{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/0v89g5j14m/manifest","type":"Manifest","label":{"en":["Dr. Paul Young"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Date"]},"value":{"en":["1991-05-07 (created)"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. John Frey (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["Society of Teachers of Family Medicine","family medicine","family physician","Dr. Paul Young"]}},{"label":{"en":["Subject"]},"value":{"en":["Paul Young (personal name)"]}},{"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. 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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/3629/collection_resources/141774/file/262301","type":"Canvas","label":{"en":["Media File 1 of 2 - Young_Paul_1991.05.07_-_Side_1.mp3"]},"duration":1895.92456,"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/3629/collection_resources/141774/file/262301/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/141774/file/262301/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/262/301/original/Young_Paul_1991.05.07_-_Side_1.mp3?1739220785","type":"Audio","format":"audio/mpeg","duration":1895.92456,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/141774/file/262301","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/141774/file/262301/transcript/75728","type":"AnnotationPage","label":{"en":["Paul Young transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/141774/file/262301/transcript/75728/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Paul YoungPRIVATE �\nMay 7, 1991\n\nPhiladelphia\n\nQ. - John Frey, M.D.\n\nA. - Paul Young\n\n_____________________________\n\n\tQ.  What I guess I'd like you to think about, if you could, is go back to the time when you started practice and then how you went from there to getting involved with family medicine academics.\n\n\tA.  Well, I started practice in Kansas City, actually in a suburb called Raytown, which is just right adjacent to Kansas City, and I practiced in some of the community hospitals in Kansas City. Now this was in 1961 when I got out of the Air Force and came back and began practice in a group. And at the time of course the Academy's office, that was then the Academy of General Practice, the office was in Kansas City, of course. I had become fairly active in the local Academy in Kansas City, and through that became acquainted with some of the people at the national office. And one of those was a guy named Hannas, whom we called R-Square Hannas. R-Square was a particularly active guy who had spent considerable time with Lynn Carmichael, and they had thought about this whole process of developing a specialty and a training program and all of those things, and R-Square was trying to stimulate the Academy's interest in this whole thing. He was serving at that time as the head of the Division of Education, and was one of the few physician employees of the Academy at that time. He came out, he had practiced in Oklahoma for, settled in Oklahoma for several years and then he came to Kansas City. Well, he got acquainted with me, and he thought it would be a good thing if we could establish a residency in Kansas City which could function as a kind of showplace for people to look at so that they could learn how to run a residency in this new specialty. That was his concept. So I talked to the people at the hospital where I worked, at Research Hospital in Kansas City, and they were interested in having a full-time DME [Director of Medical Education?] to run their continuing education and the staff education activities. And so I made an arrangement with them that we could, that I would do the DME work but at the same time work on developing a residency. This was in the late '60s. And so I left my practice and went full time to the hospital. And did in fact develop a proposal for a residency which was approved in 1969 when the first 15 programs were approved.  \tQ.  I've got that New England Journal page that they published that, I've got that and I've shown that to folks and it's really interesting to look at that.\n\n\tA.  It is. There are some features about that that we probably ought to go back and look at! But as I recall there were three tracks you could develop in a residency, and you know, it went that way. But another important issue was obtaining federal support at that time, and this was the time when Mr. Nixon pocket-vetoed a bill which would have provided direct support for graduate education in family practice. This was in about 1969, so--but we went ahead anyway, and 15 of us started and the program which I started faltered and fumbled and fell after only about 2 and a half years. And the hospital decided they preferred to put their money into a kidney unit rather than a family practice program. So I then left the hospital and I went to the University of Missouri and joined the department in Columbia down there. And at that time, that was a department called Community Health and Medical Practice, and family practice was a division along with medical sociology and management and public health and public health education. It was a--there were seven divisions in this department, and we began to work with it, and I was appointed as again the head of continuing education, but was appointed to this Department of Community Health. After about 3 years, they elected a new chairman. This was the only department I've ever been in in which an election was held to select a chairman, and the chairman had a finite appointment and the faculty elected the new chairman.\n\n\tQ.  Interesting idea.\n\n\tA.  