{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/0r9m32px79/manifest","type":"Manifest","label":{"en":["Dr. Edward Neal"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Date"]},"value":{"en":["1990-02-28 (created)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["Society of Teachers of Family Medicine","Dr. Edward Neal","family medicine","family physician"]}},{"label":{"en":["Language"]},"value":{"en":["english (primary)"]}},{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}}],"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150676/file/277907","type":"Canvas","label":{"en":["Media File 1 of 2 - Neal_Edward_1990.02.28_-_Side_1.mp3"]},"duration":3298.4,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150676/file/277907/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150676/file/277907/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/277/907/original/Neal_Edward_1990.02.28_-_Side_1.mp3?1750281090","type":"Audio","format":"audio/mpeg","duration":3298.4,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150676/file/277907","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150676/file/277907/transcript/81394","type":"AnnotationPage","label":{"en":["Dr. Edward Neal interview transcript  [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3180/collection_resources/150676/file/277907/transcript/81394/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Recording Dr. Edward Neal, February, 1990, --, California.\n\nDr. Neal: I just want to say that I feel extremely fortunate to have traveled the road to kind of determine your lot in life, I think, rather than a well conceived plan of exactly where you want to go. Beyond … When I was two (?) years old, I remember talking about wanting to be a doctor but that was because I had a Dr. Kelly who lived down the street and I admired him. But my route was somewhat secure as I got off into what I thought would be – music was an area that I really had a lot of interest in and actually started out in college as a music major, then went to -- College in Berkley in a Navy program. And it became apparent that I wasn’t going to make a living in music.\n\nWhat kind of music were you …\n\nDr. Neal: Well, I played the clarinet but I studied piano, and I started that again in my forties. Went in the Navy for three years after Berkley and felt extremely fortunate because I couldn’t have gone to Berkley except for the Navy program and I couldn’t have gone to medical school except for the GI Bill. And I did very well in medical school. In fact, I graduated first in my class and got the award of -- and all that stuff. I don’t know if you know about UCSS --, but it’s a major award. And was being groomed for all the … The Department of Medicine. Took a straight medical internship there at Moffitt (?) Hospital and walked on the ward and saw seven cases of lupus in the first … I mean when I first inherited ward responsibility --. But it was out of the reaction formation of that and I saw where my path was leading in some big internal medicine academic pursuit. And that was all very flattering and there were lots of people who wanted to guide my career in that direction. So it was a big disappointment to them and a rather terrorist step on my part to venture out. But after that internship, rather than continue on, I came up to Santa Rosa, which was then just a general practice residency. John Geiman (?) had come up before me, although I didn’t know him then, and it was a real, you know, very basic general practice residency, although it was probably one of the best in California.\n\nRight, and it’s a famous one for all sorts of reasons. But it certainly …\n\nDr. Neal: We just put together, two years ago, our fiftieth … I formed an alumni association and our fiftieth celebration of the … 1938 was when it started and people like Frank Norman and -- were the early people. So that was much more to my liking. And with that came … I knew, when I went into that, I wanted to be the general physician. I wanted to be able to take of, at least the inception, any medical process that came to me and I wanted to be involved with people in a very broad breath way. But at that time, it was very the war and the whole era of specialization was, you know, we were going to solve all the medical ills, medicine ills that were affecting the -- one more time. Bio medical research was where it was at. A super sub-specialization is where everyone was going to be and that the role of the generalist was pretty much having it all. You’ve heard all this before but …\n\nBut I’m curious why, in a sense, knowing all that was going on and you were in an opposite direction?\n\nDr. Neal: I don’t know what moved me, really, except for just the -- did not follow that route and speak what I really envisioned as what medicine is all about. My concept, I guess, of a doctor, as I look back on it, and this wasn’t any preconceived or well thought out much, that medicine was kind of … doctors were renaissance kind of people and had a lot of interests in the arts and humanities as well as medicine and highly respected and they were community members. So there was a kind of fundamental or basic ilk about that pursuit. Almost a missionary kind of thing. And for me it was something of a calling. That’s one thing that disturbs me now about our present people. So many of them view medicine as a business and they select their specialty by how much it’s going to pay them, etc. I didn’t really give any thought at all to how much I would make because I had been quite content to live in a --. You know, I was hopeful, at least, to not have to worry about financial worries if I wanted to buy a new home (?). And that was a shared experience among most of the people I knew in medicine then. Anyway, at Santa Rosa my feelings were reinforced a lot by a lot of good role models – and it happened in Sonoma County. And most of the California Academy of Family Practice has, I guess, at least a half dozen or more of the presidents have come from here. And for a small county, it’s been the prime mover. I don’t know if you know any of these names – Frank Norman, Buck Kerr (?) and Forrest -- and a guy from Mountain View (?), Hugh Upton. You probably know Hugh, don’t you? He’s on the National … Anyway, these are all people who I kind of had some interaction with. And it came along at a time in my life when it really reinforced my basic feelings about what I wanted to pursue. But I really was prepared to become extinct, you know. And for that reason I thought about saying, well, I’m going to do this for two years, general practice. But I was prepared to spend a lot of time in training, so I thought I might go back and get specialty training in OB or something and then