Thank you very much, that was wonderful and inspiring. Bill would you like to introduce Dr. Scherger?
Mr. William H. Burnett: Yes as part of our Coast vs. Heartland theme, we have a gentleman here who was born and raised in the heartland, central Ohio and then went to the coast for most of his career or maybe all of his career at one coast or the other and he has, Joe Scherger has been a prominent force in family medicine throughout the country. Just out of residency becoming part of the National Health Service Core in the small agricultural town of Dixon, California. And, and over the years President of STFM and a leader in family medicine throughout the, throughout the decades. And time has told and it’s 40 years of, as a family physician that he knows where the, where this specialty is going and has many of the ideas of what it should be; Joe.
Well, thank you Bill. It’s a real honor and a pleasure to be here with so many friends and colleagues through the years and meeting new friends. This is a special meeting. I want to acknowledge Bill, he works hard to get me here, and get me on the program during busy times. And you know Bill if you could put, if Bill’s seeds that he’s planted over his decades were actually measured what their results are, it’d be a full rain forest. Bill Norcross was talking about Song Brown and it’s money and how they get together afterwards; well Song Brown was Bill Burnett. And Bill decided so much of that and did it for decades and so much of what happens here at this meeting is really a child in some way, Bill of your work.
So thank you and thank you for the honor of doing a Charles Odegaard Lecture. I never got to meet Charles Odegaard. He retired from the Presidency at the University of Washington two years before I came there as a first year resident. But I found it fascinating looking at his history, and I’m going to use him for my talk because Charles Odegaard was an activated patient. He was not a physician and he had no career in medicine per say. He was a history professor; grew up in Chicago and taught history at the University of Illinois, and went into the military. But at a rather young age he became president of the University of Washington when it was a relatively small university; and during his time, his 15 years; from 1958-73 he doubled the size of the campus, and doubled the student body; and really made the university what it was.
But he also was interested in healthcare. As a matter of fact he wrote three books. His first book is kind of interesting. I have the title here; it’s called Minorities in Medicine from Receptive Passivity to Positive Action, 1966-76. I love that term receptive passivity; which moved to positive action. He then went on to write two books about area health education centers, or AHECs; which he was part of founding. He served on the Millis Commission that helped create our specialty. And he wrote about the importance of the personal physician.
And, and I’d like to say just to sort of jump to the end of my talk, I believe firmly that the personal physician is alive and well. As a matter of fact I think the personal physician has a future that’s better than ever. However, the personal physician is very stretched and really doesn’t exist in a model of care based on 10 or 15 minute office visits and panel sizes of 2,000 or 2,500 patients. I think the personal physician is dead and the reason why is the work of the personal physician has changed dramatically. It’s not about dominated by minor acute problems. It’s about comprehensive prevention. It’s about the simultaneous management and coordination of multiple chronic illnesses. It has become very complex and it quite frankly is not compatible with the work model that has still, still dominates our specialty. And I think the biggest criticism of family medicine is our willingness to work in a model that is not compatible with the care that we’re trying to deliver and I think that we victimize ourselves as a specialty to do that.
But I’ll get more to that later. We’re going to talk about Gayle Stephens in a few minutes. Of course Gayle has been recognized and honored in this forum for many years. And Gayle was in many ways the founding philosopher of our field with his scholarship, and religion, and philosophy; and served a special role.
And then of course John Geyman; the gentleman who has quietly been part of our meeting here today, but is such an important person. What’s interesting, and what Gayle and John have in common, besides being founders of our specialty, is they both had a deep distrust, even anger about corporate medicine. And, and they really took on in their, in their writings and in their words. Of course we know Gayle Stephens and his famous big, red bull speech that he has done. And John in the 11 books that I’m going to talk about that he’s done.
But I want to, I want to focus a bit on John Geyman as part of this journey of the family physician; cause John in many ways was my most important mentor. You know John was born in Santa Barbara, California. He was actually the son of a radiologist, who had fled rural Minnesota for better weather. And being a radiologist in the 1920s was kind of interesting. Talking to John, you know he, he would, his dad decided to go west and then he started in Seattle. And the couple of radiologists where were there said, well we really don’t need you, why don’t you look at Portland? So he went down to Portland and he talked to the couple of radiologists there and said well we really don’t need you either, why don’t you go down to California? And as luck would have it, he ended up in Santa Barbara.