With of course the blessing of the dean. And so they held an election and I was elected chairman of that department. And by that time we had built the department up and recruited some residents and were building, and it was beginning to grow pretty fast. And Jack Colwill was then the associate dean of the School of Medicine at Columbia, and I got him to get his, to do his academic and clinical work in the department. He was interested in it. And he sort of wanted to keep the dean's hand in it, you see. But he became fascinated by it himself. And so after I left he was then appointed--they began then to appoint them after I left--and he was then appointed the chair and he's been there ever since. I then went, in '75 went to the University of Nebraska as professor and chairman there. I was there for 5 years, and I followed Frank Land, Frank Land had been an early pioneer in this whole business.\n\n\tQ.  I met him once, he was one of the people that, I remember people talking about him and remember meeting him just briefly one time.\n\n\tA.  Very vigorous guy, just an absolute astute politician who was excellently clever with dealing with people in high places. And he had managed to build a great department at Nebraska, and a new building and a new clinic, and all the stuff that went with it, and had involved himself in the politics of family practice in that state, which of course is a rurally-oriented state, with a--it's the only state in the union that has a legislature with one house. It's a unicameral legislature. So there were just 50 people for him to deal with, but he dealt with them expertly, and was able to gain a great deal of support. I thought (??) my job I thought was to improve the academic base of the department, which was not Frank's strong forte, so I began to try to recruit people with a little more academic background and try to orient it that way. And I got caught in a political struggle because there were guys out, senators out in the state who wanted a residency in their hometown. And I had to appear to resist them directly, which wasn't in the favor of the university or the department, but I had to recognize that there was no way you could put a quality program in a small town and expect it to thrive. And so I didn't and so I left to go to the University of Texas then in 1980. And I went down there and was there until 1988. Now my relationship with the [American] Board [of Family Practice] began in 19--well, I had been appointed to the Residency Review Committee in about 1976, and I was appointed by the AMA, and I--\n\n\tQ.  The Section of General or Family Practice?\n\n\tA.  Right.\n\n\tQ.  Family Practice?\n\tA.  Right, and the AMA appoints three people to the RRC [Residency Review Committee] just like the Academy and the Board does. But I served on, then, the RRC, where I got acquainted with Nick and some of the people from the Board. After 2 years I was elected chairman, and I remained chairman then for the next 8 years. But that's how I got acquainted with those people, and then I was appointed to the Board in 1981 and served there and was president in '85, then went off the Board. But in the process Nick and I had dreamed up the idea of a journal, and Nick, you know, in his usual manner, he thrashed around, he went to the Library of Medicine, the people there, and he talked to them about it, and they suggested he ought to probably talk to Glen Ralman(??), which he did and Glen was very supportive and said it just so happened that the Massachusetts Medical Society was interested in expanding its publication activity at that time. So we struck a deal with the Massachusetts Medical Society and we started the Journal [of the American Board of Family Practice], which is the first Board to ever publish a journal. But that all went on between '85 and '88 and in 1988 then Nick felt he needed to bring another physician in to replace him, because he was reaching his mid-60s and he thought he would like to slow down a bit. So I went off the Board then full-time in 1988 and then I worked with Nick until he died then in 1990 in March. I had, we had planned that I would take over the first of January, 1990, which I did, and Nick's plan was, in order for his retirement he needed to drop out of employment for 2 months and then we could hire him back and he could collect his pension and at the same time be employed. And that was our plan. And so in January and February, of course he worked just like he always did, but he didn't get paid. And the first of March he was back on salary again. And he died on the 11th. And that of course changed a whole lot of things. It's hard to know what would have happened had Nick lived. His plan was to work part-time and to spend more of his time in his library, which he had built in his new home. He had just built a new home, and he had this second floor library, which is enormous. I think he may have, he may have 20,000 volumes in that thing. It's enormous. A private library.\n\n\tQ.  You should get an archivist at least to go through it.\n\tA.  Oh, yes, as soon as the estate finally gets done, why of course that's, you know, somebody will have to evaluate that and look at its real value. That's been attempted a couple of times, but the people who have come in and have kind of thrown up their hands, it's a bigger job than they wanted to take on. It's an enormous task. But he does have that, it still exists, it's still there.\n\n\tQ.  Getting back to this whole, when you were talking with R-Square Hannas about family practice, it wasn't family practice when you were talking about it, it was still general practice, I mean what was it in your own experience up until that time or in your life that made you feel like you wanted to start talking more seriously about something that was very, very formative, well I guess by that time it had been talked about a lot, but it wasn't something that--\n\n\tA.  