{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/2j6833pt7n/manifest","type":"Manifest","label":{"en":["Dr. Maurice Wood"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"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"]}},{"label":{"en":["Date"]},"value":{"en":["2008-11-17 (created)","2009-11-16 (other)"]}},{"label":{"en":["Type"]},"value":{"en":["Oral History"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. Anton Kuzel (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["American Academy of Family Physicians","Family Physician","Family Medicine","North American Primary Care Research Group"]}},{"label":{"en":["Subject"]},"value":{"en":["Maurice Wood, MD (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}}],"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: 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.\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/2195/collection_resources/158020/file/288298","type":"Canvas","label":{"en":["Media File 1 of 3 - NAPCRG_Interview_Wood_11-08.mp3"]},"duration":6881.88881,"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/2195/collection_resources/158020/file/288298/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/158020/file/288298/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/288/298/original/NAPCRG_Interview_Wood_11-08.mp3?1755699795","type":"Audio","format":"audio/mpeg","duration":6881.88881,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/158020/file/288298","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/158020/file/288298/transcript/83171","type":"AnnotationPage","label":{"en":["Dr. Maurice Wood interview transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/158020/file/288298/transcript/83171/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"We are recording and we are in Montreal, Quebec, Canada. It is November 16, 2009. I’m sitting here with Maurice Wood and continuing the conversation that we started at the last NAPCRG meeting in San Juan, Puerto Rico in 2008. And, Maurice, thank you again for taking additional time. I know that many people will enjoy hearing about the history that you helped to shape for the organization and for family medicine. What we didn’t get to in Puerto Rico was the story of the formation and evolution of NAPCRG and I wondered if you could take us back to those days in the 1970s and how did that happen?\n\nAs you know, I arrived actually on a sabbatical which was initiated on my lecture tour in 1968. One of the places I came to was Richmond. And when I got there, the legislature was agonizing about the necessity to give line item monies to the two universities and the MCV (and I use that term) and UVA. And I was asked to stay on for the next week to actually talk to the legislature as a whole about the content of my presentation which necessitated giving my giving the back-ground of my own teaching practice in England and the study on the use of a nurse practitioner and the impact of the nurse practitioner on the physician’s use of time. And I had been in Canada and had contacted an individual in preventive medicine in Dover (?) who had also done some work in a specialty. Not a generalist environment, a specialty environment. And I came there and then left him and came across to make the presentation at Richmond because I had a colleague who was actually on the faculty in Richmond. When I gave my presentation, after that they asked me if I would stay on and give evidence to the legislative committee which was in the process of making that decision. So I stayed the next week and I went through two, two hour sessions of giving evidence to the legislative committee. And then at the end of the week the dean, who was Kinlow Nelson (?) at that time at MCV, took Erika and I to dinner at the -- Bear Club on the Saturday night. And there were five faculty members that I had already met and talked to several times during the week, and their wives there, and then Kinlow said I would like you to know that this is the first meeting of the search committee for the chair of family medicine and I have to tell you that we got notice this morning that the funding is going ahead and probably, because of what you were able to give them, there will be a line item for each of the two universities. And he said, as I told you before, we are not able (which was Kinlow speaking) … We are not able. If we do it, it won’t work, so we’ve been looking for a family physician to head the department and as yet we cannot find one who is willing to leave his practice and come and do this. You obviously have a lot of experience. We’ve all heard the details and they’ve all heard the details of your teaching practice and they would feel honored if you would come and take the chair. And I said I’m at the -- of my career, I’ve got a teaching practice, I just graduated the first group of residents and I’m teaching at the university. I’ve got a three session appointment and I’ve also got a three session appointment with psychiatry and I can’t imagine being … And then he said, well, perhaps you’d be prepared to come over and give us some time. And I said, well, do you mean a sort of sabbatical? And he said yes. So I said I’d go home and see what I could do. And I got back on November 1, after being away six weeks, and the first thing I saw in my mail that had come in that morning was a notice that the National Health Service, it was their white paper which said “Sabbatical Leave for Family Doctors.” It told me what to do and I did it. Got the agreement of my partners and I got the first one. So I came over here and with the permission of the college, the Royal College of General Practitioners, because I was a member of the National Research Group, with their permission I got all the instruments that we were using to record information in our teaching practice. Well, we didn’t have any teaching practices. Mine was the first one in the northeast. And there were one or two more which were happening out in the periphery but it was not a universal effort. We were finding out how. And it did take us about fifteen years of work to develop the instruments that we were using to produce information from our practices. And this was the E book. And, of course, we had a considerable amount of demographic data because of the fact that we had patients – each practice was a microcosm of each community and we had detailed information from the National Health Service of what the ages were and how many individuals, whatever ages that we were responsible for. So every single practice population was a microcosm of the community and this gave us enormous power because we had a made to measure denominator in every single circumstance. So I, first of all, had to bring the instruments which would allow us to and develop the clinical information which was the E book that we were using. So I had to train our people to do this. And we established, first of all, Blackstone. \n\nI skipped over, of course, all of the business that went on … I think I must have addressed that previously. Okay. I skipped over that and I’m speaking now from the standpoint of what began to happen in the first year of my being here. I was due to come in 1970, in early September. Actually, I was to be here, in the United States, in September. I had to postpone my departure because of the difficulties I had in separating from my practice, and particularly my psychiatric responsibilities at the Department of Psychological Medicine. I had to hand over a lot of people that I was counseling. And, also, I had a lot of people in my practice that I was counseling. And I went through all of the ones that I felt were at risk and the ones that I hadn’t seen for a couple of years, I decided they had an open opportunity to come see me. And if I hadn’t heard from them, that I had to continue to presume that they were well. So I started this development at Blackstone and also in Fairfax. Those were the two practice environments which were real family physician environments. And so we had to change the whole of their structure and their filing system so that we had the geographic structure of their files and teach them how to record the minimum of information which was necessary for both clinical and demographic date. And I was working closely, of course, with the Department of Biostatistics and MCV who was led by an older Irishman that I had known about and I communicated with him and he had agreed that he would work very, very hard. I said I can’t do anything here without a statistician, so he agreed actually to be our professional resource. And we had a link which continued for many years at MCV. Anyway, the result was that we were beginning to develop a database which was actually the first trunch (?) of information which became later known as the Virginia Study. And I published the first edition based on (?) the Journal of Medical Education in 1974 (and I’m jumping ahead a little bit). So we were actually in the process of developing this. And during this time, I arrived, in fact, on the 5th of January, 1971, finally being able to extricate myself from all of the separation anxiety of my patients. And I’ve got all sorts of stories about that which I won’t bore you with. But that was an important part of what happened afterwards because for me a separation anxiety from this practice which I’d been running for twenty-four years and had built up from under 1500 patients, most of them prior, because I had a very … The only word I can say is the town I was in, I had a spectrum of very rich people who lived in Westfall (?) Village and they owned the ship building and the ship repairing things and they’d been there forever. And then, of course, it was an industrial town, so that was the rest of the population. But I had the kernel of two levels which was an enormously powerful way of getting the difference between … Because these people were all at the level one and the population as a whole had a substantial number of Arabs. In fact, we had three mosques in the town. So there was a mix. I didn’t have very many of those but I had some patients. So there was a wonderful mix of people. A very homogenous group of people but also a wide ranging population. Anyway, I had coped with that and brought all of this over to the United States. I had gotten a very substantial grant the first year that I arrived. I had written an application for funding to develop the system and I got funded from a group which were a special part, which after I discovered was a group of bureaucrats who were actually trying to interfere with the development of HMSA, which I discovered later was supported by Carl White. And I found myself actually, this was in the first ten months of being there, the first grant I got, I got funding for almost $450,000 to do this. And so I got up to … Hugh, of course, had come over to stay with me. Did I address that? I did, okay. Well, Hugh and I were together. So we went up to deal with this. And to me my surprise, the staff people suggested that we combine all eight branches which had been funded and they all followed my model and I would be the leader of the whole lot. Well, I was absolutely horrified at the idea of doing that because Hugh had taken the chair because I hadn’t been able to get