Now John did not have medicine as a calling. He went to Princeton University and studied geology and then went into the service and through a three year period of time realized that he really wanted to serve people and decided he would go into medicine. He had to go to Berkley to do his premed classes. So John is sort of a post back, premed classes at Berkley before going to UC San Francisco. By the time he arrived at UC San Francisco in 1956 he knew that he wanted to be a rural family doctor, which was an unusual calling. But he did not waiver from that while he was at UC San Francisco. And he was the first of two in a row Gold Headed Cane award winners at UC San Francisco that went into family medicine; he and a classmate right behind him and his career best friend, Ed Neal who practiced for many years in Healdsburg. The Gold Headed Cane award at UCSF is the graduating senior in the opinion of classmates and faculty best exemplifies the outstanding scholarship and qualities of the true physician. So John was very much a part of that.
Now John was a bit of a forerunner for Marc Babitz. He, you know, after finishing at UCSF there weren’t family medicine residencies; so he went to LA County to do a rotating internship where he did pretty much everything. And then he sought one of the general practice residencies that were around, and he studied them. We had one in San Bernardino, and one in Ventura, and one in Santa Rosa. So he went to Santa Rosa and did the two year general practice residency, finishing in 63 and learned how to deliver anesthesia; and do every, do all those things; and located his family in the rural town of Mount Shasta, California; not even 2,000 people, and went there and spent six years literally doing pretty much everything, including his own anesthesia. That was in the days of no call groups, doctors wouldn’t dare turn their practice over to somebody else if they were literally, physically present in the community; and did it all.
His record day was 56 patients in one day. He was there six years and in 1969 in the middle of an afternoon with a waiting room full of patients and all his exam rooms full, he gets a phone call from Ed Neal, who was down in Healdsburg, saying that their residency program in Santa Rosa was going to be one of the first new family medicine residency programs and Ed thought John ought to come back and run it. And John did. So he left his practice, he still had deep roots for many years in Mount Shasta. The family kept their home there for a long time. But he went down and was the founding program director at Santa Rosa. Interestingly enough, John, you know caught the bug that all of our founding people did, back of the founding of our specialty that this is really something big. I mean this is something real important and John realized that the way you were really going to create family medicine would be to be in a medical school environment.
So after a couple of years at Santa Rosa he decided to go the university tract. He spent one year at Utah; and then went to UC Davis. And it was really at the time he was at UC Davis that I first was blessed to get to know John. I was a UCLA medical student who had a conversion in my third year back in 1973 that I wanted to become a family doctor. And there was nobody at UCLA to be a role model, so I you know got connected to the California Academy as a student and found out well where’s family medicine? And they said oh UC Davis is where you’ve got these tremendous figures in family medicine, Gabriel Smilkstein was the predoc director, and John was vice-chair, Lynn U. Sandress was chair. So I sought these people out and it was very, very inspirational to me to meet them and hear about what they’re doing, where they came from, etc., etc.
And with that I was fortunate to go up to the University of Washington. And then I had a little bit to do in a small token of John’s career. I was a 2nd year resident at the University of Washington when our founding chair Ted Phillips said “I’m going to pass the baton to someone else. I’m going to step down as chair.” and we all said “Oh my God, Ted Phillips is stepping down as chair.” and I thought John Geyman. So I actually picked up the phone and called John Geyman down at Davis and I said “Ted Phillips just announced his retirement”, I think it was the same day, “you need to come up here and be the chair.” Well he thanked me, Joe that was kind of an interesting thing, he appreciated it. And sure enough he came up there to be the chair. So whatever little bit of role I played, I was proud of that.
Now John has been described as the scribe of our specialty. He spent 30 years as the editor of two of our most important academic journals and I find the most important one was back in those days in Davis when he started the Journal of Family Practice. And I still save all of the original issues of that journal and that was quite a journey to start the original academic journal and so much of John’s writing says an academic family physician are in that journal. And I still remember some really insightful editorials.
The one that sticks out the longest in my mind had to do with obstetrics. And John was analyzing why the caesarian section rate in the United States had gone from 5% to 10% and was that a good thing or bad thing? You know John practiced in Mount Shasta and indeed the historic biologic caesarian section rate of, of people, women was 5%. And, and all of a sudden electronic fetal monitoring came around, and the modern obstetric hospital unit, and the rate doubled to 10%. Now we all smile because we know it’s been at 24-25% pretty darn quickly and 10% is an amazingly low caesarian section rate. But John wrote a very insightful article about that.
