark Kerr had been President of the University until, as he said,

when he was removed from his position when Reagan was Governor,

he said he left the presidency as he came to the university,

fired with enthusiasm.

(Laughter)

But while he was President, he instituted policies

that we would now call affirmative action and that there was a profound change,

first of all, in the admission of minority students.

And in '69, we were recruiting black students from actually all over the country.

We had recruiters going out to recruit.

Within about three years, it was not only black students,

but women, and the whole place was transformed within a decade,

as has happened in most medical schools around the country.

Again, the Civil Rights Act, people didn't really think about this impact,

but it was to have a profound effect on medical education

and then on graduate medical education.

Well, in '68, the process of the health profession's educational assistance legislation,

that year we had the most comprehensive support for medical education

and other health professions, dentistry, pharmacy, veterinary medicine,

nursing, and provided not only grants for construction,

loans for students, scholarships for students,

but supports for medical education.

And the goal was to both increase enrollment and to increase the quality of education.

And there were grants specifically designed to support innovations in medical education.

And my deputy at that time for health manpower, Ed Rosinski,

who was a medical educator, Ed's training was not in medicine but in education,

was the principal person behind that idea that there needs to be,

from the federal government, supports for innovations in medical education.

It wasn't until 1971 that the federal government took a position on family practice.

Actually, in the '60s, we didn't take a position because there wasn't a board,

and we didn't want to say that the federal government should dictate to the profession

what it should be doing, although a number of general practitioners,

Amos Johnson, among them, were advocating to us that we do exactly that,

because they wanted to break down some of the barriers more quickly,

but I think that the way it went was really the right way.

Well, the family practice residence, we supported in '71, and as a result of that,

the numbers increased.

In '69, there were 30 family practice residencies.

By 1975, there were 219.

And by '77, all of the public medical schools had departments or divisions

of family medicine or family practice.

Only 50 percent of the private schools did that.

Now, the federal policies were, in a sense, permissive.

There were grants to be provided if you developed those programs.

Unlike, say, the Civil Rights Act, which was a regulatory and radical change,

in '79, the federal government expanded the funding beyond family medicine

to other primary care residencies, particularly general internal medicine

and pediatrics.

Now, by the 1980s, we were not talking about a shortage.

We were now talking about an oversupply.

We had doubled the enrollment in medical schools.

We had increased the numbers, as Pete said, from '85 to '125,

but doubled the output of the medical schools.

And we then had kind of a steady statement.

It's been a relatively steady state since then, but with a dramatic reduction

in federal direct support for medical education.

The research — support for research has continued, and the 800-pound gorilla,

of course, has been Medicare in terms of funding graduate medical education.

Now, unintended consequences, also with respect to federal manpower policies

from the Justice Department and the Labor Department.

Labor Department said in the '60s there's a health manpower shortage,

which then resulted in changes in the immigration laws, which resulted

in very significant increases in the numbers of foreign medical graduates,

now called International Medical Graduates in — in the residency programs.

Also, after Medicare, it's interesting that the number of residencies

in affiliated hospitals that were medical school-affiliated

went up from 48 percent in 1964-65 to 77 percent by 1970-71.

So in a five-year period, a dramatic shift in the affiliation

of residency programs with the medical schools.

Also, the number of foreign medical graduates, if you can believe in 1951,

there were only 1350 in residency programs in the United States.

That was 9 percent of the total.

By 1969, there were 11,000 — it was 32 percent of all the residents

in 69.

So that shift occurred, and it's been relatively steady since,

and although the numbers go up about 4 percent a year,

it is still a — the percentages haven't shifted as dramatically

as they did in those early Medicare days.

So when the hospitals could get the money to pay the residents,

they added residencies very, very rapidly.

And they continued to do that until this year.

The — I've mentioned the impact — the unintended impact

that Medicare had both on the GME policies and on the payment policies.

We could have the first slide.

Is there some way to flip that on?

It's that — oh, there's some — oh, here we go.

Here we've got it.

It's like a miracle.

Pete talked about these figures,

and this is just a recapitulation to see their dramatic effect.

And this is, I think, princely a Medicare effect.

If you look at the growth in clinical faculty,

we've had almost an eight-fold growth in clinical faculty since 1965.

The number of medical schools has doubled.

Since '85, the number of med students has hardly increased at all,

and we see, again, this huge increase in the residents

and even greater increase in the clinical faculty.

If we could have the next slide.