Well, I think what struck my fancy was the concept itself, and I looked upon general practice as being the kind of, a practice where one tried to deal as best they could with whatever confronted them, but didn't pay attention necessarily to continuity issues or family impact or some of the other kinds of influences on the way you manage patients. But my own experience told me that these were important things. But I had no structure or system to look at it, and I didn't even know where to start to learn about it, more than I already knew. And so it seemed to me--what we were talking about was the development of a training program which would provide training not only in just the medical skills that are necessary for the management of primary care kinds of problems, but also these other things for which there really was no literature in medicine that had any value to us that we could find. So we, I saw that there was something there for that. And it seemed to me that the health care system that existed in the '60s didn't provide that at all. And the other issue was that of course I got into family practice, really, into general practice, because I couldn't choose amongst the other specialties something that I wanted to commit myself to at the expense of everything else. I liked to take care of children, I liked to take care of pregnant women, I liked old people, I liked, you know, surgical problems, and trauma, and I didn't see myself as limiting myself in these areas. But the only training, graduate training that was available were a few rather poorly organized general practice programs. That's all there was. And I felt both the profession and the public needed to have something more, something that was a little more sophisticated than that in order to train people to just take care of what walked in your office.\n\n\tQ.  So it's a, it was your sense that in order to give a shape to what you knew you wanted to do and you knew it was needed, there was a structure and training program that was necessary.  \n\n\tA.  Exactly.  Exactly.\n\n\tQ.  And that, you know, it was your perception that if the general practice track had kept going, it would have died.\n\n\tA.  Right. It was headed for a funeral, because we had seen that the numbers of students going into general practice dwindling down to about 1 percent, certainly less than 5 percent were even considering it.\n\n\tQ.  Why did you become one of the 1 percent?\n\n\tA.  Because I couldn't choose any other one. I couldn't make myself decide that I was going to take an OB residency or a pediatric residency or an internal medicine residency because I didn't want to do that without being able to deal with these other kinds of problems.\n\n\tQ.  So the constraining nature of those other--\n\n\tA.  Exactly, constraint of the specialization turned me off. And I saw these people who were teaching me were specialists, and I saw that they had marked limitations in what they could do because they were constrained by their specialty. I don't know whether that was intelligent or wise, but that's, that's how that derived. And I got to talking with some other people who, strangely enough, felt the same way. So we began to talk to each other, and then we began to say, well, you know, how do you do that? Well, we didn't know how to do that. We didn't have the first glimmer or notion of what it took to develop a specialty. We had no idea.  \n\n\tQ.  But you knew, I mean, I guess what I'm always curious about is that it's, the sense that, the urgency that something needed to be done is one thing, but on the other hand there's this whole, I mean you're talking about your own specific life, your family, your choices making some things that are, you know, there's something that, I mean there seems to be a sureness that something was going to happen.\n\n\tA.  Exactly.\n\n\tQ.  Why do you think that was there?\n\n\tA.  Well, I think it was people like Hannas and like Lynn Carmichael, and there was a small group of people, when you got listening and talking to them you were quickly convinced that they were right, because what they were talking about you had experienced, and it was real, it wasn't some kind of ethereal concept, it was something you had already experienced, you knew about, you felt it every day you practiced. And they were, knew they were right.\n\n\tQ.  That's a wonderful thing to be able to think about, I mean for me and for a lot of people, is the sense of, you know, knowing that it was right.\n\n\tA.  That's right.\n\n\tQ.  That particular experience has been, less an experience of my generation, I think, than yours.\n\n\tA.  But, and I don't think they knew any more than I did, but they felt the same way that I did, and they were able to articulate their feelings very well, particularly in small group settings. You know, we'd meet in hotel rooms. That was very common for us to meet in hotel rooms and just talk and share ideas. And pretty soon--mainly through the Academy, because the Academy had connections in other parts of the country, you know, and there was a network. And through the Academy we were able to contact people in other parts of the country, and sure enough, they were thinking the same kinds of things. And so that's how it started. Now it wasn't altogether easy, because I was, we were in the minority, much of a minority as far as practicing general practitioners were concerned, and I'm sure you've heard that the Board had gone to the Academy twice and got just beat to death twice. In the meantime, Nick had gone to the American Board of Internal Medicine, 'cause he thought, you know, if AAGP won't do it, maybe the American Board of Internal Medicine would do it. And they literally threw him out of their office. They threw him out of their office. Well, John Benson tells that story, and says, boy, we screwed up.\n\n\tQ.  If I knew then what I know now type thing.\n\n\tA.  