there in time. And he told me when he came (I’ll just remind you about that) … The one thing he was going to do was to go back to practice. And he said I’m going to make sure that you stay. And I said you’ve seen what I’ve got, you’ve been in my practice, you’ve seen all my partners, you’ve been at the university and you know where we are. And he said, well, I’m going to be honest with you and say I’m not going to stay in this job. I’ll fill in for a year, then you have to take over. Well, I wasn’t going to argue about that. But I had gotten this grant and fortunately the discussions ensued over that first full day led to the fact that this is what they wanted to do, me to lead this. And I said that I couldn’t make that decision at this particular time. Hugh and I would have to go back and talk about this. And what I needed to do, of course, was to find out just exactly where we were. And at that time I did not know what the justification for this was. So I said that we would go back and do it. Well, that particular day there was a follow-up to Camille and there was a flooding and we couldn’t get back to Richmond. So I think we stayed overnight, then we went back the next day. And we had to go around to it to get back across the river because 95 was totally closed. Anyway, we started … I learned then that, in fact, HMSA was also involved in the same sort of thing. And then I got the summons to go up to a joint meeting between these two groups. So I went up there on my own to see just exactly what the situation was. And it was quite obvious after that morning that the combination, that my special unit group wanted to do was not going to work. HMSA was well established. They already actually had gotten into being the survey, the health survey which we’ve been using ever since. And they were very, very forceable about this shouldn’t happen. \n\nCan you spell out for folks, what does HMSA stand out? \n\nThis was the group that was actually led by Carl White. He was the resource person they were using. And they developed the … This was the name of the agency that, and I can’t remember the exact … Health Service … They were developing the instrument which became the regular thing that we measured in subsequent years the change in office practice throughout. So I’ll have to sort of go and look it up. I can’t remember the exact structure of it. But, anyway, I found myself in this battle between two agencies and it was quite obvious it was not going to work. And we finished at the end of that day by there being an agreement that they would sort it out, then they would tell us what was going to happen. And what came back within about a week was the notice that from the agency that had funded me and the other eight people, the other seven people, that we should actually go back to using the models that we had individually found. So I had this $400,000, or thereabouts, which I was then able to stretch over several years. And that was the basis for us building up the research capability. Because Hugh and I had made the decision that of the line item that we had, we would use one-quarter of it, 25% for research purposes only. So I had that money. And then, of course, this $400,000 which was a substantial grant at that time. In fact, it was a new department and this first grant, so we were on television and all the rest of it. \n\nAnyway, I started publishing. And I think the first crunch of information went out in – I wrote one or two things during that year and I talked about it at various of the meetings. The other important thing was that the Academy gave me the opportunity to travel on their behalf and speak to people about the information collection. So they gave me about eighteen months in which they funded my travel all over the United States and I talked to, I don’t know, somewhere in the thirties of sites. And I told them what we were doing in Virginia, what we were trying to do and why we were doing this and what I was trying to develop was an information base which would be totally American, which could be used to develop an appropriate curriculum for family medicine training programs. \n\nCan you recall who were the people in the American Academy at that time that might have contacted you? I guess we could figure it out by looking back.\n\nIt was the first head of the information base. They were trying to control how the teaching programs managed the training and they had very specific ideas, how much time they should be in hospital - and they wanted to concentrate. And I had … You remember, everything was very open at that time. I said the absolutely essential element for teaching this program is to have residency training. I said hospital is okay for the first year of the residency but the last two years clinically should be in, and that’s what we are going to do. We are going to fund the teaching practices so that they are actually clinically linked to the whole system, to the department. Their data is flowing in. That’s the basis of the information base we have. But we have to do the teaching in the office practice. The major part of the teaching in the last few years has to be in the office. I said that’s absolutely essential and I will not change from that. Well, they were open enough that they let me do it. So for two years, eighteen months that I got this open sesame to everywhere. So there was a lot of information about that. Well, what that precipitated, and this is the point of this introduction, a whole bunch of people coming and visiting me. And I had built a research group of five which were linked between myself and by statistics because we were evaluating the data and polishing the data as it came in, particularly building the demographic database which my colleague in biostatistics was going to use to try and model a mechanism whereby we could identify the demography of a practice and come up with a denominator – which was the essential thing, we thought, at that time. The numerators we could actually identify from within the context of the practice but the denominator had to be a wider thing. And that was the reason for my structuring the filing systems on a geographic basis so that we could, in fact, link into the data that was available from the counties – and so on and so forth. So all of this was going on. And I had this team of five people. And after the first year, by the end of 1971 I was absolutely overwhelmed with people coming in. And my time … And, remember, I was trying to teach family medicine. I had the only two hour session teaching family medicine. I was bringing in the physicians that I recruited in the Richmond area and around and asking them to come in with patients, with specific --, and to have an interaction with the class, about 128. And this was an exciting thing to do because those classes, they were sophomores. I didn’t get any access to the freshmen. I got two hours during that first year, which was the honeymoon period, I got two hours with the sophomores. And this had an enormous impact because the families … We had people who had had recent losses and we had the family physician tell how they were. And then we had them, and usually a supporter, talk about how it had been for them during the recovery, the grieving process and how they had gone through the grieving process, and I used that as a structure. This is one of the things. But we had all sorts of particular conditions. I used diabetes and all of the chronic conditions and the students got a feel for how they were doing. Then we allowed them to interact with the family physician and the patients. And it was a wonderful and an enormous enthusiasm from the first thing. And needless to say, the sophomore group … And internal medicine complained that what was coming out of this was not in keeping with what they were teaching, so they insisted, through the dean, that they have an internist who could stay and audit what was this heinous information that I was given. So I had a lot of difficulty with that and I had to really concentrate on that. And I was also trying to build this other thing and, also, my staff were doing a lot of the education of the people who were coming for an interview. And then I always had to see them at the end because they always had questions – now, how can I do this? Okay, I’ll find out what you’re collecting. How the hell are you going to use it? So I said to myself, in early ’72, I can’t go on like this. So the Academy was still supporting me and I was still traveling and they were beginning to get a bit fractures about the fact that I was doing two years, that we were actually funding the practices to teach, to have the residents from there because we had a -- group of first year people that we moved and so we actually filled two years of the first group. And the Academy got a bit upset because they thought that they should be also having a good, long hospital experience there. I said the clinical work is what they’re going to be doing for the rest of their lives and the information base that they’re getting is entirely different from what they get in hospital. This is where it must be. So I insisted. And, actually, let me just diverse a little and say that the insistence that I do this caused them to remove, finally after eighteen months they just stopped supporting me for this travel. They said I was upsetting them because I was trying to spread the Blackstone model too widely and so the removed me from that. They were getting too many applications from rural places who were going to use this. And, of course, the big problem as far as we were concerned, there were sixty of the 104 counties hadn’t had a new physician since World War II. And we had an ancient, I mean fifty and sixty and sixty-five year old doctors looking after whole counties. And I was the political push that led to the legislature considering whether or not we should do this. So I was in bad order with my faculty, particularly internal medicine. Pediatrics weren’t so bad but internal medicine were really, to put it bluntly, upset and they were determined to stop this. And, actually, the result was that I lost the sophomore time the next year. So I got a week in the freshman year, so I changed direction and used that as … We gave them a very quick training, then I attached the freshmen students to patients. So I was very deeply involved in undergraduate teaching, research development and resident teaching. \n\nI was going to Blackstone and Fairfax on a regular basis to teach what I looked so as the bio-medical, the psychosocial medical mix that we were dealing with. That was an important thing to get across, that people came and you were dealing with people and their emotions as well as their biological problems. It wasn’t just a totally biological scenario and you couldn’t divorce … Because family medicine is about people, it’s not about diseases. And that message was the one that I had to get across. So I was a bit overwhelmed with all of this. So in April, a month or so before, I spoke to the Academy and I said, look, I can’t continue to cope with all of this input, so I would like to have a meeting. I would like to circularize all of the people and say that I am prepared to have a meeting here. And the hospital Newport News agreed to actually fund a meeting, provided the opportunity and the circumstances and also funded a dinner for the attendees. And the Academy said, okay, they would send a representative. So they had a board member who was down in North Carolina and he was actually still in practice. But the east Carolina university was in sort of a beginning and there was a possibility. In fact what happened, he became the chair of the Department of Family Medicine there, which wasn’t until about ’73, ’74 that started. \n\nWas that Jim Jones? \n\nJim Jones. \n\nAnd just for the listeners, the hospital in Newport News is Riverside. It was also one of the places where we had the first residency. But I know that was a different circumstance than Fairfax and Blackstone. It was not a private practice. \n\nWe went on and negotiated – we did the other two practices the same. We funded them for their time to do the teaching there. Newport News, the hospital was doing it so we had the interns involved. And, also, Sam Mitchell, of course, was the director and he was working through the hospital until they took the outpatient department essentially as the teaching practice and turned it into a practice thing. And they were very supportive. And I was also installing … So I had three places that I was installing instrument. So I was traveling around. And at the same time, teaching at community hospitals and other places and also building up practice population for the Virginia study.