Then you look — Pete mentioned the revenues,

and you see the huge impact.

Where is the money coming from?

It's like Willie Sutton.

You know, he went where the — he robbed banks because that's where the money was.

Well, the medical schools added clinical faculty to generate the revenues,

which have now been the major factor in support of medical education.

We could have the next slide.

We notice here that in 6061, 36 percent of the revenues came from research,

basically from NIH.

Now, the money's increased still, but it's now only 18 percent.

Whereas clinical services, that includes faculty practice plans

and hospital and medical school programs of providing medical care,

now up to 48 percent.

You don't think that doesn't influence the policies of these institutions

where you are dependent then on the support of your educational enterprise

from your faculty practice revenues.

And, of course, in the — what some people would consider the good old days

when it was fee for service, and everything you did was a revenue generator,

now those become cost centers for many of these services.

We'll see what happens.

Now, we find that Medicare, like NIH, has now become the dominant federal policy

without being intended.

And, of course, medical — the Medicare policy for graduate medical education

until 1997, there was no federal policy except we'll support whatever the hospitals do.

And those residency training programs have continued to be dominated by service needs

and the interest of either the hospital or a clinical division head.

Again, the policy said we'll fund you for whatever you do.

We'll not only fund you with direct support for the resident

and the supervising physicians, we'll pay you a lot more for every patient you take care of,

even though it's been clear for years that the indirect medical education payments

were far in excess of what the actual costs were for those patients.

And you had incentives in states like New York because it was based on where we were in 1984,

they based the — these payments.

Monifior gets $200,000 per resident. Hospitals in Iowa get about $40,000.

Now, if that isn't an incentive and you wonder, well, why have the residents increased

in New York and Pennsylvania and New Jersey?

Well, it's a very clear, very perverse incentive.

Now, with the balanced budget act, for the first time, Congress has said

we're not going to fund any more residents.

We're going to put a cap on the number of residents.

And they also have given some incentives to New York to reduce the numbers,

and they have now passed that on.

They basically hold harmless for a five-year period if you reduce the number of residents.

And when we look at each of these areas, we see unintended consequences of the policies

on graduate medical education, on medical education.

And certainly, there's been no incentive in any of the federal policies with respect

except for these small discretionary grants out of the Bureau of Health Professions

to support the development of family medicine in the medical schools

or in residency training programs.

And you compare those dollars to the Medicare dollars to GME,

which trained huge numbers of physicians and specialties in excess of what the needs were.

There's been no focus on geriatrics or the needs of the elderly in funding of the GME programs in Medicare.

And now we have a movement with the balanced budget act to support managed care.

I mean, to move HICFA from being a payer to being a purchaser.

And I think we can anticipate unintended consequences of these policies as well.

And nobody is really looking at that.

The one thing they did in the balanced budget act, they said we're going to reduce your IME funding

over the next five years by about five and a half billion.

But we're going to take the money away from managed care plans, about four billion,

and give it to the teaching hospitals at 20% per year.

So they take it away with one hand and give it back with another.

There will be a modest reduction also in the payments for direct medical education

in an attempt to really slow down this constant growth.

And the only reason that happened this year is because the Republicans control Congress

and Senator Moynihan from New York isn't able to prevent that continued flow of funds

uninterrupted without any limit into the teaching hospitals in New York and New Jersey.

And Pennsylvania.

So we've had over the years, over the last now 40 years,

and going back to the context of Millis and the problems that they were addressing

as Pete said, we're still facing many of the same issues.

The federal policies, Hillburden, NIH certainly had no beneficial effects

on primary care, on the development of S, or on the development of family medicine,

either as an intellectual field or as a practicing specialty.

We have Medicare policies, which have now become the dominant policies.

Again, perverse and unintended effects.

The only policies that were really directed towards sort of a rational system

were the health professions, educational assistance funds.

We still have, you know, about $200 million maybe in the Bureau of Health Professions,

maybe 250, and Medicare has about $7.5 billion just to support a graduate medical education.

NIH is $11 billion, so it gives you some idea of where the incentives have been

in the federal government.

I think it's been a miracle to my mind that this has — family medicine has developed

to the extent that it has in the face of these very, very formidable not only obstacles

within the institutions, within the universities, but because of these financial incentives

that have flown from outside into those institutions to accomplish what's been accomplished

to date.

Am I any more optimistic about the future?

I would say I don't think so.