come back and do what then was family practice, becoming family practice. This was in the early sixties. Then in the late sixties when all the metamorphosis took place from episodic care of -- patients, although I didn’t ever really think that was true, to formalizing it in family medicine. And John Geiman and many others talked in depth about the direction of general practice into family medicine and all the arguments that went on at that time. You know, whether to change the name. And some of those arguments are very interesting as historical things. But that suddenly became very exciting and everybody was looking around to John and I as some kind of pioneers. In fact, people from the university, you know, and I had one professor, --, ask me, how did you know that things were going to change in this direction? (Laughter.) And it was crystal (Inaudible). Of course, I subsequently realized that everything is pendular and in most anything you talk about, particularly in medicine, we had this huge biomedical subspecialty. And now it’s obvious all the answers were not there, so we go back to a much more humanistic approach and keeps shifting back and forth - as much as we train engineers in one decade and train educators in the next and on and on it goes. Then having been in Santa Rosa, I guess you might determine a suburban, not a real urban area, and interacting with some of the local doctors around here, it was something of a medical disaster area with a couple of doctors leaving. And two of us decided we would just move in and try it out and I never regretted that decision. Along the way there were a lot of opportunities to do academic family medicine because the opportunities were boundless in the early years. You didn’t have to know anything or do anything or have any training or anything else, just be willing to take on the job. I laugh when people say something about what kind of qualifications did I have to start teaching. This was in ’73, when I graduated. I said, well, I was a warm body and I was interested. And that’s all you really needed then. In some sense that was good though because you didn’t bring any preconceived notions. \n\nI hadn’t thought of that. But I think what is happening now so clearly is this tracking of academic family doctors. I mean I often have people come in who have their career mapped out ahead of them. They have all the tickets they have to punch and so on …\n\nDr. Neal: Certainly the Lynn Carmichaels, the Gail Stevens and the --, etc. didn’t come from that soil.\n\nWe’re going to have to do something to keep that alive, I guess. Do you remember what that decision to go to Hillsburg, how that came about and what that discussion was like in your family, for example?\n\nDr. Neal: Well, my wife was very supportive. She was raised in the small town of Hayward, in a farm community, so she was very supportive of going to another rural area. And I had no great desire to live in the city. \n\nSo she knew something about what life would be like in that community?\n\nDr. Neal: She was very enthused about my becoming a small town, country, family doctor and less enthused about my following the academic track.\n\nWhy do you think that was?\n\nDr. Neal: Well, two things. Her own role in that, you know, there’s a kind of pecking order. It reminded her of the military, which we had a lot of experience with. But from my point of view, she knows, in a different sense, it took a lot out of me. You know, (Inaudible), but there was a lot of anxiety and stress and all that. So she saw that as for me … In fact, I almost went to Davis at one time. (Inaudible) but didn’t quite ever make the change. And decided I had the best of both worlds by being involved in Santa Rosa. And I was chairman of the committee that brings the affiliation between the Santa Rose Community Hospital and UCSF. And so --, who you may or may not know, was one of my mentors in medical school. He’s an enlightened internist, as we liked to call him, and worked with him a lot. And as they formed their department at UCSF and ambulatory and community medicine and finally the department of family medicine, which is still very strong. But, anyway, I was involved in all those machinations. \n\nSo that satisfied that part of my own desire to be part of things in the specialty and still do family medicine. Our training back then wasn’t different than what it is now. I had large surgical skills and did a lot of OB and just gave that up two years ago. By the way, my son’s joined me this year.\n\nBecause they asked me on the phone which Dr. Neal did I want …\n\nDr. Neal: Yeah, and he went here and just took an extra year of obstetrics, so we’ve got babies coming back in the office, which I think is fun to know. Anyway, again, the whole experience in Hillsburg was one of a real sense of small community. And yet I had all these opportunities not too far distant to keep an eye, larger thoughts alive.\n\nBut you’re right about it. I don’t have to tell you. The community will kind of swallow you up, if you’re any good at all. In fact, my wife had to ring the bell. I was out every night of the week and after about five years into our life here, she said, you know, you’re going to have to give up some of this stuff. You don’t know your kids and I’m not sure your marriage is going to hold up. So I got rid of a lot of medical political stuff, you know, but maintained my interest in the residency. And got a little more involved in the community up here with migrant farmers health issues and a lot of school health, for several years, and that was fun and enjoyed it. From that, most of my patients, as you  know, become your friends. And it’s a trite phrase, but you’re sort of a family member – and you really are. You know, you see them socially and you really have to make the allowance for the intrusiveness of that. I don’t it … If someone is really interested in doing good rural family practice, I think they have to give up the notion of sequestering themselves from their patients in social things. I frequently give out my home phone number and all my OBs had it, for example, and things of that kind. My wife had a large tolerance for that, fortunately.\n\nI was going to say … Because the things I’ve heard about that, some of it has to do with, you used the term intrusiveness where a number of people have, both they and their wives have said there are places where that doesn’t go on. I mean there are little sanctuaries, is the term I’ve been using. Did you think that … Were there places or situations where the potential intrusiveness of medicine in your life or her life or both of your lives was \n\nminimized?