\n\nWe went ahead and had this three day meeting and we circularized everyone. And at the time, I had a British buddy who was up in, would come across much as the same sort of time as I had and with the intention, actually, probably, of staying in the United States. He was up in Rochester with Gene Farley. And I had gotten to know Gene Farley very well. I’d been communicating with him before I came. And, of course, I knew that David was coming over. So we actually got together and we did a little bit of sort of traveling together and talking, reinforcing each other at the various places which had departments. Places like Wisconsin, Madison, Wisconsin, because they were one of the early … And there was an American colleague who was actually the department head there and his idea was not to do what we were doing, using the college classification – which incidentally, David and I had modified it (this was David Metcalf, incidentally) to Americanize it, with the permission of the college, and this is what we were using as a filter for the clinical data that we were collecting. And, of course, we had symptoms in that. This person wanted to actually only collect symptoms, nothing else but symptoms, which I saw enormous problems with because the funding, there was no way you could use that for funding purposes. Anyway, that’s another issue. But we had fifty people who came to that meeting and David Metcalf and I were there. And I had written three papers and I got our internists from Newport News to read one paper on age and sex measures and I did the one on the clinical information and how to do it. And then we had another faculty member who gave the warm-up on the family size and things of that sort. And David had also written three papers and he got his faculty, including Gene Farley, of course, with his own view of it. So he did a presentation. Then David had two himself and another person from Rochester. They had a very much smaller setup than we had. They didn’t have anything like our line item. And, of course, our line item that we had we were able to use totally and completely for the teaching practices because Hugh and I were paid through the dean’s office with the state step (?). And then we were doing clinical work in the little practice in -- and there were still houses there and there was a pharmacy and also this little practice. So we actually did that for the first year as well. I had forgotten about that. I did a couple of deliveries in the United States and I had an enormous obstetric practice in Briton. We were doing over 350 deliveries a year - and that when it was just a small practice. I really enjoyed obstetrics. There were an enormous amount of stories about that. But, anyway, I was able to do two in the United States and I had more data to complete for those two patients than I had for the whole of my practice of the population. I got paid for having four dates in Briton. That’s all I had to do and put it in and I got the full payment for the whole thing from diagnosis to delivery and also the first year of looking after the baby. So I didn’t do anymore deliveries after that. In any case, by this time everyone had left and the practice was down to practically nothing. So we never got to start another practice again. And I did my clinical work down in Blackstone and I did mostly in the context of teaching. So my clinical work stayed actually at Blackstone during the whole time I was there. \n\nBack to the meeting. We had teaching sessions for what we were doing for each session. And we had a full day to start with and we had a get-together, a dinner at the country club, which was funded by Riverside Hospital for which I would be -- grateful. And then we had another second day that went right up until 5:00, 6:00 in the evening when people could leave – because some of them were staying overnight. But anyway, towards the end of this the enthusiasm was just absolutely infectious. Everyone was really delighted with this. And we were sort of sitting at the last session and Gene Farley had asked if he could say a few words towards the end. So David and I were sitting together and sort of making notes because I had to make a report of this to the Academy which was to be supported by whatever John (?) said. So Gene Farley said, well, I have to give you my own personal opinion about what’s happened here. And, also, I’d like to sort of … I’ve talked to a lot of people about this and I have to say this is the most significant thing that we’ve ever had in family medicine since we’ve been talking about this. Remember, this was only a year after it had become a specialty. So he said I’m going to ask Maurice and David if they would sit down together and come up with doing this on an annual basis. And I was absolutely horrified – I thought, oh, my God, something else! Anyway, I got up after he said that … He said, I’d like some sort of reaction. So I got up and I said I did this, I organized this and David agreed to come into this because I was absolutely overwhelmed with the visitations, to look and see how we were doing this in practices. I said I think this will have an impact. Obviously everybody who’s vaguely interested in this is already here. And if this cuts down the amount of visitation that I’m having and the work that my staff are having to do, I’ll be willing to try another couple of … And there were some people from Wisconsin and Minnesota and they said, well, we could manage … This was in the spring, and they said why don’t we manage a second meeting to see how it goes towards the end of the year? So we came up with November. And we actually had the second meeting up there. There was one individual who had been in practice and they’d been linked with the department. They had a different setup. But he set that up. And, of course, it was snowing like hell and it was cold. We had the second meeting there which had around fifty, sixty people, reinforcing, I did the same things again. And then I arranged the third meeting actually up in … Because we had Canadians there and David and I had decided that we would, in fact, reinforce the Canadians and use them to … We talked to the representatives there. And I’m trying to remember who specifically it was. There were a couple of Brits who were actually working. There was one from the northeast of England and he was there. Anyway, they said they would like to hold the meeting the next year. That would be 1973. And I pulled together one of my colleagues from the northeast of England, called Keith Hodgkin (?), who had written within the actual study, looking at the difference between his residency and what he saw and his first year in practice. And there were just two different parts of the spectrum of clinical experience. And he said why are we using hospitals to teach this when all of the stuff we’re doing is done here? And that was the basis of, and he had done this actually ten years before … And this was the thing that really made us realize in England that we had to teach family medicine in family medicine offices. And I used that to beat the Academy and all of the people, we used that as … He actually came to Newfoundland as the chair and I got him to come down. And he was a wonderful speaker and he was the theme speaker. And that was what set the pattern for the future. And it was a great success. \n\nHis name again? \n\nKeith Hodgkin. He was the grand-nephew of – Hodgkin. And there’s a long family history of physicians in every … His father was a physician and he was a major, major figure in all of the research environment. And he was in the northeast of England. He was actually in practice in a seaside resort in the north of England. And we had worked together – I had been working with him for almost fifteen years doing our research studies. We had as many as a dozen research studies going on in the Northeastern Faculty when I was chair of the Northeastern Faculty Research Committee and then I was the vice provost of the faculty. We divided the country into faculties. \n\nI remember that from our previous talk. I want to be clear then, Maurice, about how the Canadian connection happened. And let me just paraphrase: So the meeting moved to the northern parts of the United States, Wisconsin. Was Keith at that meeting in Wisconsin or was it one …\n\nThere were several other Canadians who had come over. \n\nHow did that happen? How did the Canadians get involved?\n\nIn my lecture tour in 1968, I had gone to Canada, first of all, and I had visited…I had a colleague who had been in practice in Oxfordshire (?) who was also research-oriented and also a very good teacher who was in [Ian] McWhinney. And so in McWhinney, whom I know and I had worked with, with the college, had already come to Canada the year before, to western Ontario. And so I went to four places in Canada. And we went to Ian’s place and spent some time there with his students and we looked at the building that the university, which was literally a foundation. That’s all he had to show us. And I talked to students that he managed to collect. And so I had a close link with the people that I’d been in Canada and I involved them when I had this meeting. I said perhaps you’d like to come down – and you have a better idea. Because particularly those colleagues who had come to Canada, they had been involved in what was … Because we were doing family medicine training in practice at that time. So I got these half dozen Canadians to come. \n\nDid they come to the first meeting? \n\nYes, they were there at the time. And so I talked to them I said, are you prepared to be involved in this? And they said they would like to, if we were going to do this. So David and I sat down with the back of an envelope and said what are we going to call this thing.  