{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/d21rf5nb4j/manifest","type":"Manifest","label":{"en":["Dr. Robert Graham"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Description"]},"value":{"en":["\u003cp\u003e This is an exceptionally long interview, covering six sessions with two interviewers. It captures Dr. Graham's very successful career(s) with the federal government and the American Academy of Family Physicians (AAFP), as well as the parallel careers of his wife, Dr. Jane Henney.  \u003cbr\u003eDr. Graham attended medical school at the University of Kansas, where he became a student activist, primarily through the American Medical Student Association (AMSA). Upon graduation he joined the Public Health Service in Washington, working at NIH to incorporate behavioral science into the medical school curriculum. It was there that he met his future wife, who had come to Washington as a medical student working with AMSA. \u003cbr\u003e In 1973 he went to work for the AAFP as Assistant Director of the Division of Education. During his time there he served as Interim Administrative Officer for the Society of Teachers of Family Medicine (STFM), a young association for which the AAFP was providing administrative management services. He and Dr. Henney were married in 1975, and they moved to Houston, where she was in an oncology fellowship. While in Houston, he had an appointment at the Baylor College of Medicine, until he was recruited to Washington to serve as Acting Administrator of the Health Resources Administration. Dr. Henney followed him to Washington as the Deputy Director of the National Cancer Institute. Dr. Graham subsequently became Director of the Health Resources Administration. During his time in Washington, he also served for two years on Senator Ted Kennedy's staff. \u003cbr\u003e In 1985 he was recruited as the first physician Executive Director of the AAFP. Since that involved a move back to Kansas City, Dr. Henney secured a position as Associate Vice Chancellor at the University of Kansas School of Medicine .During his 14-year tenure with the AAFP, he described his biggest challenges as externally managing the AAFP policy positions in terms of the President Clinton's health reform,  and internally as realignment of the AAFP staff with performance evaluation and  hiring people with skill sets in finance, publishing,  and human resources, as well as implementing staff development . He implemented regular meetings with all of the AAFP divisions and brought a new level of professionalism to the AAFP. Much of the interviews covered his changes at the AAFP. \u003cbr\u003e  \u003cbr\u003eDuring his tenure at the AAFP, his wife was recruited back to Washington as the Deputy Director of Operations for the FDA. After 2 1/2 years there, Dr. Henney became Vice President for Health Affairs at the University of New Mexico. In 1998 she became the FDA Commissioner, a position that lasted until 2001. She subsequently became Vice President for Health Affairs and Provost at the University of Cincinnati School of Medicine. \u003cbr\u003e In 1999 Dr. Graham stepped down from his AAFP position. He returned to Washington where he was Acting Director of the AHRQ for three years. He then joined his wife in Cincinnati, where he served as the first Endowed Chair in the Department of Family Medicine, where he spent five years. \u003cbr\u003eThere is considerable discussion in these tapes of the developments in medicine, the role of government in medicine, and the AAFP during Dr. Graham's career. It is enriched by his recollections of his wife's career progression. It is an extensive history and one that deserves preservation. \u003cbr\u003eLocation: Kansas \u003c/p\u003e (summary)"]}},{"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":["2008-12-15 (created)","2008-12-23 (other)","2009-01-21 (other)","2009-02-26 (other)"]}},{"label":{"en":["Agent"]},"value":{"en":["Sandy Panther (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["family medicine","family physician","American Academy of Family Physicians"]}},{"label":{"en":["Subject"]},"value":{"en":["Robert Graham III, MD (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}}],"summary":{"en":["\u003cp\u003e This is an exceptionally long interview, covering six sessions with two interviewers. It captures Dr. Graham's very successful career(s) with the federal government and the American Academy of Family Physicians (AAFP), as well as the parallel careers of his wife, Dr. Jane Henney. \u0026nbsp;\u003cbr /\u003eDr. Graham attended medical school at the University of Kansas, where he became a student activist, primarily through the American Medical Student Association (AMSA). Upon graduation he joined the Public Health Service in Washington, working at NIH to incorporate behavioral science into the medical school curriculum. It was there that he met his future wife, who had come to Washington as a medical student working with AMSA.\u0026nbsp;\u003cbr /\u003e In 1973 he went to work for the AAFP as Assistant Director of the Division of Education. During his time there he served as Interim Administrative Officer for the Society of Teachers of Family Medicine (STFM), a young association for which the AAFP was providing administrative management services. He and Dr. Henney were married in 1975, and they moved to Houston, where she was in an oncology fellowship. While in Houston, he had an appointment at the Baylor College of Medicine, until he was recruited to Washington to serve as Acting Administrator of the Health Resources Administration. Dr. Henney followed him to Washington as the Deputy Director of the National Cancer Institute. Dr. Graham subsequently became Director of the Health Resources Administration. During his time in Washington, he also served for two years on Senator Ted Kennedy's staff.