\n\nDr. Neal: I had a hard time drawing a line between where medicine stopped and friendships and community involvement began because virtually all of your patients become your friends and you see them in the Safeway and you see them at the movies and commonly share social experiences with some. And inevitably medical questions will come up and I never felt badly about that. You know, you could even site legal constraints of giving free medical advice. Sure, sure. And the few times I kind of held the line, I was kind of feeling guilt about it later and I  was sorry I did it, you know. It was sort of like the few times I sent patients because of bills unpaid, I almost always -- that one. \n\nMy visit to Wales was very much full of all that where I would walk down the street and somebody would ask me something and, of course, I hadn’t had that kind of experience, so I said things, like, why don’t we just talk in the office. And they said, what’s with you (?)? And I realized that was my issue, not so much theirs. And I was always worried about confidentiality or something. But I think it was probably something about control, much more in control. And I was younger then. So for what it’s worth, I think I’m able to see things now, you know, twenty years later, much clearer than I could ten years ago. But this whole sense of privacy is something that I think is still, at least it’s a term brought up a lot by younger physicians – privacy, you know.\n\nDr. Neal: They put a lot of, too much, I think, stock in not working hard, you know and not being consumed by a practice out of control and all of that. I never had to be the sole physician in a community where that might really be an issue. We’ve always had doctors around, you know, someone I could sign off to.\n\nSo you did have somewhat of a sign off system?\n\nDr. Neal: Yeah, although it was -- except to say we had a bunch of older physicians here who would just walk off suddenly and leave their practice unattended, and that was infuriating. And I can’t say, come back from a vacation to deliver a baby. You know, that kind of thing. And that gets old. The obstetrics part was really the most interesting in that I did a lot about those patients and you really tended to govern your life around them. You wouldn’t go away … And, of course, another way, when you make a vacation, to accommodate one person when they delivered early.\n\nActually, one of the things I did on sabbatical was to come in for delivery of a patient. It was third baby and I had done the first two. She was very kind and said you don’t really have to. And I said I will, so I worked it out with one of my colleagues. And she followed her for her prenatal care, then called me when she was in labor and we jumped in together. It was fun. But it’s less intrusive in that way now because of coverage and so on. But it’s been a strain to try and get people to understand that. For example, on weekends, we cover our own OBs during the week but on the weekends we rotate among the faculty members. And it’s more livable. You know, your life is more manageable. But you also feel guilt, sadness and all those other things when you’re not there.\n\nDr. Neal: That’s very true. And if it’s possible for me to do it … Because I would average thirty, thirty-five deliveries a year, so that was maybe three a month and it wasn’t overwhelming or a big volume of OB practice. Then I think you would have to share it more.\n\nYou intimated a little bit about what I’ve been calling the social role of the physician, that kind of community advocate, community participant. Can we talk some more about that? Was that an expectation you had of how your life would be before you started?\n\nDr. Neal: Yeah, a little bit. I had had visions of being on the city council and getting involved with the community and that kind of thing, something I hadn’t done. All the opportunities were there. I served on the school board and I was heavily involved in parochial education here in both the elementary and the Catholic high school, sports and  school boards. And I was the team physician for seventeen years and things of that kind. And each one of those had its own experience as far as being involved in the community. I used to sit on the EH (?) committee, the medical person who would evaluate all the learning facilities and all that. That was very much an education for me. And I say on blue ribbon committees kind of things, ad hoc committees for community betterment and that kind of thing. \n\nBut I never held any office other than the school board. But other physicians have. Probably anyone you talk to has been heavily involved in the public school system and very much a community leader.\n\nDo you think you had a sense that that was one of the roles that a physician should play in a small town? You said you had visions of yourself approaching that way, so you must have thought of more than just medicine?\n\nDr. Neal: I had probably thoughts about breaking into it, but I didn’t actually seek it. First of all, when we came here, with the underserved population, just practicing medicine swallowed you up, so there wasn’t a lot of time left. But I didn’t want to turn down the opportunities, so I became selective about what I thought I did well and what I enjoyed most.\n\nBut those opportunities always came up to you? People were seeking you out? Yes. So, is your sense that being a doctor in a community carries with it a certain,  not an obligation, that may be too strong a word, but a certain sense of service to community that they will seek you out? I mean that’s a common experience, it seems, for people …\n\nDr. Neal: I think it may be lessening some because I think on the larger scale, the role of the physician as the educated -- in the community is less. And there’s more doctors around and they help don’t hold as much prestige as they once did. You know, I’m sure there was a time when the few people who graduated from college, there weren’t many medical professionals in a small, rural community like this. And now that’s much less so as the educational level gets higher. But the opportunities abound and still do and the obligation, as you say, is too strong a word. I think it’s hard not to give a feeling for your community. I never saw it as an obligation. You kind of wanted to be part of what was going on. And when things were happening that I wasn’t involved in, it was, why weren’t you there, you know. That kind of thing. You have something to say about that and you might have been able in that sense. \n\nIt’s a very different way that you’re talking about, kind of your sense of what it was going to be like. And my suspicion is then that if you would talk with some of the senior residents in family practice programs these days and there’s almost a kind of hyper-awareness, and