So we came up with all sorts of things. I said, well, we can’t make it just American; we’ve got the Canadians. So why don’t we make it North American and try and keep this link between? Because there are so many Brits there who have the background of what the college has been doing over the past fifteen years and even that little bit of information is a resource which we ought to be able to use.\n\nSo I brought in the Canadians from the word go. And then some of them came to the second meeting. And then, of course, having the third meeting with Keith Hodgkin. And they all knew Keith Hodgkin, so they came. So we had about sixty-five or seventy people at the second one. I can’t remember the numbers now. But we did the same type of thing again and there was a different group, so it expanded the American spectrum considerably. And at that meeting we planned the next one and we said, well, we’ll do it again in the United States. And I had all of this in my mind at one stage, but I’ve got the record of it. I’m just trying to remember exactly where was the fourth meeting. I think it was out west somewhere. I know San Francisco wasn’t until 1976, which was the first one that Carl White came to, and it dealt with the publication of the second trunch (?) of the -- study, which Hugh and I were trying to recruit David with his neonatal background. He had been in the service and he was linked to Riverside because of his army work. But he was supposed to be going back up to Boston to his neonatology. And Hugh was determined that one way or another we were going to … Because he had shown considerable interest in this and was a quintessential academic. I had said to Hugh after my publication in the Journal of Medical Education of the first Trunch (?) in 1974, I headed that, and I said we’ve got this much more sophisticated data and we have now something over 500,000 consultations. To be quite honest with you, I had just accepted the associate editorship of the Journal of Family Practice and I had agreed to do that if they would give me the full edition because we had only just started – if they would give me the full edition that I could put the whole thing in. And, of course, I had gotten Keith Hodgkins to write a research aspect of it. I had gotten Ian McQuinney to talk about the educational aspect. I got a guy down in North Carolina, an American whose name escapes me at the moment. He was the chair down there. And he dealt with the practice aspect of that. And then I wrote the rest of the opening describing what I was going to do and meld the four bits together and then showed excerpts. Well, the publication is available, so … I’ve read all of those. You’ve read all of it. Anyway, it was an achievement. I didn’t expect it to have the enormous impact that it did have because it also transferred to Canada. Dr. Rosser (?) took that up and immediately said he used it. He had just taken the first of the chairs. I think he had four or five chairs over time. And he said, I want you to know that I used the Virginia study in every single one of those environments to initiate the curriculum development and it was the tool that we used at North America to develop the curriculum. Of course, it was also being used by individuals. And, of course, all of the instruments that … That was another thing that upset me a little bit. One of our colleagues out west had taken the instruments I brought and I modified the college ones and I made them available because the college had given me the authority to keep it. In fact, I said to Hugh, you know, this is so important that we do this that I’m going to put all of this in open, so it’s available to everybody. I want it to be used, so I have the permission of the college to use the basic instruments and the modifications that we’ve done. And by this time, incidentally, David Metcalf had gone back to England, so by the second year I was on my own. In fact, I was on my own for the development of the third meeting which was up in Canada. And David, he actually had gotten the offer as the second university chair, so he went to Nottingham and started there. And that was obviously the appropriate thing to do for him.\n\nI was subsequently offered a chair which I turned down after I decided to stay because I thought the Manchester chair, --, was coming up – and I thought I might have a chance to do that. And that’s the reason why I stayed. After I changed my mind, I’m sort of jumping a little bit, I suppose, but it’s the natural continuation of this. I’ve gotten up to perhaps ’75, ’76, when the meeting was in San Francisco. In the meantime, I had gotten over this dissidence that I had with HMSA and I contacted Carl White. He was then at Johns Hopkins. And I met him I 1963 in London at a meeting. And I called him up and he remembered me because I had done \n\nthe chronic bronchitis survey and we’d also done the first part of the practice nurse study and I was busy with that. And he said, oh, I remember you; you’re that small person who is doing nursing stuff. So I went up and saw him and talked. And he had just taken the responsibility for the U.S. National Committee and Vital Health Statistics. So he listened to me and he said, look, I have got the opportunity of bringing in consultants to the U.S. National Committee. Would you be prepared to perhaps come up, not on a regular basis unless we feel that’s necessary, but to come up and have input into this? I already was fiddling around with the feds because of the grant that I had and I was using that simply to expand our system. And I managed to stretch that over a period of about six or seven years. So I thought, well, this is another opportunity to get to know … But I thought I’m not a statistician by any stretch of the imagination, so vital statistics? I thought I’ve got that epidemiology background – and the whole of the medical education in Britain has an epidemiological base to it. I mean you cannot avoid that. And I had done an extra – during the time I was in premed, I had taken the opportunity of doing, because I was having to repeat that, because of zoology, my school didn’t have a zoology thing and they wouldn’t let me take anatomy, physiology and zoology at the same time. So I had to collapse those two years into a single year and I took a course at the university on epidemiology for that. So I was pretty well steeped in that. And that’s the way I thought about practice. I couldn’t think of it except as an epidemiological unit, a microcosm of the whole community.  And, actually, I enjoyed that. And I finished going regularly to the meetings. In fact, they called me virtually every time to come up. And, of course, I met a very young Barbara Staffield (?). And, also, after I think a couple of years Carl White agreed to take a second tour of that and he proposed me as a member. So I got a four year stint as a full member and got to know a lot of other people during that time. And got to know NIMH and NCHS in a very, very detailed way because I chaired the international committee -- and I was up in Washington literally every weekend. But it was a very good experience because I got to know things about … Because Washington, at the time, was all torn to pieces because they were building the subway and it kept changing. So I always stayed in Embassy Row and had my meetings in the Embassy Row Hotel which worked very, very well. And I was able to take my family with me, Erika and -- which made it very, very comfortable. \n\nCan I ask you something about the NAPCRG meetings that I think people would be interested in knowing? There is a persistent honoring of the supportive nature. And you, yourself, as we talked earlier before we started the recording said it’s important for these meetings to feel casual and welcoming. So can you reflect back on how that idea started and how it became such a central theme of the culture?\n\nWell, you have to remember that I came to the United States with a background in running a research organization, a very, very effective research organization for almost twelve of the fifteen years that we’d been doing it in Britain and I had as many as six projects going. I learned some things which were important; first of all, research, you have to have a critical mass of people, you have to have multiple inputs and you have to think together. And so the important thing was the critical mass and the environment in which you did it. And we had, of course, formal presentations of other disciplines and all the rest of it. And the to and fro of aggression that went on, people would get up from the floor and ask pointed and difficult questions and there was this … That I hated, you couldn’t do that. So I organized always supportive role because everyone who came to these meetings were not as researchers. I mean we were recruiting new people all the time. And they were all doing a little bit of something, they had an interest in some aspect of their practice and they had collected data from it. So the idea was to come in and talk about what they had. How many patients they had, this, that and the other, and then get input from everybody else. And that way, by being supportive and asking questions in a positive way and not using as a … I found that the only way we could do that and bringing new people in, trying to get the elements of research patent across, was to be supportive. Then I thought, well, if we do this, I’ve got everybody’s who’s coming in, most of them were from practice. Many of them were politicians who saw this as another way to enlarge themselves. And they were beginning to take chairs or positions in new departments. And I thought they’ve got to have some idea of what research is about and how much of an imperative it was to have in the teaching environment that we knew nothing … We only had the first skimmings of the detail about the work, was how different it was, what we did compared with other commissions who were hospital based. And the only way I could think to do it was the mentoring and supportive process. From the very beginning I dressed down. I took off the tie and I sat there. And I was doing a lot of lectures. I’d been all over the country for eighteen months. And I made it low key. I battered around with the individuals who were hosting me and we had a lot of fun. And I made it low key and I always reached out to the audience and said, you know, if you have questions ask me what you like. I may not be able to answer them, but I’ll be honest with you. If I can’t answer them, I’ll tell you and I’ll tell you why I can’t answer them. So I guess this grew during the eighteen months the Academy gave me. And I certainly got to know the United States because I ranged from Maine down to San Francisco, to Seattle and to Midwest and Columbus down to Alabama, New Orleans. I was all over the place. \n\n-- and I made an agreement that … He went on to leave at the end of a twelve month period and I perhaps ought to fit that in. I’m not sure that you know that story. No, I don’t. Well, said I will transfer it after a year and I said I’ll do the politics for you and you, by that time, will have a feel for this. Then we will go and talk to Kenlow (?) and have it transferred. So I was deeply involved in all this other stuff and what politics there were, he shared with me. We did everything