I mean, I think we have to look at the unintended consequences of managed care

and see if we can anticipate what those will be and try to move to get some more rational

policies, and maybe with Peter's help we can do that.

Thank you.

All right.

[ Applause ]

I'm astounded Phil.

That was ever so brief.

I appreciate this.

You've intimidated me.

Not likely.

Last, introducing Dr. Hewitt Lee.

Hewie's the past president of the Palo Alto Medical Clinic is the emeritus executive

director of the Palo Alto Medical Clinic, trustee of the Palo Alto Medical Foundation

professor at Stanford University.

As my dad noted, he's a surgeon.

At one point, he was, however, doing so many hemorrhoids that he was known as a vascular

surgeon, though he is a general surgeon by practice.

Hewie will give a perspective on the Miller's commission's impact on the real world

and practice, rather than the lofty ivory tower of the world of the Beltway.

[ Laughter ]

Lawyers are the real ones we want to do hemorrhoidectomies on.

[ Laughter ]

It's really an honor here as a specialist to talk to all of you primary care people

and particularly to follow these distinguished members of my own family.

As Pete just had a birthday, as he mentioned a couple of days ago,

and he's now older than Mickey Mouse.

[ Laughter ]

And he found on a trip to Italy last year that he was older than most of the monuments.

[ Laughter ]

So I've had that.

I've had three older brothers that were in med school.

We were all one year apart, and I learned from all these guys the easy way to get by everything.

They would tell me who the professors who graded easily were

and who the ones didn't require, you know, work very hard were,

the ones who didn't have eight o'clock classes and all those things.

So I had a much easier time getting through than they did.

I could just flow along and learn by their mistakes and accept,

toward the, each time I introduced, get introduced to a new professor,

he'd say, "Oh, my God, not another lead."

Well, that's what all you can say now, "Oh, my God, not another lead."

I had the pleasure of interning those days when there was still an internship at Western Reserve,

and Warren was the dean and the nurse was the president,

and these things were beginning to ferment at that time.

Then I came back, I had a residency at Stanford in San Francisco

in the old days of a surgical residency, you know, the final pay of the final year,

after six years was $150 a month, and went to the, and joined the Palo Alto Clinic in 1956.

And the, at that time, we were 70 physicians, and all but three were specialists.

We had three general practitioners at that time, and 67 specialists.

The, and concerned by the ever decreasing impact

of the general practitioner, my dad and his grandfather, said,

and he's quoted in the millis report as saying that we should build a monument

to the general practitioner, barium, and originate the concept of a personal physician.

And as you know, the, there's been some discussion this morning already,

the, what to call this new personal physician that, that was beginning to evolve

as a result of the millis report, and then the later creation or the very soon later creation

of the board of family practice was generalist, primary care physician, family,

physician, family provider, and so on.

And, and ultimately out of the distillate came the term family practitioner.

And, and with the, with the meaning had three additional years of training past an exam,

and this was occurring, began to occur at the time when there was really severe,

increasing fragmentation of the care.

And I think there's one of the problems with, with health care.

It's been its fragmentation, and Peter, I'm sure is, Peter Jr.,

I'm sure is faced with some of these complaints that there's no continuity of care.

The, it's all distributed amongst specialists who don't really know the other half.

And when you have a primary care physician controlling this, or guiding this,

or being the, the manager of this, there's going to be, I think, a major increase

in the general happiness of the, of the patient.

I, I had the pleasure of being a delegate to the AMA at the time the millis report was

commissioned, and it was commissioned as, as you all know, by the AMA itself,

the Council on Medical Education, which has probably been the most significant committee

of the, of the AMA over the years.

The, and with the, is the general practitioner's status declining,

with the specialists getting the cream of hospital appointments,

the best and easiest hours, the most pay, and the greatest status.

It was no wonder, really, that, that their general practitioner was going

into a steady decline on a national basis in the United States.

With the, with the creation of the board and, and of family practice,

this was an incredible shot in the arm for the evolution

and, and beginning to pull people back into the field of general practice,

or now family practice.

And, and the mission as a comprehensive doctor,

a true primary physician, with equal educational rank

and status for the specialists, I think was, was really something incredibly important.

And a reversal of the specialization trend began,

of course there were other reasons for this, as Phil pointed out,

because sometimes that's where the money, money came from.

But, with the evolution of the board and the, and the two subsets of the board,

the competent special competence in geriatric medicine

and a special competence in family practice.

I mean, in sports medicine, each requiring additional training in those fields

allowed further enhancement of the primary care physician.