John also nurtured me with my first article I wrote as a medical student. It’s the first article in the book, but his managing editor, Marian Frank, who I still see from time to time, by the way, was his assistant with that journal, really helped teach me how to write; because I actually wasn’t much of a writer at all.
But the most important contribution that John made in creating our specialty is, he started the first department, university based family medicine residency network, including community hospitals. He reached out and formed a network with Modesto, and Merced and Martinez and Reading, and created that network; not only created it but he wrote about it. And he really laid out the framework of what makes a good network. He wrote articles of what makes a good department. He analyzed and wrote about all of these things contributing to the field and went on with his 14 years as chair at the University of Washington. And of course did a great job.
And he decided to go full circle and go back into rural practice. And so he moved to San Juan Island, Friday Harbor, the main town there in the San Juan Islands; and practiced as a family physician for seven years.
What was interesting in listening to John and his oral histories been taken, where I get a lot of this from, also taken from John directly, but he had changed; no more of those, you know up to 56 patients a day. He found that he liked to spend time talking to people. And he was always running behind, because his schedule was the old schedule that he was spending time talking to people in longer visits really a forerunner of the way, the way we should be working today. But he did that for a period of time.
On John’s 70th birthday, right on the birthday, he was doing what he loves to do, which was swimming, and he was swimming there in Friday Harbor and had a sudden death. He had a cardiac arrest and became unconscious. There was an older woman in the lane next to him, who saw him and then there was a nurse practitioner in the lane next to her; they both got his head out of the water and began to try to resuscitate him. Fortunately EMS was very close by in Friday Harbor, the responded quickly. They had to shock John seven times. The first five shocks were still ventricular fibrillation. The sixth shock was V-tach, and the seventh shock was sinus rhythm. He was described as blue as this shirt and then was sent to Bellingham by helicopter where he was intubated and in the ICU for six days. And before he started to come around, and he doesn’t remember all this, he has to learn it from all the people involved. That was 14 years ago on his 70th birthday.
And you know it’s kind of interesting, what does that do to somebody? And obviously to John it did not reduce his scholarship; it did not reduce his intellectual ability. And who knows what it did, but there is a curious coincidence. Before his cardiac arrest, John was a Republican. He didn’t, he didn’t get upset at corporate medicine. He didn’t talk about single payer. He was a Republican. And sure enough, he comes out of this and you know, after many months goes back to work. And you know talk about an absolutely unique person; after this and at age 70; he starts a whole new career, and a whole new focus. And I think one in which he may end up have more enduring than even all the things I’ve talked about with family medicine.
He’s written 12 books, 11 on one theme. And the titles of these books are all telling. So I actually want to run through them. Those of us who knew and love John and sort of watched this happen after age 70, we always wondering when he was done, when he was really going to retire. Like was it going to be after the fifth book? You know and then came a sixth book and we thought, and sure enough at age 84 he’s just published his last book, which you all know.
But his first book as a, as a no longer Republican was Healthcare in America, Can our Ailing System be Healed? You know it’s all been a passion to save American medicine from the evils of the profit, corporate medicine; and the problems we have. He’s got an absolute deep passion to save. It’s about fixing the system.
The second book was the Corporate Transformation of Healthcare; Can the Public Interest Still be Served? Third one, Falling through the Safety Net, Americans Confront the Perils of Health Insurance. Next, Shredding the Social Contract, the Privatization of Medicine; followed by The Corrosion of Medicine, Can the Profession its Moral Legacy? Do not Resuscitate, Why the Health Insurance Industry is Dying and How We Must Replace it; these are all incredibly detailed, data driven books. The next, The Cancer Generation, Baby Boomers Facing a Perfect Storm, amazing book talking about how much money we spend treating cancer and how that illness alone is going to bankrupt the American Healthcare. The next is Hijacked, the Road to Single Payer and the Aftermath of Stolen Healthcare Reform; followed by Breaking Point, How the Primary Care Crises Endangers the Lives of Americans; followed by Healthcare Wars, How Market Ideology and Corporate Power are Killing Americans.
Now during some of this journey his wife of many, many years, 50 or so years; her name was Jean went into Alzheimer’s disease. And John cared for his wife the whole journey. And she passed away a few years ago. He wrote a book that’s gotten actually a lot of attention as part of the, the caregiver of Alzheimer’s literature. The book is called Souls on a Walk, the Enduring Love Story Unbroken by Alzheimer’s.
And now we know John is Obama Care is unsustainable, why we need a single payer solution for all Americans. So I, I don’t know that legacy, to me, deserves a round of applause.