together, incidentally. I went with him to the department chair meetings. And, of course, I was supporter at MCV. The big supporter was the massive surgical resource we had at that time which was David Hume (?). And he was a very --. He was literally a personal friend of us because he used to go down personally to Blackstone and teach. And he would fly down and he would call me and say, Maurice, I’m going to be there at such-and-such a time. Will you have somebody working at the -- for me, to take me to the … \n\nIf I could just interject briefly for those who don’t know – David Hume was a pioneer in transplantation and I think was working with … Who is the gentleman from South Africa who actually did the first ... \n\nDr. Barnard. \n\nChristiaan Barnard, that they were actively in dialogue. And I think the first heart transplant in the United States was at MCV by David Hume. \n\nYes, and they had the longest living transplant at that particular time. And he dominated MCV at that time. He would come into the chair meetings and he would walk in, go right to the board, erase whatever was on it and put what he had, deal with that, then he would leave. \n\nYes. I’ve heard stories of what a strong personality he was. \n\nBut he was wonderful. Without those first two or three years … I remember the devastation happening because our honeymoon didn’t last very long. I think I’ve already stressed that in. Yes. Really, by the end of ’71 I had lost the sophomore thing. And the next year I got the one week. And, of course, I turned that into a clinical experience for students, which was incredibly popular. And the internists tried to stop me because they said they hadn’t yet had the training. We were doing the clinical training, so at least they knew how to touch a patient and how to use the instruments, the --oscope. So, again, we did sort of a crash course for that for each group, the class up. And the whole class got an experience in family medicine. And that was the freshman class, in the second year. And, of course, at that time there was an enormous interest nationally from all of the turmoil of the sixties and they were all now becoming into family medicine. We were inundated with applications. And they would come in groups of six and I tried to take over a whole program. And Blackstone was enormously popular and people came on and said we want to take the whole of Blackstone; I’ve got five people, all of whom are committed to this. We had an awful lot of sorting out to do and I was spending a lot of time interviewing applicants for the residencies. It was just enormously exciting turmoil. And most of the attitudes and most of the things involved were introduced into NAPCRG because the NAPCRG meeting became a bigger and bigger thing. We started in ’72 and by 1975, which was three years, we were up to 120 people. And as I say, Carl White came to the first one, I think it was in ’75 or ’76. I think it was probably ’76, in San Francisco. And I managed to persuade him … I was, by that time, on the national committee and he became a member. And he came every single year after that. And he said this is the most magnificent … And everyone talks about the early ones who are now – Larry Green and all the rest of them remember the enormous input that he had. And he was an enormously powerful supporter and I’m eternally indebted to him for the support he gave me. It wouldn’t have been possible without him. We’re still buddies and he’s still alive and that’s a very important part of … I don’t get to see him as much. I’m going only about every two months now. But I think it’s going to get better now because I’ve got more support for Erika and I can leave better. I’m seeing him when I get back after this on Wednesday for lunch.\n\nYou were going to tell me how things changed for the agreement between you and Hugh. And Hugh was going to be gone for a year.\n\nI agree to go and talk to -- Kenlow (?). And I said, okay, I still need support with the politics of it because we were having to negotiate with the legislature at the end of every … The biennium had come up and we had to go down together and talk because there were always difficulties. But our budget, obviously the one we put in together, had to be cut. Well, I was going to have to do that if he went back. And I thought, well, if I’m going to get less and less, I’ll just have to get more resources to do the research stuff, which was taking, still, an enormous amount of my time. And I said, can you not stay on temporarily or can you not … Of course, he was in Virginia Beach. He was going to go back to his practice and come up from Virginia Beach. We were just then actually thinking about negotiating with his practice as a teaching practice. And he said he would be able to deal with that down there. And I said, well, the problem is going to be up here with too few of us and I can’t be doing what you have been doing in the political sense as well as do all the other stuff. So we went along and he said I’ll stay but you’ve got have the chair so that I will be able to opt out if any … But his attitude was also changing at the time. But anyway, we went down, talked to Dean Kenlow, who I think we going to be leaving the next year. And he said, you know, your honeymoon is over. He said Maurice has upset the internists considerably and that’s why you lost the sophomore experience. And he said they’re not really very happy about what you’re doing in the freshman year. And, of course, they had just put me in charge. The previous dean had put me in charge. Or Kenlow had put me in charge of the community hospital experience and I used that opportunity to actually expand it by using local practitioners who were using the community hospital and bringing experiences in their practices for third year. Of course, we had a month in the community hospital experience. So I was bending that very, very considerably and getting more input into the third year program. And I wondered, actually, because the database that we had, I wanted to … Epidemiology was taught terribly. It was taught from a book. And I had been teaching epidemiology to the medical students in England from the basis of the data that I had from my practice, which is much, much easier, because I had a direct link between the total demography and I could talk in epidemiological terms. So we had come to the point where we had demographic information. And Carl White then taught me that it was better to be directly right and precisely wrong. So we had a demographic handle. And I had to cut down the amount of resource I was giving to my statistics to polish up the database. I said you’ve got as much as I can give you. I cannot continue paying for this tool which you’re using. And he said, well, I’ve got enough data here, I can manage to extrapolate, so I’ll use that for the modeling. So we separated the Virginia Study data into the -- group that he had. Then I kept the other stuff. Which we still were validating all the time. I had the validation process continuing from all practices. Anyway, Hugh and I went along and Kenlow said, well, they’re all upset and your honeymoon is over. And I can tell you that if you want to come … And this will have to come up to the faculty and the fact that Maurice is going to take over the chair and that they will say this is an opportunity for us to get rid of this guy and they will insist, almost certainly, on a national search and there will be an enormous amount of pressure. And he said I’m not going to be here to be absolutely certain that it will happen. He said I think you’re taking an enormous risk. And he said, you know, the driving force, whatever is happening is Maurice’s --. So he said, why don’t you stay as the chair and do whatever you’re doing and let him get on with it. And that was the essence of it. We had had a long conversation. And Hugh had obviously been thinking along those lines. We literally lived together for those … It was a full year, so it must have been just before the NAPCRG thing. So he said why don’t you let him get on with it and you stay around for a little while longer, ‘til this sort of settles down – or words to that effect. I can’t even remember the detail of it. But anyway, he his advice was very specific, don’t do it. So we went back and talked about it and talked about it and talked about it. And I know this was a painful thing for Hugh. So he said I’m still going to make sure that you stay; If you go away, I can’t do this on my own. And by that time I was getting pressure from my practice. They had kept everything going. And I had two senior partners who were essentially about my age. One was a classmate of mine and he was very positive and supportive, but he was a bit more airy-fairy (?) than my female partner, the next most senior one. And she had brought her practice in to me. She was in the practice next door (?). And the physician that was working with had just retired and she came in with the whole practice. And he’d been looking after my practice during the war time years while my partner was away. So, anyway, Nora moved in until my partner left, because he was a Scot and very fixed in his attitude and the sort of guy who got up in the middle of the night and put his collar and tie on and dressed fully to go out and do a night call while I would haul things over in my pajamas when I did that. Anyway, we decided to keep it at that. And then he just became more and more comfortable. Then, of course, the next major issue was my return. And I discussed with my practice if I could have another three month’s extension. And I extended my time. I’d been there actually two years and three or four months and a sort of crises really occurred with my practice back in England. Particularly from Kitty, my female partner, she was calling me at all times because she could never get the time difference right and she was calling me in the middle of the night with details. And I would say, for God’s sake, we agreed to do it – and I’ll sort it out when I get back. And I said I’m trying to extricate myself but this is very, very difficult. A lot has happened here and I said this is why I’m talking to you, because I have to get a commitment from you all. And I want you to sit down and talk. And you two, Kitty and my classmate, Paul Tanner (?) … I’ve got to agree to come for up to a three month tour as a sabbatical to keep this thing going. That’s the only basis on which I can undertake to leave here. And so I said if you will agree to do that, and there’s possibly one of the other junior partners that I had, one I thought might be capable and the other one was useless. And he’d been at the top of his class … Anyway, that’s another story. But I finally found three of them to agree that they would do this. So I arranged with the practice … And I would fit into that, so there would be four of us coming over. And I would do three month tours with a gap in between. And we would expand it and  diminish it as people became more and more. So he said I don’t think that will fly; perhaps you shouldn’t even try it. You should just stay. And he left me, actually, to do my own negotiating. He knew that I was having trouble again. He was very supportive but he was obviously very distressed as well. And then I said, okay, I