\u0026nbsp;\u003cbr /\u003e In 1985 he was recruited as the first physician Executive Director of the AAFP. Since that involved a move back to Kansas City, Dr. Henney secured a position as Associate Vice Chancellor at the University of Kansas School of Medicine .During his 14-year tenure with the AAFP, he described his biggest challenges as externally managing the AAFP policy positions in terms of the President Clinton's health reform,  and internally as realignment of the AAFP staff with performance evaluation and  hiring people with skill sets in finance, publishing,  and human resources, as well as implementing staff development . He implemented regular meetings with all of the AAFP divisions and brought a new level of professionalism to the AAFP. Much of the interviews covered his changes at the AAFP.\u0026nbsp;\u003cbr /\u003e \u0026nbsp;\u003cbr /\u003eDuring his tenure at the AAFP, his wife was recruited back to Washington as the Deputy Director of Operations for the FDA. After 2 1/2 years there, Dr. Henney became Vice President for Health Affairs at the University of New Mexico. In 1998 she became the FDA Commissioner, a position that lasted until 2001. She subsequently became Vice President for Health Affairs and Provost at the University of Cincinnati School of Medicine.\u0026nbsp;\u003cbr /\u003e In 1999 Dr. Graham stepped down from his AAFP position. He returned to Washington where he was Acting Director of the AHRQ for three years. He then joined his wife in Cincinnati, where he served as the first Endowed Chair in the Department of Family Medicine, where he spent five years.\u0026nbsp;\u003cbr /\u003eThere is considerable discussion in these tapes of the developments in medicine, the role of government in medicine, and the AAFP during Dr. Graham's career. It is enriched by his recollections of his wife's career progression. It is an extensive history and one that deserves preservation.\u0026nbsp;\u003cbr /\u003eLocation: Kansas\u0026nbsp;\u003c/p\u003e"]},"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153003/file/281609","type":"Canvas","label":{"en":["Media File 1 of 5 - Graham_Robert_Pt_1_08_a.wav"]},"duration":2713.61707,"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/153003/file/281609/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153003/file/281609/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/281/609/original/Graham_Robert_Pt_1_08_a.wav?1752075000","type":"Audio","format":"audio/wav","duration":2713.61707,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153003/file/281609","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153003/file/281609/transcript/81601","type":"AnnotationPage","label":{"en":["Dr. Robert Graham interview by Sandy Panther transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153003/file/281609/transcript/81601/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"CENTER FOR THE HISTORY OF FAMILY MEDICINE  HISTORY INTERVIEW WITH ROBERT GRAHAM, MD \n\nINTERVIEW CONDUCTED ON DECEMBER 15, 2008 \n\nBY SANDY PANTHER, CFRE\n\n\nPlease give your name in full. \n\nIt’s James Robert Graham . There is now an MD after that but that only happened in midlife.  \n\nCan you tell us your birthdate, when and where you were born, your parents’ names and sort of give a general history of the early years on Bob Graham? \n\nI was born in Pueblo, Colorado on February 15, 1943, so obviously right in the middle of World War II. My parents were in Pueblo because my father had grown up there. My mother was the daughter of a gentleman who was a civil engineer on the Missouri Pacific Railroad. Civil engineers, to the great disappoint of young boys, were not the type of engineers that drove the trains but they figured out how the tracks have to be laid and look out after the maintenance of it. So Grandfather Smith, my mother’s family name, both her mother and father were graduates of the University of Kansas and lived all of their life in the general Midwest area which was where the Missouri Pacific ran from St. Louis to Pueblo. So that’s how Mother happened to be there. She was a bachelor’s degree holder from the University of Denver in elementary education and was a school teacher in Pueblo. My father, who obviously is James Robert Graham Jr., was an orphan by the time he was fourteen. His father and mother were divorced at some point relatively early in their marriage and then both of them died separately while he was still young. And so he was raised by a maternal aunt, the sister of his mother, and he had two sibs, a younger brother who subsequently was killed in the Korean action, and a younger sister who died about twenty-five years later of tuberculosis. So he was in Pueblo as just the place where he had spent most of his life and was working. Because he was the oldest son and had dependents and did not have parents, whatever the draft rules were, he was not draft eligible. Which was somewhat of a disappointment to him because he always had a great interest in flight and probably would have been enlisted in the Air Force.  \n\n\nAt about my age of six months we moved to East St. Louis, Missouri where he got a degree. It wasn’t a full bachelor’s degree, it was probably more of a technical degree from Parks Air College which qualified him as a pilot. And by about the time I was three years old they moved to the Kansas City area where his original intent immediately after the end of World War II was that all of these returning servicemen would come home and just the way people were buying cars, they would buy airplanes. So he started trying to make a go of it selling airplanes but that turned out to be not a real good business plan. And by the time we were in Kansas City for a couple of years, he had started working again in the lumber business, this time with R.L. Sweet Lumber, which was a family-owned business at that point. And he stayed with them through the remainder of his career in the sales area and winding up as the Vice President for Sales. So that’s how we got to Kansas City.