this is, again, my projection, using what I’ve heard … But there’s a hyper-awareness of the difficulty in keeping these kinds of personal/professional spheres separate from each other. Whereas if you go into it realizing or even expecting or anticipating, in some way, the positive aspects of those things coming together for you and for your community and for your family, then that’s a whole different way of going into a community than it would be now where they’re looking at the nature of the job, as you said. It’s now much more of a job. And I’m not sure how it is that your consideration of people had the sense that community involvement in a variety of ways was going to be part of the …\n\nDr. Neal: I’m not sure what the answer to that is. You might cite the process of selection at the medical school level in the beginning, you know. As  I mentioned, when going into medicine was something of a calling, it’s a little less of a calling than the ministry of the priesthood or something like that. There was an implicit that becoming a doctor was a service. And I think a lot of lip service has been served, but it’s much less of a concern, unless I’m misreading what the younger people are doing. On the other hand, there are plenty of them. Boy, we’ve had many examples in our own residency here of people going to third world situations and things that I haven’t … I had one trek to Appalachia and that was the extent of my involvement there. So there’s certainly no lack of young people who have those kinds of thoughts. Some kind of talking -- to come here, but there seems to be some trend. But I guess what I really want to say is too much emphasis is placed on this inability to control your practice and all that implies and your personal life, you know, to the detriment of your personal life. Everybody recognizes you need a life. And for me that wasn’t such a big chore. I told you about the five year experience that my wife rang the bell on me. So you really have to get selective about it. But part of what I did then, I started running and I resumed my piano and I started doing things outside of medicine. And I really think that has to be the leavening. \n\nIn some ways, one of the things I wanted you to reflect on a little bit is what I’m calling kind of normative changes in the adult development or change points. There clearly seem to be points during a twenty-five or thirty year career that there’s been some, oh, taking stock, re-evaluating. Some of that is maybe forced on people by some external forces, an illness or something. And other times it …\n\nDr. Neal: I’m at the point right now of that type, a pivotal or rights of passage, if you will. And I’ve had a bunch of those along the way.\n\nDo you remember … Obviously, that five year bell ringing must have been one of those points.\n\nDr. Neal: That’s one. And the others were academic medicine versus rural medicine. (Inaudible) and a lost opportunity, what could have been.\n\nWhen was that the clearest to you, that particular decision about academics versus I’ll stay here?\n\nDr. Neal: When I finally made the decision forever, that would have been about 1970 and I’d been in practice six years. That was the time that you really … Yeah, that was the time that I could have gone to Davis in an exciting role there. And came very close to doing that. Because by that time I was a seasoned physician. (Laughter.) \n\n… Not to be quite so dangerous! (Laughter.) Right now there’s quite another point – I’ve kind of backed away from things I was involved in most recently and I’m really enjoying … I got involved in a research project through the National Cancer Institute at UCSF and had to do a screening. So office-based research was an interesting thing and that really heightened my interest in preventive medicine. They gave me a computer and I’m in the process of expanding what was actually a tickler system for cancer research screening into a particular system for individualized interpretations (?) for cardiovascular risk factors or all the other things one does in preventive medicine. So that’s kind of my new thrust. And with my son there, heavily involved … You know, before it was all the surgery and the exciting case and the difficult to manage the problem and all of that and those are the things that turned me on early in practice. But now the less of that I have the better I like it. I used to insist on putting in my own pacemakers and all this kind of stuff. It was a point of honor. But lived through that era in the seventies when coronary care units were just opening up. I was involved in the planning the one here. And I was a member of the Legislation for Heart Disease, Cancer and Stroke and it later became RMP, then became AHEC (?) through periods of changes. And we had lots of training involvement in that. And those were exciting years in the introduction of modern coronary care problems and dealing with the issues of emergency management of myocardial infarctions and so on. And all that was very exciting and that was kind of the thrust of the seventies for me.\n\nTo use your words, this whole interest in that has a big part of your practice has changed and you’re becoming more interested in things that are -- …\n\nDr. Neal: Yeah, and less dramatic and more thoughtful of … And, also, less stressful. I’m certainly at an important point in my life where I want to become less in … And real difficult management problems I share much more readily now than I did before. Partly because there were only general practitioners here when we first came and to get specialists up was a difficult process. Now we have them all represented in our community, so they’re at your elbow waiting for work. \n\nAnd the kind of pressure to get them involved … It’s different for your son coming here and being in that kind of dramatic part of his career. I mean there’s all these other folks standing around putting maybe some not so subtle pressure on you that you need to get other people involved. And there’s this whole belief system that even young residents do, after they had the experience themselves, and said that you have to get other people involved all the time. What’s hard for them to understand is when you get them involved in the community, you can do it through asking their opinion, getting their advice. And that kind of quigiality (?) can make you the best kind of CME I can think of.\n\nDr. Neal: A lot of relinquishing of role, I think, young guys coming in … I don’t think it’s taught very well, at least the residencies I know about, how one maintains position as the quarterback in management and a simple thing as somebody coming in with a hip fracture where the orthopedist’s role is dominant … I always insist on maintaining any heavy involvement.