will pass this on and see what happens. Well, of course, what was happening, too, is the three practices had gotten together and they said we can’t let this guy go. So they decided to say, when I spoke to them about it, that they would just resign. So I proposed this to Hugh and he said, well, you’re going to have to talk to them. So I called Blackstone and spoke to Epps (?). And he said, well, we can’t cope with this and this is only functioning because you’re here and if you go, it won’t work. So I want you to take this as notice of our resignation from the program. I said, woaw, just a moment; don’t make any moves at all. So I called Fairfax and I got the same story. And I said down for about a half hour and I thought there’s no point in calling Stan Mitchell. They will obviously stay on their own and they’ll just keep doing what they’ve done but they won’t be part of the teaching program. So I thought, God, this is two and a half years wasted. Not for me only but for everybody, for Hugh and all the rest of it. So I went outside to my secretary and I said I’m going to close my door. I want my telephone turned off. I’m going to spend probably the whole of the afternoon. And, of course, I told Hugh that I was going to actually have to go back. And he had left … He had come into my office and said, okay, I’m going to go back home early and be there for the rest of the day, so I’ll talk to you tomorrow when you’ve gone through this process. I sat down and I did a pro and con. And looking at my inner turmoil about going back and picking up all of the relationships that I had with my patients. And I’d already had an offer of a chair in England which I turned down. And I thought I’ve got to go and pick up all of that. Probably work another couple of years, then go through all this separation anxiety. I had a physical discomfort about it and I thought, well, I’ll have to resign from the National Health Service. And I owned all the practice premises and I’d had a very positive relationship with them. We had a very good meeting process. We made decisions very rapidly. And I did all the management of the whole thing. And everybody was following … They all joined me and they all joined my business model, which was a very effective one. And we were making a lot of money and doing, in fact, better. I was the highest paid physician in the town and I was making more than the consultant from practice because I had a very effective practice. And I had this private practice as well, all of which income I put into the practice. And I had it set up whereby, because of the partnership law, so that we were individually and severally responsible, I had the mechanism whereby I extracted the money from the tax and kept it in escrow and paid every … No one got a final payment until two years after they had been here. And this worked very well. In fact, so much so that they kept it for twenty-five years after I left. Anyway, I went through this process and I came up, by around 4:00 or 4:30 in the afternoon, with the idea that I would stay for five years, which I thought would give me time to … Because I knew that Pat Burn (?) was retiring from Manchester and that I might be a candidate for that because I’d been working with him very closely. So I thought five years is a reasonable time. And it would take away the separation anxiety, which was really burning me up, about going back and picking up all of these relationships and having to go through all of that again. And I don’t know that I can actually paint how painful that had been. I knew there would be concern but I hadn’t expected it to be quite so … And there were one or two little things that happened. I probably told you about the story about the ninety-two year old who came in, like she had an open chart, nothing in it. But I knew her very well, I knew all of her grandchildren and her children’s, the younger ones, I had taken care of and had seen her time and time again. And she came in with an inconsequential thing and I said to the nurse, put her in the examination room, get her ready, then keep her there after I’ve seen her because I need to go in and talk to her. Anyway, I went back to her and said, okay, we’ve done your blood and everything and everything is alright. Now you’ve got to tell me why you’ve come. There has to be a reason why you’ve come with this. You’ve never been here before. And I showed her the chart. And she blushed a little bit and said, alright, Dr. Wood. She said, you know, you’ve been an important part of my family’s life and my life and she I’m ninety-two years old and I hear you’re going to go away for at least two years and I may not be here, so I came to say goodbye. Anyway, that kept occurring. And I thought, I can’t do this again. So I had to go and talk to Erika first. It was 4:00 and she was sitting outside with the neighbors. I went across and whispered, can you come back in, I need to talk to you because I’ve got to talk to Hugh. And before that, you and I have to talk. And she looked at me and said, you’ve changed your mind. And I said I’ve got to talk to you about this. She said, okay, if you don’t want to go, I’m here. So I went in, picked up the phone, called Hugh. I said have you recovered (because he was going to go out and get drunk) … And he said I’m alright, I just had a couple of drinks and I came home. He said I’m pretty miserable. I said, well, I’m going to stay. I said I’ll stay at least five years, I’m going to do it. So could I come along and talk to you, because we have to sort out how we’re going to do these responsibilities. And I said if I come up with Erika, can we take you out to dinner? He said, no, we’ll have dinner here. So I drove over with Erika and we sat down and he said why don’t we keep things as they are. Just you do what you continue to do and I’ll do what I continue to do. Then as time goes on we’ll probably find … He said five years might not be enough and I’m still going to come back to --. Of course, he never did. But that’s essentially how we arrived at that. And I then had the problem of getting leave to go back. And I had been there two years and a bit and I had to go to the dean and say I’ve got to have at least six weeks. God, everybody’s hair went up at the idea of my going away for six weeks. And I said I have to essentially sell … Resign from the National Health Service. I got to sell my premises to the partners. And I’m going into a scenario in which there will no longer be six people all supportive. I’m going to be five against one. So I said it’s going to be a very painful process and I know that there are going to be problems about money and all the rest of it – and, sure enough, there were. And there were going to be problems about my leaving. And Kitty, particularly, she was a single female who attached herself to older men and she had enormous social problems and behavioral problems of her own about men particularly. She was a Catholic and all of the men had died. Her father and her grandfather, that she lived with. And she spent all of her medical training, she was sent off by maiden aunts to a convent. And the only way she could think to get out of the convent was to actually do medicine. And there was enough money from her family to do that, so she finished medicine and immediately left the Catholic church. Then she had problems with men thereafter and was always looking for secure older men that she could attach herself to without getting into … Two or three times she was engaged to her boss. She was doing orthopedics to begin with, then came into family medicine. And she attached herself, so she looked for married men who obviously had stable unions so that she could, in fact, be a sort of very close partner in that, and that was the relationship we had. Of course, like many, many Irish people, and she’s the quintessentially Irish, you can very rapidly change from love and support to antipathy. And that’s what I went through. So it was a very difficult separation problem. And she’d been the only one who had actually asked questions about … She agreed that I should go. And when push came to shove and I was going to leave, she said, you know, this practice is you. We’ve gone along with what you want because it’s successful and we’ve got influence – and it’s you. And she said how do you know that the Americans are going to do what … I said I’ve shaken hands with them. I’ve shaken hands with the dean. And I said it’s a commitment. And she said, you know, you can’t be certain that they’ll do it. I said, I have no anxiety about that at all. I know these people and I know what role I’m going to fill and I’m very comfortable about it. And this was a dinner the night before I left. So I knew, because the pattern of behavior over this two and a half years had been increasingly anxious and calling me at all sorts of hours for all sorts of problems which were really quite simple to deal with. And I came back with that, this very negative process. So six weeks, but I cut it short and just cut my losses and came back. And then was never really able to fit back into my practice. And I thought, in my innocence, I would be able to go back on occasions. I kept in touch with all of the other parts of the college and made reports to the college. And, of course, Pat Burn (?), as the president of the college came over and tied him into our educational structure and he became a great hit. In fact, we tried to pull together … We did pull together a group of our chairs, four schools on the east coast so that would actually, after he retired, bring him over for three months at a time, then share him with all the people who were linked into NAPCRG because he was just a wonderful figurehead and a wonderful presenter. I’d had him over several times to NAPCRG and he came regularly to see us. And he did a tour during the last year of his presidency and he came and talked to us about it. He said you may not realize it but I’ve just come back from a world tour and I’ve announced everywhere that there is one superb example of a primary care teaching in the world. Now, try and guess where it is. Then, he said, I’d tell them Blackstone, Virginia. And that’s absolutely quintessentially true.  And he said whenever I’d deliver that, they were astounded. But he said nobody else has done what you’ve done. No practice in the world that we’ve been involved with have we gotten the results of what’s gone on here. And he was down there and he taught every single time he came.