So how do we solve this problem? I’m not going to claim to have any greater insight than John does, but it, you know it’s this, I’m a real student of history. And I’ve been through Will Durant’s Story of Civilization, some of the volumes twice; and done Winston Churchill’s History of the English Speaking Peoples.
When you think of things like corporate American medicine of course Gayle Stephens and John are absolutely correct. But somehow Congress doesn’t magically solve these problems. I mean it’s not going to happen, we all know that. It is going to be as John predicts, as a result of sometime of collapse; some sort of unsustainable nature. And when collapse happens, what’s really important is that there’s people there ready to pick up the pieces. And you know in some places when collapse happens, there aren’t the people there to pick up the pieces; like you could talk about the collapse of the Soviet Union and what’s happened after that, or the collapse of the Saddam Hussein regime, or these various things where the aftermath isn’t pretty.
But the collapse that you know could and, and potentially will happen, we need to be ready to pick up those pieces, and I think move forward. So what we do is we don’t just sit there and solve problems; we move onto a new tomorrow and tend to solve it. Now I believe that there’s actually a new tomorrow that’s underway. I think there are people who right now are reinventing our specialty; and in an incredibly, incredibly exciting way. And those people are, for example, someone that John had the pleasure of mentoring, Erika Bliss, who’s in Seattle. Erika Bliss a former UC San Diego student, someone who helped in a seminal role starting the student run, free clinics; became a pisacano scholar. I actually interviewed Erika in 1999 for that scholarship. She’s the President and CEO of Qliance Healthcare in Seattle, that now has six offices, has just doubled its patient population because Washington Medicaid has said “Wow, you save, you lower healthcare cost 20%. We’ll buy up our primary care. We’ll invest in direct primary care; give you a good, sustainable prepaid fee to do this high quality, personalized high tech primary care to our, to Medicaid patients, and, and work to achieve the same results.
Freshica Fernandopulle in Boston starting Iora Health, very similar model; both recently written up in the New York Times as representing the new primary care. One Medical in San Francisco and JenCare is a new, again a new modern, 21st Century, primary care based on smaller panel sizes; 6-1200 per primary care physician, longer visits when visits happen; but a platform of communication and care that is online based that is always available. Docs supported by a robust team, but these are highly relationship centered, personalized care model between a family physician. They can’t hire family physicians fast enough.
The data has come in on direct primary care that you, you buy up the primary care. You, you know reduce the panels because the work has gotten way more complex, you increase the amount of time that the physician has with patients, you support the doctor with the robust support team, and you deliver highly personalized care. We do that at Eisenhower. We know have 6,300 people getting this model of care. We’ve had 99 percentile press ganey scores every quarter for six years. We’re the far and away the highest patient satisfaction in our system; with that and the relationships that I’ve gotten to experience with my 500 patients are deeper than anything I’ve ever had in the, in the practice of medicine.
We use the, you know, not the, it’s a, it’s a minor modification of what the client’s model is, which is the nonhospital based model; ours is modeled after Green Field Health in Portland. But there is coming out, these are, this is the new way to do relationship centered family medicine. And that’s the model that students need to see and learn from, with this, it is a different way of practicing. It is not the productivity driven, bean counting, you know eat what you kill model of primary care; which given the nature of our work is not sustainable. It’s a model that needs to become integrated into community health centers. I know the issues, we don’t have enough family docs, what are we going to do? You cut the panel size in half, where’s the work force?
But quite honestly, you know, the other model’s a failed model. And you can’t take a model that takes students run the other way when they see it and experience it, and expect to have a solution. We convert people, rapidly when they come and see our model. I watch the conversions. I thought I was going to go into radiology, or anesthesia. Your relationships are so deep. I thought I was going to go into emergency medicine, but this is too much fun; every patient is your friend, you know not a stranger, which all these other things that people are going into. And boy, you know we saw six people this morning and that was really deep. That was really rich, what a morning. And the next day is completely different. So again it’s a, it’s a very deep relationship centered model, but I believe it’s the future, and I think as it gets out there, we can create a wave of interest that will come. I think you, you solve the problem first to go into it.
So that is I’m sure I’ve provoked a few questions, and hopefully some comments with this. Just like Odegaard and the personal physician and I think John in his later years at Friday Harbor, that’s really where our specialty needs to go. Thank you very much.