\n\nA bunch of old people needing medical care and somebody else looks after them …\n\nDr. Neal: And it’s sometimes hard to get paid for those services, you know, and all that. But that’s not a reason not to do it, I don’t think. So we have three new family doctors in town here and they bring with them this notion that they can just turn over the patient at a moment’s notice because they’re going away this weekend. I had one the other night call me and say, they were on call for … It was a person who was in practice with another person. And ten minutes before they were going to turn over the call, they got a call from one of their own patients with a very trivial problem. And they wanted me to make the phone call. You know, this kind of changing of the guard. And I talked to Tom about it, my son, and he said, you know, that comes from being a resident. When you turn over the service … It’s like it’s out of my hands? Yeah, and that needs to be addressed. I think most people abandon that after a while, but it’s a learned phenomenon. It certainly is.\n\nI have two issues that I’d like your thoughts on. One is the whole question of if you’re a physician in a community over a long period of time, what do you think about mistakes? I mean how are mistakes looked at perhaps differently than they might be for somebody practicing in San Francisco or a larger city?\n\nDr. Neal: Well, I think there’s a much kinder environment here. It’s kindler and gentler. I remember I made one horrible mistake early in my practice where I gave a gal what I thought were birth control pills and turned out to be a card sent to me of another similar name, it was a menopausal hormonal (?) replacement. And she promptly got pregnant. She didn’t realize what was the matter and I just bared my soul about it. I hadn’t been with patients long enough, but they were very understanding and just wrote it off as a human error. I think if I’d not had a relationship with all her family members, it would have been quite a different story. They were unhappy about it. They were a young couple and got married and they didn’t want kids right away and they didn’t want an abortion. And they went on to have this baby and we kind of joked later about this little kid who is not this person, there’s something providential about what happened. (Laughter.) So I think mistakes along the way, I find as I get farther into practice I am much more circumspect than I might have been early on. I’m not sure the reason for it exactly. I tend to share things more with other doctors if it’s difficult or if I’m unsure of myself. A good example is a mammographic lesion on a breast, I will commonly get second opinions rather than going ahead and biopsy or whatever. And the patients expect that, to some degree. Or I may know perfectly well what the outcome is going to be, what’s going to happen. But as part of the process, for their sense of, what their expectation is of the medical system, I’ll do it even though I know it’s probably not necessary. But as far as out and out making mistakes, I don’t live in fear of being sued. The other thing, corollary to that, I see my son coming along and how bright he is and all the stuff he knows. And suddenly, as much as I’ve made a major effort to keep up and all … But I think a lot of older physicians lose touch with the fact that they’re losing it. You know, they’re not current. \n\nI’m not sure what your definition of older is, but every time … In six months I’ll get back and I’m sure there will be a new -- of some sort or the other. And the hospital experience in the medical center is just awful because they get into these enormous discussions and conversations about, you know, some new technology … Which I get very cynical about because, I said, the last time something like that came around, everyone was all enthused and I’d give them the medical history about certain tests, which were the ones … They kind of disappear. But, yet, at the moment those are really crucial. So if you don’t know all about those particular tests of whatever technology is around, you’re seen as being --. And I’ve kind of gotten over that in the last five years and am easier on myself because my role is really not to be, to ask questions of the people who own that technology. And if you’re a good question asker, that they start to see the holes in their argument.  And I explained it to them and I said to the residents, this is how you get information from people – you ask straight-forward questions like will it make a difference? What difference will it make? What will I do differently? And just knowing something is not good enough. You have to do something. \n\nIt’s a different environment. But I’m sure your son will see, after some period of time, the same kind of thing you did about, you know, what the real job is. It’s not so much carrying a knowledge of all the technology and all the treatment modalities and so on. It’s a whole different kind of …\n\nDr. Neal: Right. And, of course, whereas you used to have to keep it up here, now it’s in a computer somewhere.\n\nA wonderful thing for me, I went on the National Library Medicine committee and wonderful to be able to use them. I’ve had a lot of contacts there and I use their  PDQ and I use their Grateful Dead and I use all sorts of search engines. I was one of the first people to start using that in the department. And I ended up looking real smart because people were, like, wow, he really knows, he can pull all these articles out the next day. Then all of a sudden you start teaching the residents to do that themselves. Now I just say, you go do it and they go do it. But it’s very helpful. \n\nDr. Neal: My son got a teaching award down here. In fact, he got the national award from Parke-Davis. That’s terrific. For teaching … And he was a fellow down there. And how he earned all that, he would go to the library and do the --. Then he would construct from the articles. A patient he had seen the night before, he would come in the next morning with a nice synopsis of literature and give it to them. And, of course, they loved him because he did all that work for them. And, of course, it was great for him because he really integrated it.\n\nOne of the other things about practicing, and another theme that seems to be coming up, is the whole question … It has to do with my working residents and my whole experience … The idea of confidentiality as the premier and ethical principle of the practice of medicine or any kind of … I was wondering what your experience has been with all of that.