\n\nAs I recall, he left the gift of a watercolor to that. It hung in Hugh’s office, then it hung in David’s office. It’s now hanging in my office. That’s marvelous to have that background. I didn’t know about that. Thank you. For me, personally, that’s very helpful. Maurice, I’m going to pause for just a moment here and off the recorder let’s group as to how we’ll use the rest of our time. Is that alright, to take a brief pause? Yes. \n\n[Pause.] \n\nWe’re recorded again. And, Maurice, I would like you to now turn to the story of the development of ICPC and give a little bit of a background of what was the preamble and the circumstances that led to that effort. \n\nOf course, we had ASPN in being at that time, in its very early stages, and most of us, who were members of it, were recording data in our generalist practices. And we had been unable to persuade WHO to incorporate this massive data that we had collected from all over the world into ICD-9 at the symptom level, which we felt at least would have given us something more realistic to use in primary care, family medicine office practice. So, at this time, ’79, ICD-9 was consolidated. And, of course, began work almost immediately on ICD-10. And this was going to be a very different structure and it was going to have a three digit classification which would have branching, specialty classifications from those items. And each of the specialties would have an open-ended numbering system which would allow them to expand; whereas the three digit classification that we were producing would be fairly stable and comparatively stationery. And that one, they thought, would last for the … Because the average length of a classification development was around ten to fifteen years. So NCHS, I was working with at the time on the U.S., the recent visit classification, with Sumi (?), who was the sub-person … NCHS interacted with WHO and offered to fund the development of a three digit classification and they required that I should be the chair and that -- Sumi (?) should be the staff person. That was agreed. So they offered this to me with agreement of my partner, Hugh --, because I was going to have to be traveling to Geneva for probably up to five to six years. I accepted that role – and the first thing I did was, of course, to contact Hank Lamets (?), whom I had known since his graduation, essentially, from medical school and his work with his PhD while he was in the armed forces. Who was then in a practice that he had built, a multi specialty practice in Rotterdam. He and I had met many, many years before while we were both, I was in Britain doing a joint research organization from the University of Rotterdam and we were the only two people who had papers on data collection and information in practice. And from there we became very closely linked and during the years I had stayed in touch with him. And at or about that time he was recruited to chair the Department of General Practice at the University of Amsterdam. And he was deeply involved in research. Although he was a practitioner, he was deeply involved in the same type of information that I had been involved in. And we had continued this together during our period, while I’d been in the United States and he was still in Rotterdam. So I went to WHO and organized the first meeting, having told Hank that he was the first person I chose. I also invited a general practitioner from Malaya (?) who had some influence at the international level through WONCA, the World Organization of Family Doctors. And I knew him personally, having met him several times, and he agreed to come aboard. WHO had chosen a Norwegian, who was rather elderly, who actually only stayed for the first meeting and then told me that he would have to opt out. He couldn’t cope. And WHO accepted this and allowed me to replace his position with one of my own choosing. So I finished up with two other people, one was Bridges Webb (?) from Australia and the other person kept changing depending on what sort of elements that we needed. But there were only four or five people who continued all through this work. We actually, up until the first meeting, came to absolutely agreement. I didn’t join them until fairly late. And usually the meetings were two to three days. And Hank and I had already talked earlier about how we would do it. And when I arrived there, that was already set in stone, so that was fine. And we continued these meetings and we moved them … We had to base it in Geneva because the resource that we were using to record all of this was available only in Geneva. So we were given a young Russian information specialist who actually was the son of the then Soviet Minister of Health. And the unfortunate thing was that every time that his father left the country, he had to leave to go back to Russia. They wouldn’t allow he and his son out at the same time. So we had a couple of sessions in which we had to stop because he was not available, which made it very, very difficult. So Hank and I finally organized a mechanism whereby we would come over and do two to three day’s work together, thinking how we were doing and what we had to do for this. And I have to say that these sessions were really quite incredible because the basis of what we used was our experience in practice. Everything that we decided to do was based on our agreement of the clinical context of what we were dealing with. And that was the absolutely rigid environment in which we did this thing. And we made some enormously peculiar decisions which caused an awful lot of difficulty. We had most of this confirmed by the others, when they came for the open meetings. So I divided the meeting up to a couple of days of Hank and I sitting down and talking and then the others coming for the other three days. So we were had a week, essentially, to do this. And we would be working together, then the other three would come in towards the end. And we could kick it around and change it whatever way and come up with a product at the end of it. We were obviously using the money that NCHS had put in. Each of the time that Hank and I were together, Sumi (?) was working. So this triad really was the resource that crafted what became ICPC. And it took longer than we expected. It was almost six, seven years of effort. And towards the end we had the finished product which we obviously had to test throughout the whole world. And I had deliberately left the classification committee of WONCA and I had taken the chair of the research committee, which was not really doing anything at all, and I managed to expand this so that I had access to recording physicians in multiple countries. And so I used that basis to build a testing spectrum of practices. And I forget how … There were about twenty-five countries. And we tested the use of this in primary care environments in both developed and developing countries where they had, in fact, practices which were functional. However we didn’t, at that time, test in village practices where there were ill-educated people who were just putting, as I say, colored stones into colored containers. But during the course of this five to six years that this was evolving, the attitude of WHO to their original model changed and then they got insisting that most of what we did at the primary care level should be what they called basic care. They called what we were doing primary care. Their primary care approach was this basis in the villages and they called our basic care. So that was the terminology they wanted to use – that was fine. Anyway, we went through this process and we had to test it. And for a period of almost two years I ran the testing and the modification of the three digit classification, testing it again and modifying it. And then we came up with the final debt, which was going to be ... And we were fitting in, of course, with the classification work that was going on with the specialty except that we were involved except insofar as the effective, what items we had in the three digit classification. But there was influence from the other committees which were meeting which drifted down into us. And it was not very, very much. It didn’t alter things very much at all. So, really, what we had was a fairly stable thing. So by the end of it  I had recruited probably eight to ten academics who had been able to come and were paid by funds from WHO and what NCA -- had given. Of course, I was managing the money and things changed, as it was going through, and we sort of kept the … We used as much WHO -- as we could and kept the NCHS so that the influence was there and we could continue to use Sumi (?), who became an imperative for the development of this. Hugh was absolutely superb. And we came to the end and I was summoned through a meeting of the classification unit which was headed by … We had been working with a senior staff person who had come to all of our meetings. We had meetings everywhere, all over the world, including Richmond. They came to Richmond for four or five days. So I was able to sort of move everywhere. And he was always there and he was a difficult person to work with, used to manipulating things to his own advantage. And we had one or spats and I had to dig my toes in several times and insist that without getting my way it as not going to work. And by and large we’d been reasonably successful. So we got to the stage where I had to begin to talk with them about the publication of this. And what I wanted to do, there’s a red book set up within WHO which they accept the data and they publish it and it goes out as the official document. So they dropped a real big stone on my head, I suppose, by telling me they weren’t going to publish it as a red book. So I said, well, we’ve got a problem. I said I have a problem which that will not solve. I’m going then to have to publish it privately. Oh, they said, you can’t do that. It’s published first as a red book – this is a WHO product. And I said, no, it is not. There has been considerable input over these last seven years from my faculty colleagues that I have recruited and they have responsibility to their universities to show a product for the work that they have put in. So you may have paid their way here but their salary has been paid and the time that they’ve given is seen as academic work. So I actually pulled together an approximation of how many hours each individual had put in and faced them with this. And I said there is no way that I can keep this and not have it for the recognition, so I am going to publish it. Whether you like it or not, I am going to publish it. I’ve got all of the data. I’ve got everything that I need to do and I will stop further work … Because they were having us then – I set up a system whereby we could take from one particular country, we were going to actually use the data that particular one which had the most number of what I could call basic care practices. We were going to use that, distill it down and make a very, very simple thing which would be used by illiterate people. And, actually, we started work on that. Anyway, I said I’m going to do this.