Yeah, that's right. Well, we, through the Academy we were able to make the contacts. There was a meeting out in Colorado at Estes Park which was a kind of a rump(??) meeting of people from all over the country that were thinking of this. And we went out there and hashed out the kind of general concepts that we wanted included in a training program. And that's what was polished and carried forward and sold through the political channels that it had to go through. It had to go through of course the process that still exists today for the formation of a new specialty, a joint committee of the AMA and the American Board of Medical Specialties. And of course it was rejected initially, but I've learned, since I sat on that committee recently, that they always reject at first. And so they kept polishing, kept working, kept the politics going, until they really--they got it through there. And then it got through the ABMS and you know, we were recognized as a specialty.\n\n\tQ.  Do you remember the first time that you heard the discussion of this idea of a family practice center or whatever you called it then?\n\n\tA.  Yeah.\n\n\tQ.  I'm always curious, that's probably the most significant medical innovation, educational innovation in my lifetime and probably most of the people now.  \n\n\tA.  Well, that was the key, because general practice education up to then had been entirely within the hospital. And many of the people who had sat around that room had been through general practice training programs. And of course what they recognized was that that didn't prepare them well for the problems they saw in the ambulatory setting. And so they said look, why don't we prepare people by giving them the experiences they're going to have when they actually go into practice. That it's a simple thing.\n\n\tQ.  Now it is.\n\n\tA.  And so we said, sure, but how are we going to do that? Well, we'll set up a model practice and we'll have guys who are experienced supervising these residents and managing whatever walks in. Because surely that's the best way to prepare them for being independent, is to supervise them in a setting that's as much like practice as we could make.\n\n\tQ. (??) as you said, that all hospital, I mean all of residency education in every discipline was hospital--that was a pretty radical thing to say.\n\n\tA.  Oh, absolutely. But we saw some other issues. We said, we saw look, you know, most of our patients aren't hospitalized, and how are we going to finance this thing. We can't give up our practices and just go into the hospital because nobody's going to pay us. So in order to fund the thing it's important that we have a panel of patients or a body of patients that we can treat in order to create income to support the training program. So it was fairly simple when you began to put it all together. 'Cause that was one of the major issues, is how, who's going to pay for all this.\n\n\tQ.  What was the reaction of people when you first broached the idea of having this family practice center?\n\n\tA.  Well, they'd never heard of anything like that, they thought that was just absurd. And the hospitals, though, paid attention. And the reason is that the hospitals liked to have family physicians on their staff because they refer patients. And they understood that where they get their patients is from primary care docs who identify people who need to be hospitalized. And the faculty, you know, the specialty faculty recognized, particularly in community hospitals, recognized that they get their referrals from these guys who are in the trenches seeing all these patients. And they didn't want to discourage that. And they thought well, we have a practice here, I'm going to, you know, if I help them they're going to give me all their referrals. Well, to a degree that's true. And so they said this may be okay.  \n\n\tQ.  So hospital support was clearer than the support from the educators.\n\n\tA.  Oh, yeah, the hospitals saw the dollar sign right away. They saw that right away. And this was, Medicare, you know, passed in 1966, and the hospitals weren't sure what was going to happen, but in those days that was a boon to hospitals because that meant they were, they got paid for doing things that they had been doing for free before. But they wanted to keep that alive, and they saw family practice as a way of maintaining their older patient population. Which was good for them at that time.\n\n\tQ.  Some things, some good ideas, I mean some things are still true, it seems to me, where assumptions that were made about, you know, it's always fascinating when the rest of medical education discovered ambulatory care.\n\n\tA.  That's right.\n\n\tQ.  It's like the word primary care was a dirty word when I started as a resident, and ambulatory care was something that came along, and everybody just dismissed it. And now every surgeon in the country that's an educator says, 'well, we do two-thirds of our work in the outpatient department,' so you know, it's amazing how a real clear sense of what had to be done still makes sense.\n\n\tA.  It's hard to know how much impact also was given to this by the Millis Commission Report, which came about in the late '60s, '66, I think, '67, along in there, the Millis Commission, and then the AMA had a special commission which came to very similar conclusions about graduate medical education, that it needed to be more emphasis on primary care and needed to be office-based. You know, those kinds of ideas came out of the AMA reports. So--and that just happened sort of serendipitously because these groups had not been, you know, that wasn't planned, that just happened.\n\n\tQ.  Well, you know, when people talk about, I mean I was a medical student in the '60s. And I was in Chicago, I mean I had grown up in a small community and had gone to a, went to Notre Dame, which at that point was a pretty isolated place, and going to Chicago in the middle of the '60s was really amazing. And it seems to me there are a lot of alliances that got forged in that period that are real strange to think back on, if you think about it.