\n\nDr. Neal: I guess I’m constantly having to bite my tongue because I’ve slipped up on occasion in the past. The first thing that happened was the first week I was in practice, as an example, we inherited a couple of employees and there was this older gal that worked at the hospital. She was essentially untrained but she was a surgical circulating nurse. And she was a tyrant and she would have a doctor for breakfast in the morning. (Laughter.) And I went in there the first week, I was there assisting on a case and saw how abusive she was. And I came back to the office and said, boy, what a bitch that lady is. And it turned out to be the mother of one of the people working for us. (Laughter.) So that taught me a little lesson about watching your tongue. But as far as confidentiality as a medical processes, the unwanted pregnancies and going down the street for abortions and all this, the antennae is out around here and it’s awfully easy to feed into that. I have -- make a big thing about it with my employees at regular intervals. And we just had a meeting with the school nurse about getting the teenage girls – a big problem here is teenage pregnancy. And keep them from going down to some … They took away the funding for family planning clinics and it costs them $30 and they just don’t have the money to go down for that. And they’re trying to make themselves available for teenagers to come in at a reasonable cost. So, anyway, the trust in reassuring them about the confidentiality when they come in and get birth control pills, we’re not going to turn around and tell their parents.\n\nI don’t know what else I can say about that issue.\n\nIs knowing a lot more about most everyone ever a burden or a problem or a conflict?\n\nDr. Neal: I have to laugh … The problem is when I know my wife knows them all, as well, and ask for juicy tidbits. When she asks me about it, I’ll say I take the Fifth Amendment or something. (Laughter.)\n\nWhen I talk to folks, I say what about your family. There’s an interesting article which I don’t think has ever been published because, unfortunately, it was not very well done, a number of years ago … I like the article because no one has ever raised the issue, the whole question of confidentiality as it applies to families. There was a survey of, I forget exactly, of family docs asking them how often or how much do they talk to their spouse about what goes on in the office and so on. And, of course, the other side of that is how much your wife, for example, and all this time, in this community, ends up being a kind of …\n\nDr. Neal: Well, she gives out medical advice all the time. Exactly. Somebody told me one, in a funny phone call, there was a message to call Mr. Smith. And by the time he got back to Mr. Smith, he said, oh, that’s okay, doc, I talked to your wife and everything’s okay. (Laughter.) So that’s an experience that your wife … \n\nDr. Neal: Yeah, to some degree. She’s really careful about that. She’s got her own opinion about what I should do but she doesn’t always share it with me. In fact, I get criticized a lot. (Laughter.)\n\nDo you have a general guideline for yourself about what you talk about, what you’ll talk about at home and what you won’t?\n\nDr. Neal: No, I really don’t have a formal .. \n\nFor example, if it has something to do with friends of yours, you tend to keep it to yourself more than you would if it’s people who are not – or something like that?\n\nDr. Neal: I can’t really honestly say that I don’t tell her things. She’s good about keeping stuff confidential. Sometimes I’ll --, I’ll say this is absolutely confidential. \n\nThat’s a big burden, I think, especially at a time when you were more by yourself, a practitioner, not having colleagues to talk about difficult problems with. \n\nDr. Neal: Around here you can’t use a hypothetical case because people will know who you’re talking about. \n\nI think there’s a fair concern, people joke about Peyton Place and things like that. There’s a certain concern among patients coming in with whom I’m going to tell. Or are you going to put this in the record? You know, that kind of stuff.\n\nEspecially with HIV and AIDs and stuff nowadays, it’s getting to be …\n\nDr. Neal: Right, extramarital affairs, you know, etc. \n\nIt’s a big responsibility …\n\nDr. Neal: Yeah. I was asked by this journal, --, family medicine in rural, northern California. That was back in ’82. You can borrow that, if you want it. Could I do that, Xerox it and send it back to you? I don’t know if that adds anything to what you wanted. I don’t think you want them, but I happen to have the pictures … \n\nWell, I would. One of the things that we’re going to do, and Margaret and I have talked about this more, is try to … There was very little photographic representation of physicians in communities. It’s one of those things where you’d be amazing … I went to the National Library and I looked at the photographic collection. 30,000 photographs. I said do you have any … They said, we’ve got French hospitals, German hospitals, English hospitals, every hospital in this country. I said do you have anything about physicians in practices? They said no. And I spent a morning looking through everything, 30,000 … So there’s just no … \n\nAre these pictures from that area? Yeah, from that area, in 1982. I took them myself. They’re not very good quality. I’m going to send these back to you. I talked to Margaret about it, but I still haven’t got the ability yet to take … We’re getting away of trying to take photographs of home photographs. So we’ve been doing, not just doing kind of modern photographs, which we may do in a couple of weeks, in the North Carolina communities where she could go back and forth. But, also, to use peoples’ family albums. That’s been a technique we’ll use …\n\nDr. Neal: You saw that original thing that --. These are all those pictures. Oh, this is spectacular. \n\nDr. Neal: That little old Russian lady … And this kid here, --, he was the star basketball player for --. He’s an incredible athlete. That’s his mom? Yeah, his mom. This gal died, she was a nurse, she died in the street at age thirty-six, the day after Christmas.\n\nThis is wonderful. Who did the photographs of these? \n\nDr. Neal: It was Bill Rogers, the executive secretary of the California Academy. Bill Rogers, he’s a good friend of mine. And he brought along the photographer. I’ve thought about redoing this … Oh, really? Yeah, this guy, Riley, down there, wants to do it again. Good for them.\n\nThis would be perfect because Margaret can … We use a photo stand, so what she can do is take … I’ve been using slides from a book called “Plain Pictures of Plain Doctoring,” which is a book that John Stokol (?) --. He was a wonderful man. He and the photographer went and got FSA (?) photographs out of the FSA collection and got whatever they wanted. And, again, they were kind of amazed by how little documentation there was on this very important, the glue of communities – and there was nothing. So part of what I feel like I’m doing is just beginning to get people to collect some photographs of what their own lives have been like. I will return all of this back to you.