\n\nIf I could just ask, what was their issue? Why didn’t WHO want to publish it as one of their …\n\nThe explanation to me was that it was going to interfere with the use of ICD-10. That they were putting out a three digit classification version, would be taken up by everybody, they might then ignore the rest of the subspecialty branches. And they had changed things a little bit in the sense that they found that the concept they had of specialty groups being separate and opening up, they had to consolidate it and it was being moved into the three digit version that we had. They were going to retain the three digit version but we could not publish it separately. And so I said I’m going to go ahead and do it. And then I had said that I was going to label it the International Classification of Primary Care and they said you can’t do that because … I said it’s international, it’s primary care and the people who have been involved are all primary care clinicians and that’s the work that’s been done. They said that type of designation is a purview of WHO, you cannot do that – and I said I’m going to do it. So I wasn’t asked to go back to Geneva again. By this time, we had stopped meeting. But I was the chair and I was going to Geneva on my own. After I got that statement, I went back to NCHS and I said I’ve separated myself from them, I’m not going to go back on my own because they’re threatening me. There were all sorts of things. I said I’m not going to go back there again without I either have the head of NCHS (and I forget his name) or No. 2, the person I had been working with. And I said to them I’m not going back there. They’re trying to set up a kangaroo court and they’re going to have five, six black ministers of health from the republics in Africa and they’re going to program it so that if I go over, it will be a kangaroo court and it will be rejected. So I said I’m having nothing to do with that unless either of you two come with me. And they said, okay, that’s it.  So I went ahead and started negotiating with the Oxford University Press and I used the label International Classification of Primary Care and we went along with the considerable work. And Hank helped me a lot with this. Through his department he had access to more statistical resources. My statistical resource was still doing the data that we were collecting. So he had a new department and he had a lot of things going on. A lot of PhD fellows who were prepared to work on this, do specific parts of it. So there a lot of that work came out of Hank’s shop, so we worked very, very closely together. I was doing, if you like, the politics, because I was the particular and active head of this thing. Well, the first thing that I got, which was a bit of a shock, was a letter indicating, from WHO, telling me that I would be sued if I went ahead with this. So I went to the university legal people on this and they said, well, they’ll have to sue the department and it’s a state owned university, so they would essentially be suing us and then also the state. So we need to get some ruling on this from the current attorney general. So that went through the whole process and what came back was a letter to me to propose, with my missive (?), to WHO an official letter indicating that if I was sued, as a member of the department, a tenured professor, they would also be suing the university and the state of Virginia and the state of Virginia was prepared to protect the validity of our position, which I didn’t then. And that letter is now in the state archives somewhere – and I can’t even find the copy. Anyway, this was a shattering shock to WHO. Well, it was very stupid it threaten me. They thought that I was going to be an isolated stupid thing – and then having the whole state of Virginia. So there was silence for a while. And then I got a call. I’m not sure whether it came from NCHS, whether they got the letter first or whether I got it and then I sent it up to … I think it came to me saying that they were prepared to talk to me about this. So they set up this meeting and they mentioned that they had five ministers of health who would review the product that we had and see if it was appropriate for use in their countries. So I called NCHS and got the agreement for the No. 2 to come with me. We had to pick a date when he could do that – and I said I’m not going without you because I know this is a kangaroo court. So we picked a date and sent it and finally they agreed. And, of course, the person that I’d worked with, at the personal level all through, he was way, way down in the … And his boss was chairing this committee. NCHS didn’t have anything to say. He was just there. And I made the presentation to these five, all black, ministers of public health. And, of course, by this time I was really used to this sort of stuff. You know, I did a presentation on my own, when Hugh wasn’t there, when the Board of Visitors (?) had a review, asked all internal medicine, pediatrics, obstetrics and family medicine and any other department chair that wanted to come to talk about the primary care effort of their departments. Well, of course, they left me ‘til the last and what I gave was an overwhelming data-filled presentation and the others just stumbled through some sort of thing with seeing patients and the outpatient department and things like that. So I had all this stuff at my fingertips and we went through this. And the enthusiasm from these five guys was actually incredible. They all, of course, had a university hospital base and they could see the use of this in their outpatient department and they all were absolutely enthusiastic about this. And it was a shattering shock to WHO. They had expected a total rejection – and all we got was universal support. This is absolutely a thing we must have. So at the end of that (at least I had made the decision) I said I’ve had enormous problems with the title and I said I think this is an international instrument and you just agreed with me and I think it should be the international classification of primary care. I said my colleagues here are unwilling to let me do and have been resisting. And they said, oh, absolutely, without any question. So I turned to the boss (?) and I said I’m going to have to leave in about an hour to catch my return with my NCHS colleague, so can I have (because I knew that they could change what they recorded because all of the report of the meeting was going to be changed). So I said, can I have a formal statement from you that I can use, that with your agreement I will use the title of ICPC for my publication and meets with your agreement. Wow, getting around putting those words … He wouldn’t do it. The person who had worked with us formally gave me permission to use the title ICPC. And exactly as I had it, when the thing came back in the report it did not include that. So, fortunately, I had NCHS involved. They wrote back and said this has to go in – and it went in. It went into a copy which probably was never published and it probably just sits in … WHO … But, anyway, I left with the permission and I went ahead and published nothing, that that happened.  \n\nThat is a remarkable story. Let me pause for a second so we can talk a little off the mic.\n\n[Pause.]\n\nWe’re recording again and closing the interview today with Maurice Wood with a question of what would be his advice for the next generation of primary care investigators.\n\nThe thing that concerns me at the moment, there are enormous things that have taken place. The thing that excites me at the moment, which I concur with, is the concept of the medical home. And I see that as something which is not just limited to primary care but should incorporate all of the general specialties, I would call them, internal medicine, pediatrics, obstetrics and gynecology. All of those people who over the years felt that they had a primary care responsibility, they particularly. But, also, it should be open to, in fact – and I’m sure the other specialties and subspecialties will feel that they haven’t (?) at all because they’ve all got some degree of outpatient responsibility. And I think this battle between whose patient is it should go and the patient should belong to the medical home and that the basis of the medical home should be primary care. There are those physicians who are people persons and who are interacting with the individuals as they walk off the street with whichever is the problem they have at that particular moment. And I think we should accept that concept and do the best that we can to incorporate the others, then build around the enormous capacity for coping with uncertainty that exists in the really good family doctors. And there has to be, at some stage, a realization by our specialty colleagues that what we do in terms of the personal demand on us is much more difficult than the procedural processes at which they may carry out. They are limited in the sense of what they do, so they have less uncertainty about what they do. There’s still risk. As a transferred surgeon, I know about the anxieties the surgeons have and I know about the fact that I was taught, as a surgeon, to distance myself from patients because I had to do painful things and that I personally would not have the emotional resource to cope with it. So I was told, in my early days of training and throughout my training, that I should, in fact, diminish my interest in people and should actually keep my aloof and distant. And that is the reason why I left surgery, because I could not do that. To me medicine is an interaction with people and that I use what experience and information and knowledge I have to help them in whatever way is necessary. So, in a sense, dealing with patients is a very strong emotional experience and I enjoy the interaction and it’s the reason why I have enjoyed it all the way through. And let me say, at this point, that my concept has always been that family doctors are born and not made. I do not think you can take every single student or any student, which is what the Academy in the early years felt, that they could take any student and turn him into a family doctor. Not possible. It is not possible. Without the emotional equipment you cannot be a family doctor; therefore, I think it has to be self-selective. And I think we ought to apply that sort of approach to whatever we do with the medical home. And I’m learning that there are new models which are not quite the medical home concept and without even the acceptance of the medical home concept might, in fact, exploit what we already have in a very positive way. And I’m very pleased about that and I’m going to do my best to learn more. Apart from … Are there any specifics that I could suggest? Well, that’s a large area. But I think we ought to try and center on being able to define what is the essence of primary care and the essence of caring for people is about. We’ve done – work a lot in the last few years, which is certainly a move forward. But we should really be able to go in and see how important it is to have continuity of relationship with one individual doctor or can it be spread effectively through a range of a number of doctors. And to me that means that unless you’ve got a group that have actually come together and find themselves compatible, you can then exchange relationships and accept one another’s assessment and go on from there. But until we’ve articulated and defined what those essential elements are, which I don’t think we’ve done yet, then we’ve got to go by what comes from inside. I probably ought to stop there.\n\nWhat I’m hearing though, to paraphrase that, I’ve heard you say we have to not lose sight of what makes primary care … \n\nDifferent. \n\nDifferent and essential. And not to be distracted by efforts to create other ways of making sense of what we do. We have to hang onto the things that brought us to this point in the first place and that our research needs to be informed by those same values and sensibilities. \n\nYes, that’s well said. \n\nNo, I’m just learning from you and many others. \n\nThank you very much Maurice. It’s been a privilege.\n\nThank you very much. 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