Well, it’s embarrassing to have you talk so much about me. I’m John Geyman. And thank you for that eloquence and overstatements, but several comments; I met Charlie Odegaard when I moved to Seattle. He was PhD in medieval history. He was the ultimate generalist. He was President of the University. He became very big in the AHEC program across the county. And he learned a lot about medicine. He knew more about parts of medicine than physicians did. He, one of his books I think was The Task of Medicine and he was very interested in the doctor patient relationship and all that. So he was just an amazing guy and, and a figure that helped to develop WWAMI in the Northwest which is now WWAMI including Wyoming. So, so that’s interesting. And he was the ultimate generalist.
A couple comments about we’re hearing a lot about the new way, well the new challenges in opportunities in the different landscape of medical practice, and the need for new ways. It’s been really encouraging to hear different ways including virtual training centers; that’s amazing stuff. And computers, I gather computers are a bigger deal nowadays. So, so, I’m glad I, as a dinosaur I wasn’t around when the electronic records really started. Well I was a little bit. Dave Gimlin who is medical director of our little interisland medical center on San Juan Island; he introduced computers to me. And all mine did was collect dust. And he had lots of ways I should have been using it, but, but I kept my old way.
So in a way though, old ways, a lot of it worked, and I’ll give you an example with our interisland medical center, it was established with Hill Burton funding in 78, as a hospital on San Juan Island; 20 miles by 10 miles. And eight foot wide hallways and an OB delivery room, labor room, surgery, ER; never operated as a hospital. It was operated by as a primary care real family docs, real family docs practice with ER 24-7. A good medevac to the nearest hospital over here in Anacortes, another hospital in Bellingham, and it all worked fine. And, but we were running out of money and it was threatened for closure. So with community leadership, we formed an ambulatory hospital district, elected hospital district to run this here hospital that wasn’t a hospital. OK, and it worked, and we got a tax base of a million bucks, which saved us from closure.
So, I’m going to get to the new way in a minute, but, but, but the old way too, with that facility and we did a study with medical student about out of hospital cardiac arrest. And we had a guy who was in Vietnam and came back and he was a medic there. He became head of our EMS system. And he had a little paper, non-computer medical record of all the cardiac arrests on the island since 1978. OK, and in the early 90s we did the study, and what’d we find? We found that we had a response rate of something like three minutes that the policy, the protocol, was always the defibrillator went with the EMTs and the paramedic on the call. And we had an out of hospital cardiac arrest survival rate, including months later, with still being able to think, as good as Medic One in Seattle, and better than any reports in a rural area. So in paper records I emphasize that, so but the old way worked.
Fast forward, two years ago, on San Juan Island we had a small group, three years ago, a small group of vulture capitalists from the city, who wanted to establish their legacies. One guy, he had 10 friends who could all put up a million dollars each, so let’s build a hospital here. So they got a 10 bed critical access hospital, CON that was not a problem that was wired up. They over build the facility, this is a micro cause of the big problem of corporate medicine. So $40 million project, kind of like an art museum now. ER group now, primary care, we used to have real family docs in a group, that did all this, now we’ve got an ER group with turn over, and a clinic you can get one FDE family doc there with two people. The others are internist or coming along, but there’s still short a primary care. And the costs have gone like that; facility fees, more and more people can’t afford to go to the ER. Patients are shunted from the clinic to the ER. CT Scans have gone like that.
I mean this is not good; and how about this elected hospital district? They are so proud of themselves for engineering this deal, 50 year contract. I mean it’s a micro cause of, of expanding hospital systems, and fractionation of care, and decline of primary care in our microcosm. So I’m really glad to hear of the new things we’re seeing, but it all comes back to a crummy system, and we’ve got to change the system. And mostly as I’ll say tomorrow, we’ve got to change the financing system.
Yup, thank you John.
Also, and it would be only right to introduce John’s new wife Emily, who is with him. I got to meet Emily at lunch yesterday; they’ve been married for two years. So, welcome Emily.
Lee Burnett, Second Infantry Division, U.S. Army, Joe, thank you fantastic lecture on amazing history of Dr. John Geyman; really appreciated hearing that. You know truly a living legend. I just wanted to let you know, Dr. Geyman, your books, I’ve read a number of your books and they’ve really made an impact on me as I’m sure they have a number of people here. I wonder, short of, you know sudden cardiac death and resuscitation, how do we, how do we select, grow and train future family medicine leaders of this caliber, and character, and dedication that somebody like John Geyman has given to the profession? How do we, how do we get those people? Because I don’t see a lot of them.