\n\n\n\nSide 2: Can you tell me the story of that pamphlet? As I said, that was the way that I first heard about you. I heard about you through the Journal, then Julie came across, she was the librarian and came across the pamphlet that … This was in Massachusetts. And I don’t know how she found those things. She was always coming up with interesting things. She said is this the same Dr. Neal who’s on the JFP? And she knew a lot about all that kind of stuff. And I said, I guess so, because it was Hillsburgh, California.\n\nDr. Neal: Actually, those years we were very worried about general practice dying and Bill Rogers brainstormed to … You know, as a big recruitment effort to get medical students to even think about general practice as a specialty or as a discipline. And certainly we had no entry to the medical school in any shape or form. There was no department of family practice --. So this is his way of enticing people. I must say, I got a lot of feedback. And the California Academy (Inaudible). Because when you think about it, it was in the sixties during the Vietnam era and there was that social climate where people were turning away from the high tech establishment kind of stuff and putting medicine, the return to primary care discipline. So I kind of road the crest of that and that era of social consciousness.\n\nAs I remember, that was prior to family practice becoming a specialty. It was like the mid-sixties as opposed to the late-sixties.\n\nDr. Neal: Right.\n\nBut is that right, you called it family practice then, if I remember?\n\nDr. Neal: Yeah. I was quick to jump on the bandwagon because I thought that was where it was at. (Inaudible.)\n\nFrank Norman thought it was kind of contrived, to be called family medicine.\n\nI heard-- Carmichael, back when I was a resident … People were always asking what is family practice. And he said, the way you describe family practice is the way he described it to one of his older patients who had been with him for a long time in Miami. She said, what does family practice mean? He’d say, well, you know what a GP is? She’d say, yeah. He’s day, that’s what a family doctor is. You know, for reasons which historically may have been important, I think it was essential to do something.\n\nDr. Neal: It was reducing basically what a general practitioner is to a recognized discipline with a set of rules and a body of literature and an arena. In other words, it formalized what we were doing. \n\nIt’s what Gail (?) calls moving from a sect to a church. (Laughter.) That’s pretty good. And, again, from my perspective I think so much of what family doctors do, and I see it as somewhat of a constraining notion which is that there is a focus on the family, which I think is, at least, one level of expansion outward from the patient, which is what goes on if you’re any good in medical centers. At least you’re not an organ system person, you’re a person-person. But I think so much of what family doctors do are the kinds of things you’re talking about, which is that it’s relating to much broader social content …\n\nDr. Neal: Although I do think there’s a bit of a retrenchment taking place. So there is this … I remember the seventies, maybe you do, too, you know, there was a lot of talk about the … And -- and I --, because the only thing we could do that nobody else did. But we -- family systems. And I remember for a while I was getting involved and really back out of in a hurry, family therapy, because I was clumsy and I made some big mistakes and things blew up in my face and so on. And it became apparent to me that that wasn’t the arena. That I still have to go ahead and get medicine into a laceration with the babies and all that kind of thing. So it kind of sifted out. But the love affair of the family was very important as a conceptual context of what we were about. But as far as the implementation of it, it colored everything I did and really didn’t change a lot, what I did.\n\nSomeone said the difference …It’s not so much what we do but the way we think about what we do, which is rather than suturing the laceration, that laceration is of someone you know and you know that that person, you know, may have to stay home from work or from school. I mean all this stuff, which is never in any kind of algorithm. I get into these huge fights with people who try to reduce anything that people do into some kind of algorithm because all of what’s left out are the essentials, in my way of thinking. \n\nDr. Neal: The ER doctor who is suturing a laceration, all he’s thinking about, how pretty the wound is going to be. Whereas the first thing …\n\nA friend of mine, a young physician, I think he was up in Seattle for a number of years. He, at age forty-nine, was a marathoner and all these other things – and had a substantial infarction and ended up getting a triple bypass. Well, he was leaving the department and his final, you know, I want to do something on my own, differently. And he made the decision to leave academics, and this was right at the time he was leaving. He tells the story about how the cardiovascular surgery resident came in and said you’re going to have to stop running. You know, an offhand comment. And doing his running was the way he kept some kind of balance and it was really absolutely essential. He knew that he didn’t have to. But on the other hand, it was a kind of callous. And not knowing anything about it, he didn’t say, is running important to you?\n\nDr. Neal: The same thing happened to me. I had run fourteen marathons and I had knee surgery. And my -- came in and casually said, well, no more running for you. But I still run. The best benefit is that I get much more benefit out of it than I worry about my knees.\n\nSo it’s that context. We keep calling it context, and it’s probably an overused word. It’s all that other stuff that’s part of making people better … (Inaudible.)\n\nThe other thing I’ve asked people about – and, obviously, your son coming back here has had some affect … How your life has affected his life. But has being the family of the town doctor, as you think back on it, has that any effect on your family in any way? Have they been a kind of different role than say the sons and daughters of a person who runs the local store or something?