\n\n\tA.  That's right.\n\n\tQ.  A lot of the small town physicians and people who were, by their nature, not particularly politically-oriented and were fairly conservative, and you had these students who were rebelling against, they didn't really know what, and I think it was, in a sense I backed into family medicine in a, very similar to what you did. I mean I went to the Department of Internal Medicine and said, 'I want to be, I don't know what to call it, I want to be an outpatient doctor, I want to work in the community.' They said, 'Do that after you do all your other training.' The pediatrics people said the same thing. So somebody calls me and says, 'Hey, Miami's got this place where you can go be--'and I said, 'It's legal?' (??) said sure, so I mean there was a lot of stuff happening. What's your sense of how all that, did all that come together in some way?\n\n\tQ.  Well, of course Gayle has pointed out to us very well that what we represented was a counterculture, which in the '60s was an acceptable thing to do. Society was willing to entertain countercultures in those days. The profession I think was also, that is medicine was also driven to accept the possibility of countercultures. And to not necessarily support it vigorously, but at least to permit it. And we are, and I think we continue to be a counterculture when it comes to academic medicine. We still are. And what we were doing was making, we were taking the profession and making it fit a social structure which it was not intended to fit. And that's what I think we accomplished in the '60s. Which we probably never could have accomplished at another time, because people wouldn't have permitted it.\n\n\tQ.  I think you're right. I really do. I mean it's amazing that all of this stuff that had been building up over the '50s and the rejects, you know, you're right, there was something about the time that was really--\n\n\tA.  There was something special about the time, and I have to think it had to do with the whole social milieu that it occurred in that allowed it to occur. Now you know, we're still doing it, the milieu is not nearly as friendly now as it was at that time. And, but yet we've made some beachheads, we've made some progress which means to me that we can continue to progress--\n\n\t[tape side ends]\n\n\tQ.  Well, you know, as soon as the rains come, you know, the desert's going to bloom, but you go out and you see the desert and it looks like a desert, you can't see any flowers, you can't see anything, and then the rain comes and all of a sudden boom, everything, and I think that, you know, the way that I reassure myself about the future, which I think is not just making up a story to put myself to sleep, so to speak, is to say that all these seeds have been planted all over the place, and there's still these, you know, the plants aren't completely quiet, I mean they're working their way, the cells are metabolizing and as soon as the rains come, you know--\n\n\tA.  It'll blossom.\n\n\tQ.  --there'll be some flowers. And I think that what exactly the (??) nature of the rain that's going to come is going to be, I don't know, but--\n\n\tA.  My suspicion is that it will come from economic reality, that it will occur to somebody, to a lot of somebodys, that health care costs too much in this country, and we have to change it. And one of the things that we'll be sitting in front of and to look it is primary care, family practice as a part of the solution to the problem. And I think that's what's going to happen. Because I don't think our society is going to continue to spend 12, 15 percent of its gross national product for health care, it's just not going to be.  \n\n\tQ.  As you, kind of putting yourself in a reflective mood, I mean as you think about what all happened then and what you thought was going to be the result of all this, I suppose there were some pretty concrete issues back then, but as you thought about what things might be like, what's surprised you about what's actually happened?\n\n\tA.  Well, I think we really at that time thought once we got it started, that it would be self-propelling and that by this time, you know, by the '90s, by the year 2000, medical schools would be oriented to training family physicians and it would be the exceptional student that would go into some other specialty. I think we felt that we would have a system of health care which would allow family physicians to function pretty much the way they're trained. I don't think that's necessarily true now, and I think our predictions were not realistic. I think we may have had some higher expectations than were appropriate for changing the education system, and we have run smackdab into reality of the inertness that exists in academic medicine and the resistance to modification involved, and whose (??) can be ignored, and how powerful some people really are that you didn't think were that powerful. I think we are facing the realities of academic medicine that we didn't know about in those days. I think in terms of our relationship with the public I think we recognized we had good relations with the public then and that was an asset to obtaining federal support for graduate training in our specialty. Nobody else gets it any more. For a while the psychiatrists got it, the anesthesiologists, but they're not getting it either. We have a favored position because of our relationship with our patients, and I, you know, I hope we never forget that and that we pay attention and curry that, because we're going to need it down the line in order to accomplish what we'd like to accomplish I believe. So, and that was an asset we recognized we had and we used it wisely. We used it wisely. You can get in trouble using it.