Well that’s a great question. You know the enduring skills, you know, first of all nobody’s going to hand relationship centered care to Americans on a platter. It’s got to be preserved; it’s got to be earned; it’s got to be recognized as being better. But we have loads of data that relationship centered care and continuity care matter. But we’re moving into a new world. The acquisition of information and knowledge will become passé. I mean the, the acquisition, I mean today’s New York Times talked about IBM’s new venture now with Watson Health. I mean we’re, we’re all going to be provided you know all the medical information and knowledge in the world. But the real critical thing is going to be clinical judgment; it’s going to be wisdom; it’s going to be motivational counseling; being able to use all of this in a caregiving way that really works.
It isn’t man vs. machine; it’s man and machine. You know that’s been proven in chess, for example, and others, you know that the most powerful thing you can do is the synergy between man and machine. I think illness will always be a human factor and a human denominator. And I don’t think you could ever take the human out of the equation. But it’s going to be a whole different world.
I wanted to, you know give a book recommendation. It’s a book that I think is so important that I read it twice. And it’s called Abundance, the Future is Better than we Think. You know every generation has a negativity biased. We all tend to think the world’s going to hell in a hand basket as we get older. But yet, you know, John was part of something, and we’ve all been part of the creation of family medicine. The new generation is, is the creation of 21st Century medicine. And it isn’t of course the, the family medicine that we had in the past. It’s going to be using whole new tools and methods. And it’s just going to get real, real interesting and real exciting in the very near future.
I think exponential change has been happening to technology for 50 years; since Gordon Moore first described it; is about to hit medicine. And it’s going to completely turn our medical education upside down, away from spending four years trying to acquire knowledge. And it’s all going to be about skills of, of using knowledge and how do we do this in a new, in a whole new context. And it’s going to be very different. It’ll be invented by, you know, I mean by you Lee. I mean you’re, you’re one of these folks who was Studentdoctor.net and your own savvy. It’s really going to be, I think your generation that’s going to reform the relationship centered family physician of the future.
Thanks, thanks. I have a follow-up question, cause I think your lecture had kind of two components. The second question I have would be highly personalized, or direct care I think it’s a great model. And it has been fantastic to see it growing over the last 10 years. How do you see that working for indigent population?
I think it works as well for indigent population as it does for any population. And I think that you know, somebody, somebody’s paying for healthcare. You know for everybody, and obviously the indigent population, it’s the safety net that pays for healthcare. But just like North Carolina Medicaid figured out and the, and, and Washington Medicaid has now figured out; if you want to, if you want to save money and create efficiency in buying healthcare, it isn’t having the safety net sitting in emergency room waiting rooms with untreated disease and no prevention. It’s getting out there in the community health center.
I think it will be robust teams led by, you know personal primary care, family physicians are the ideal as, as we heard just before. And you, you invest in that to lower healthcare costs. And if you’re paying for the whole, the whole banana if you will, the bottom line is if you’re going to lower my healthcare cost overall; I’ll pay you more to do that. And that’s the, the great reality of what we do. And that’s why it shouldn’t only get six percent of the healthcare dollar.
The fee for service market we’ve got, you know it eroded down. We get less money than, than drugs. You know we used to, when I went into practice the amount of healthcare pie that went to primary care was twice the size, the slice that went to drugs. Now drugs are twice as big as the primary care physician; which of course is absurd. But if you, if your ultimately need to make the system work you invest in primary care, not just try to recruit it and put it in there in an old run on the treadmill model, but, but actually invest in models that work. And that’s why these new models are so important.
I think I’m out of time. Thank you.
I’m just, I’m just going to invite you back up Joe; to sit on the panel with; and Dr. Clasen and Norcross who are going to give us a presentation about the intellectual contribution of Dr. Gayle Stephens as our final event of the day.
Thank you.
That was just really wonderful.
Thank you.
You guys out to lead off.
Yeah, you should get a break.
Do you want to start?
Sure.
Well it’s a pleasure to be here again and every year I guess it’s more of a pleasure as the turn of the dial goes. Well a lot of things that I was thinking about Joe touched in his presentation. But there’s a few new people here and it was, what was it the second conference Bill in Beaver Creek, or there abouts where I really had a chance to interact, have lunch with Gayle Stephens and of course he gave the most powerful metaphor that we’ve been talking about through this whole conference. And that was the big red bull; who eats and eats and never gets full. And, and then he described the nature of this bull, of not being humane or human; didn’t want to be touched, didn’t want to be coddled. Everything that we’ve been talking about that has made medicine impersonal and the amount of money, the ungodly amount of money that is going to various entities and CEOs as Chuck described. I think it was 106 million, is that correct?