\n\nDr. Neal: Yeah. Well, my oldest son is a dentist in town. He came back. My second is an artist who he came back. And my third son is a doctor who came back. And my fourth son just got into Cal Poly. They commonly allude to the fact that they were the doctor’s son and there were certain expectations placed on them by the community. \n\nThey did talk about that? Yes. And it usually had to do with money. You know, if they’d go somewhere, your dad has enough money to do this, that, and the other thing. And it used to be a source of irritation for them because … Their biggest thing was there were certain expectations of them. They were set up to my position in the community at an age when they were high school students and so on, like that. Not that they didn’t have problems, but I’ve been fortunate not to have any major disasters. \n\nBut they felt a certain kind, a little bit different than other students because of your role?\n\nDr. Neal: I think so, a little bit. It was a mixed thing. There was a negative connotation, but it was more positive. I was well-liked, well-respected and I think they kind of road along on that coattail kind of thing. But the teachers, if one of them did poorly on an examination or something, they would know that shouldn’t happen with this child. And I think my youngest son kind of reacted to that in a very negative way. He was a lousy student until he left for college. \n\nIs Cal Poly in San Luis Obispo? Yes. A good friend of mine, I’ve been down there to see him. He heads a California agricultural leadership program. He’s a dairy genetics scientist but is now running this program for young agriculture people. \n\nDr. Neal: That originally was a big ag school, but now it’s a good department of engineering.\n\nTell me a little bit about … Tom is your son who’s come … What was …\n\nDr. Neal: He was the perfect child. He was a star basketball and football player – very quiet though. Then he went to Davis, then USC Med School. So he was never any trouble along the way. Always had a smile. \n\nBut did you talk about him coming back here and going into practice?\n\nDr. Neal: No. In fact, when he went into medicine I didn’t try to influence, with any conscious comments or anything like that, his entry into family medicine. He was still making a decision … \n\nI’m delightfully surprised at how much there continues to be a multi-generational history in family medicine. \n\nDr. Neal: I always talk to Doug about that. You know, he has a brother that’s a family doctor and his father was a great GP. \n\nIn western North Carolina there’s a community that I’m kind of studying a little more intensively than I am other communities because I have developed a variety of ways of knowing some of the doctors out there. And it’s a very interesting community, very isolated. And I have an interview that I did with Mathew Fine (?), you know, the notorious Osten (?) Peterson of general practice in North Carolina back in … It was the one that kind of almost killed general practitioner. I remember, the GPs, when I first got into family practice, were talking about kind of shooting Osten Peterson on sight. (Inaudible.) This was published in “Family Medical Education,” deploring the lack of machines and the lack of … Well, this study was actually done through the University of North Carolina. I have all of the transcripts of the interviews that were done with the GPs in 1954. And this I was talking to, he was interviewed in 1954, so six months after he started practice. And he’s just going to retire, so I’m talking to him now. But he was saying his brother and his father and his brother have all been GPs in that town. And his brother died some years ago. But he’s just retiring, and now his son and his two nephews are coming into town. So this family … It’s really quite extraordinary and I thought, wow, this is rare. And as I look around, it really isn’t that rare. There’s a fair amount of that. Because there’s all this press about doctors telling their kids not to go into medicine. I hear that some. But I think they tend to veil it sometimes and don’t say what they really mean. I think there are a fair number of absent fathers and husbands, that kids react to that in a negative way.\n\nYou know, in a sense, what I wanted to ask you … First of all, are there any other things that you can think about that we haven’t covered or important areas I should continue to be looking at?\n\nDr. Neal: You’ve covered it. All I can say, it’s more in the area of Gestalt than it is any … It defies critical analysis or reducing it to a set of observations. There’s a real feeling about being a family doctor in a small community. It’s a very warm kind of … A lot of reinforcement of the things you do as being worthwhile and good. And the fulfillment is there maybe more so than in many other medical arenas. And for me, anyway, it’s very much a part of my being, to be important to other people and to know that what I do is important to them. It has a value. I can’t imagine being a pharmaceutical representative where if they were all annihilated tomorrow, nobody really cares, you know. So to be important to people, to be useful to them in their lives, gives me my --, the work. And I’m sure you can get it in many fields of medicine, but perhaps no better than this. And you get it, it’s not just practicing medicine. You feel, like Gestalt, very integral to the community. If I left tomorrow, there would be some memory of me as a doctor, but also being involved in schools and the clinic in town, that I’m partially responsible for, and things like that. So you can create a kind of -- for yourself, if you want to.\n\nThat opens the question, why you’ve been doing what you’ve been doing for all these years. \n\nDr. Neal: It’s self-serving. You know, we always do things selfish. But it’s a nice --, a sublimation of what you do.\n\nI’m struck by how much … You said it a lot better than a lot of people I’ve talked to, that this whole sense of feeling a part of a community, feeling needed by a community, feeling that what you do is important is, in some ways, probably what keeps you going in the middle of the night and a few other times. You may question … Yeah, why bother …  I always talked about how I don’t know, not too many people get out of bed in the middle of the night with a big smile on their face saying, oh, boy, I have a chance to go to the hospital. (Laughter.) So the residents who moan and groan about that, I say I don’t feel any differently than you do. It’s just …\n\nDr. Neal: It gets better. I tell everyone, getting up for the alcoholic you’ve never met before at 2:00 AM and deal with a drunk in the ER is not what everyday family medicine is about. The drunk I get up for is the guy whose wife, I delivered their kids, and I know he’s about to lose his job and, again, the whole context. 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