\n\n\tQ.  I think in general it hasn't been abused--\n\n\tA.  That's right.\n\n\tQ.  --and I think the question, you know, the danger is always promising more than you can deliver, and I think that from what I can tell, inasmuch as we have control over things like medical education and such, I mean we've really delivered what it is that we've promised, and so I mean that's, to me, in the future that's something that we're going to have to be able to remind people of. That you drive around towns in North Carolina or anyplace now and you see, you know, you see graduates of programs who are practicing in those communities, and maybe the numbers aren't as high as you had hoped and so on, but you know, there are people there and they're generally happy doctors and they're struggling with what's going on now.\n\n\tA.  They're doing all right.\n\n\tQ.  What do you think about--I guess you're in a really unique position to look at the products of all these programs. And what are your senses of what's worked and what hasn't?\n\n\tA.  Well, I think our training programs have worked. I think we train our residents pretty well. I think cognitively they have what they need, I am concerned about attitudes among residents which are not what I would like to see generally, but maybe that's because I'm from a different generation and have a different set of values.\n\n\tQ.  I'm curious what those attitudes are.\n\n\tA.  Well, I see people, I see the younger people being what I think are excessively concerned about their own security. Now that's different from my generation. Maybe we taught them to be, then we have to accept responsibility for that, but I see that as a problem. I see medical school selections of students being much less favorable to us now than they once were, and the people that are being selected it seems to me are oriented to their own security more than they are to trying to be of use to their patients. I really see that, and that's troubling to me. I don't know what to do to turn that around other than to somehow impact on the selection of students, which is difficult.\n\n\tQ.  Somebody said, you know, you gotta work with the material you're given.\n\n\tA.  Exactly.\n\n\tQ.  I mean, having been on an admissions committee now for one year, I mean this is my first time in 20 years I've been on an admissions committee, I'm stunned. I just, I said to somebody when I started on this thing that what I dreaded was running into the difficulty of, how do you sort out the students who say they want to take care of people from the people who, students who say they want to take care of people and they really do want to take care of people. What I've found is that the cliche of saying, 'I want to take care of people' is not the operative cliche. They're saying, 'I like science.' 'I'm interested in the human body.' 'I like to solve problems.'  \n\n\tA.  Right. They don't even talk about it.\n\n\tQ.  I keep saying, my hand is going up every time and saying, well, this person doesn't say anything about people. And one of the other guys on the committee said, well, if we took that as a criteria we couldn't even fill the class. What kind of statement is that about the world?\n\n\tA.  Well, maybe they ought to think about that, though.  \n\n\tQ.  Maybe the process is maybe what we ought to start teaching, in a lot of ways, and I'm not sure how to do it either, to the generation that's coming along, is that a life of service and a life of contributing to the health of others is satisfying and is happy and there's a sense of, 'get your pension plan set up when you're 25' as opposed to whether or not you've made a difference in the world.  \n\n\tA.  That's right.\n\n\tQ.  Anyway, I gotta be careful because I've got a 20-year-old at home and he's in college, so I can't be too hard on him. Are there other things you can think of that we haven't covered that might be good to talk about?\n\n\tA.  Well, I think the issue of, I think because of my academic background, or at least in medical school, I have to think about research as an issue to our specialty, and it seems to me that here again we're counterculture. We're not going to gain much advantage doing strange things to small animals. We're just not going to do it. Any better than other folks are doing that. If we tried we could probably do as well, but that's not our ball of wax. So what, somehow we have to modify the attitudes of the academic community toward the kinds of research that we can and are interested in doing. I don't think we ought to reject the kind of research that we want to do, that is, to look at clinical research at the community level. And I think that's what we can do differently from what anybody else can do. And I think we ought to stick with it, and not try, and not get sucked into the idea that we have to do bench research and do it as well as everybody else does. That's my concern, and I think we ought to stick with our guns and continue to bang away at the idea that this is valuable to the profession and to the public, what we do in research. And taken to the right audiences, I think we can make that stick.\n\n\tQ.  I think, I certainly, just in what I've been doing, see that--I've got great hopefulness, I think that you know, when we've talked with people, my main concern about the people who are coming along who will be the teachers of the future and the doctors of the future, is just this real crisis of vision, I mean do they--they're going to be successful by a lot of different measures, but what's driving them, I mean what's there in their gut, and what is it that they want to do and why do they want to be successful. 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