108 million.
108 million.
Yeah but it’s rounded number.
It you know, you know give a million here, give a million there and you’re finally talking about some money. But when Dwight Eisenhower left the presidency he warned, or counseled us about the military industrial complex. And of course we needed a gob of money to save England and to win the Second World War. And Eisenhower did that, and he was maybe in the best position to comment on the military industrial complex. And what Gayle was talking to us about was the medical industrial complex.
And having been a practicing physician through my whole career, and also as a leader and person responsible for profit and loss; I’ve spent a lot of time with bean counters. Not the one we just heard about, previous to the Odegaard lecture, but people who are out talking about the soul of this entity; you’re going to go down. Because if there’s no margin, there’s no mission and so, gee Gayle talked about the medical industrial complex but he also talked about the I, thou relationship. And Martin Mover, others that he quoted was a very spiritual intimate, kind of relationship.
And that’s what Joe was talking about. That’s what John Geyman talks about. That’s what brought me into family medicine; was gee I want to be involved in humanity. And I’m a part of it, I’ve got the same kind of clay feet that other people do, but maybe some more insight into how to heal. So that’s what Gayle brought to this conference. And he was generous with his time. And he was honest.
And one quick story on Gayle. He used to go out in his older years, I guess, and take over his brother’s practice in Kansas; so his brother could have a couple weeks off. And I said “Well Gayle, what did you think about that?” He said “I was scared every minute.”
So anyway that’s the contributions of Gayle and John Geyman are enormous.
Well I’ll go next to give Joe further time for vocal recovery.
When you get older you wonder about the validity of some of your memories but this one well, I’ve a witness in the audience, and if he doesn’t remember it then it’s probably not true. But the first time I met Gayle was also the first time I met John Geyman and it was at a reception at Doris Howell’s house. And Doris, this would have been around, would have had to be 1979 or maybe even earlier than that.
It took family medicine, well actually it still hasn’t happened yet, but family medicine at UCSD only transiently has ever had a family physician as Chair. And Doris was a pediatric oncologist. But she was a really interesting person. She’s still alive now, well into her 90s and was the first woman chair of a medical school department in the United States history. And she is still with us to give a, give us all an idea of how recent some of these things are.
I think what Gayle gave to this conference is really much of what he gave to my professional life through his writings mostly. I was not really an intimate of his although I had met him. But he described what, what a family physician is; a lot of his writings have to do with that.
And I graduated from Duke University School of Medicine in 1974. I had zero role models for family medicine at the school, but I knew vaguely that I wanted to be one, because family physicians who had taken care of me and my family as I was growing up. And it was really difficult to go into family medicine from Duke. The pressure was so, so great against that. There were people, at that time, in internal medicine, Jack Meyer for example, who was Chair of Medicine at PIT who actually wrote that the limits of a physician’s duty end at the, you know, biomedical end of the cell or something like that.
That totally had nothing to do with psychosocial issues. And Gayle wrote that it was not only OK to take care of patients and their psychosocial issue, but that was part of being a family physician; and even talks about it being OK to take care of. I think this is a quote “bizarre patients”, which came to be his specialty, I think of the family medical center at the UCSD medical center for its first five or ten years because when a new primary care clinic opens in a big city like that, you not only get all the patients who nobody else wants to take care of because they don’t have money; you get all the patients that nobody wants to take care of because they’re bizarre.
And I mean I’ve got stories. I won’t go into them now but it was, you know, it was great. And it was really, really an important mission. And I think when we look back at Gayle’s voluminous literature those were some of the things I take from it. Another thing I take from it is like a phenomenal sense of humility. Now all of us here are very intelligent people. We couldn’t have gotten to where we are in life without fairly high IQs and a love of reading and things like that. But you know, you, it, I consider myself a pretty well-read person, but I’m constantly challenged by anything I read that Gayle has written.
You know he’ll be talking about Marin Luther one minute and he’ll be talking about Søren Kierkegaard the next, and so forth. And you better know something about those people if you want to make sense of it. So he’s a great intellect, I think not just in family medicine, but I think one of the greatest intellects of our time. And I think that’s what he brought to this meeting. Sort of the freedom and intellectual basis of what family medicine is all about.