In the U.S. in 1900, there were 76 million people in the entire United States.

And we had 119,000 MDs, almost all male,

and there were 10,000 specialists at that time.

In 1975, there were 482,000 male and 30,

and, and 86,000 female physicians saw this major, major change degree

for a total of 568,000 doctors.

And, at this time, there were 37,000 male family practitioners.

And 7,000 female family practitioners, and general practitioners numbered 25,000.

So they had, the, the, the change had begun to occur.

The family practitioners beginning to ascend, and the general practitioner was beginning to disappear.

The, by 1996, there were 580,000 male and 157,000 female physicians.

Serving a population of 265 million in the United States.

So in less than a century, we'd gone up, you know, about 100 million people.

We had, at this time, there were now 47,000 male family practitioners,

15,000 female practitioners for a total of 62,000 family practitioners,

really labeled as such, and there were family, and, and general practitioners,

the ones basically without the board training, had dropped to 16,000.

It was still, it was a major turnaround, but it was still not enough.

In, in Palo Alto, now at the Pali Clinic, we now have 180 doctors,

and we have 33 family practitioners up from three in this, in the, in my,

just in, during my tenure there.

We have 45 internists, and we'd have only three general surgeons,

one vascular and one thoracic surgeon.

So you can see the balance is really very, very different from the national balance.

The, the Miller's Commission felt that their ideal place for a family practitioner was, was in a group practice.

And then he or she could utilize the, the specialized colleagues for their help in, in diagnosis and treatment,

and, and special procedures, and group practice would give the patient the advantages of continuing contact

with the physician who knows him well, and, and knows his medical history,

combined with access to the wider array of skills and facilities.

The, the, with these, there also has been an increased status of the family practitioner.

He, he or she now has boards.

The pay has become somewhat comparable.

They, at least in our institution, and, and they pass the exams.

They have, they need to re-certify every seven years, and they get two weeks off for education every year,

and all the time necessary to study for the, for the, the new or the review boards that they have to take.

They are staffing now.

Family practitioners are now staffing.

The urgent care facilities.

The female physicians are able to job share, which is a great plus for them.

We have sometimes two share, we have, we have about ten female doctors job sharing at the present time.

And they work in sports medicine and geriatrics.

And, and have an ever increasing load of patients who really love them for the comprehensive care that they're able to give,

without the fractionated care they were getting at the hands of the specialists.

The, the, it's really, I think, a major evolution from the lonely, isolated general practitioner, sleep deprived,

relatively poorly, poorly paid, to the, to, to the new family practitioner who has significant empowerment,

with management positions, and a marked increase in, in quality of life and lifestyle, and good pay.

And, and in the spirit and letter of the recommendations of Millis and those who followed him,

we now make provisions for, for these, for additional time off.

They have sabbaticals and vacations, things almost impossible for a, for the individual and solo practicing general practitioner.

The, the course is still a tremendous shortage nationally, and people like Pete have done a great deal to help that.

I mean to, to, to alleviate that by establishing a 17 residency programs in the Southern California area.

And that's pretty significant, isn't it 17 people that you've made?

>> Not I.

>> Well, you, you evolved, yeah.

>> You've watched.

>> Watch, oh yeah.

>> [LAUGH]

>> But there's been, there's been a real move, though, though, at Bill Fox would know that Stanford does not have any primary care,

any, any family practitioner program at its own university hospital.

The, and I think this still, I don't know if they have one at UC or not, so they have a family practitioner.

>> We just moved it out and put the, the in vitro fertilization group.

>> Yeah, let's.

>> [LAUGH]

>> That's, that's where the money is.

>> [LAUGH]

>> Well, we, we find, we find the, the knowledge and, and vitality and energy and intelligence.

And intelligence of the new family practitioners that we were able to recruit.

Just fantastic.

And they've been a wonderful addition to our institution now and we're, we're really delighted to see them.

And we'd like to see the increasing turnaround.

It's still pretty competitive in our recruiting for family practitioners.

The last surgeon we got, we had 70 applicants for one job.

And as you know, Stanford anesthesia last year turned out 13 anesthesia residents and

six of them couldn't get a job.

And three of them went to Kaiser as nurse anesthetist, even though they were MD anesthetist.

So, you know, this great glut of specialists that we have, we still keep cranking them out.

But we're, we're doing better on the others.

Well, it's been a great pleasure addressing you all and thank you for your attention.

>> [APPLAUSE]

You