You know Gayle was clearly one of my heroes. But Gayle and I were at odds with each other for almost two decades. First of all in the 70s I especially loved Gayle, because I was growing up in the field and he was such a hero. And I still remember being at a meeting where he said, “You know the mark of a good meeting is there’s always somebody in the back of the room that yells out every once and a while ‘Horse shit!’”. And I, I thought that was, I’ve, I’ve used that a few times that I’ve been in a, he especially referred to AAFP meetings that they get a little off. And so somebody would have to yell “Horse Shit!” every once in a while.
But I was, I got my Master’s in public health. And actually John Geyman steered me away from leadership in the Academy to leadership in the STFM. And I got fortunate to be the first resident on the board of STFM in the late 70s thanks to John’s advice; and got to rub elbows. But I believed in the promise of managed care and managed competition. I actually thought that was going to be the American solution to finally a rational healthcare system away from the cottage industry that we learned so much about.
And so I was a bit of a pro on what was, you know starting to happen in the 80s and the 90s. And Gayle thought it was horrible. And he gave a speech in Orlando at STFM in 1984 called What’s True about What’s New. And I got very angry. And actually it was at that speech that said, it’s time to turn it over to a new generation, I’m going to run for President. This is, you know we’ve got to get rid of this kind of thinking. Because what was new had a lot of potential and promise, so my anger at that 84 meeting caused me to run for President in 86; which I was successful.
And then, believe it or not, I took on Gayle which is not a too smart of a thing to do, but there was a debate in the journal, I think it was the Journal of Family Practice, where we had to write the pro and con on the gatekeeper role. And I wrote the pro on the gatekeeper role and he wrote the con; which I think came out OK. But, and of course we all know what’s happened to manage care and the word gatekeeper I’d never try to defend right now.
But Gayle got, Gayle could get angry and he got progressively angry at what was happening to American medicine through managed care and the robber barons of the 80s and the specialty incomes skyrocketed in the 80s. It was very interesting, when I finished residency the average family doc in America earned $40,000 a year in 1978, but the average specialist earned $60,000 a year. I mean the difference was not that great. And what happened in the 80s, the decade of investment banking and you know tremendous corporate appreciation is that various specialists, all of a sudden their income was 5, 6, 10 times what they were in primary care. And of course that whole formation of that medical industrial complex that caused the managed care 90s to actually happen was developed. And he was really an angry voice about all that.
We should let others talk I think to wrap up the morning.
Yes in fact, your question.
I mean this morning’s been a little like talking about, I’m Rick Flinders, I graduated from Merced High School and finished the Santa Rosa residency where I graduated and still teach to this day. This morning talking about Geyman and Stephens is a little like talking about George Washington and Abraham Lincoln. It’s one of those debates; and I don’t think we really appreciate just how lucky we are to have the tradition and the legacy of these two men to guide our specialty. I had the privilege last year to give the Gayle Stephens Lecture. And I want to comment, I want to compliment Marc on his wonderful presentation of Gayle today. And I think I said something to the fact that the canon of Gayle’s written work over 40 years already contains everything that we need to know to become good physicians, as well as to teach good medicine.
I learned a lot from Gayle, speaking to him personally, and the correspondence that we had over the last year. But I also spent four, four days in the archives of the Center of the History of Family Medicine looking at the works of our, of our leaders. But the gold mine was Gayle. And in there I found a wonderful letter, personal letter I mean hundreds of letters of his personal correspondence. And there was a letter, written in his hand, to a man named, a family physician, prominent, to a man named Joseph Scherger. And I don’t know at what period of your, of your relationship with Gayle this was written, before, during or after the debate, but it was written in his own hand.
And it said “Joe, in my 35 years of observation the surface of medicine has changed dramatically. But the principals which underlie the practice of medicine have fundamentally remained unchanged. And that is the suffering humanity knocking at the door of the physician, asking for support, for help, for comfort if not cure.”
So Joe, I respect your debate with him, because that took some guts to take on. And I think it speaks to your own commitment and understanding, and I think it is a good sign of our specialty that we continue these debates. And I just want to add my “Horse shit!” to this meeting, Joe.
Bill Burnett, Coastal Research Group, I just wanted to mention that I spent time interviewing Charles Odegaard at his home in Seattle, and also Gayle Stephens at a favorite restaurant in Birmingham. And he went through his whole history of the evolution of family medicine, but as he went through it, he talked about the new generation. And you may think of him as angry with you, but he, he talked about the two kids that he respected so much. One was you and the other was Terry Cane. And he disagreed with you, but he really respected the two of you; and others too. He mentioned you too.