\n\nTell me a little bit about your early education – where you went to grade school, high school. \n\nI began grade school in the Kansas City, Missouri grade school system and that school was Hamlin School which was located probably a mile and a half north of the Country Club Plaza. We lived on 44th Terrace. The Plaza runs pretty much from 46th to 49th, so we were just right up the hill from the Plaza and could walk to the grade school very easily. I stayed there halfway through the fourth grade. And in 1953-54 was part of the general suburban exodus that was going on in most of the urban areas and in Kansas City specifically. People started moving out to Johnson County, Kansas, Prairie Village. My father bought a lot and he and my mother designed a house and we built a house on 65th Terrace, the first block off Roe Boulevard. So I finished my grade school education at Highland School. My junior high, which in the system at the point were grades 7, 8 and 9, at Indian Hills Junior High. And then high school for three years at Shawnee Mission East. The one distinction that I would claim is that in each of those schools, I entered the school the first year it was open and became a real expert at choosing school colors and mascots.  \n\nAnd where did you go to college? \n\nWound up going to college in a liberal arts Quaker school called Earlham College in Richmond, Indiana. It met the three criteria that I had for college that point. It needed to have a strong pre-medical program because I knew I wanted to go to med school. It needed to have a good cross country and track program because I was getting serious about distance running. And it needed to be at least a day away from home because that was the time in a young man’s life where it was just time to get away from home. And it fulfilled all of those characteristics and turned out to be an absolutely wonderful experience.\n\nAnd your major? \n\nMy major was probably cross country. On the scholastic record it would show me majoring in psychology and minoring in English but doing all of the pre-med work too. I think I was a course or two away from minors both in chemistry and biology.\n\nYou mentioned that you always wanted to go into medicine. You then came back close to home? \n\nWe had looked at family finances when I graduated from high school. And I had been an only child until I was fourteen years of age and then my parents had a second child, a sister. So we didn’t have to look at putting two kids through college immediately but looked like we probably could afford to be away from home one time and do state tuition one time. And I felt we had a much better medical school right down the street than we had a liberal arts college. So that is one of the reasons I selected to go away to the first four years and then come back to the University of Kansas for med school.\n\nYou are married. First of all, give me Jane’s full name. \n\nI am married to my first and only wife, Jane Helen Henney. Jane is a native of northern Indiana, right outside of Fort Wayne, a town called Woodburn. She is four years younger than I. She did her undergraduate work at another small religiously-affiliated school, Manchester College, which is associated with the Church of the Brethren. And then went to Indiana University School of Medicine and got her MD degree in 1973.  \n\nSo you did not meet her when you were in Indiana? \n\nNo, we did not meet until after I had graduated from med school and had my first job in the federal government and she was still a medical student.\n\nSo you graduated in 1980. What did you do immediately following graduation? \n\nI moved to Washington, DC and joined the Commission Corps of the U.S. Public Health Service. While I was in medical school, starting in 1965 and not graduating until 1970, so it took me five years rather than four, this was a time of a significant amount of social and political upheaval in the United States. We were involved in the Vietnam conflict in 1968 and of course we had the Tet Offensive in Vietnam. We had the Russian invasion of Czech[osolovakia]. We had the assassinations of Martin Luther King and Robert Kennedy. And for a variety of reasons, my cohort of medical students, in Kansas in particular and a number of other schools around the country, had a lot of energy in trying to change the system. So we were what was referred to as medical student activists. And spent as much time during medical school years on activism projects as I did studying medicine, much to the dismay of the faculty. But we were trying to change medical education. We were trying to carve out a role for student perspective and the governance of the medical school. We were starting community health clinics. And some of this I would have to say, each of the student activists came to this based upon their own philosophies and backgrounds. I would have to say for me, having been a pretty traditional student going through the public system in Shawnee Mission, a lot of it was the intersection of my experience at Earlham and then a very traditional medical education culture at Kansas. The Quaker communities are absolutely wonderful places in terms of inculcating a sense of personal responsibility and accountability, expecting you to ask questions and to be very much self-motivated in pursuit of knowledge. And also a very strong approach to social justice. And so when I was back at Earlham, and this was during the very early part of the Vietnam era, students were already protesting and holding vigils. This was quite unfamiliar to me. That was not going on in the Shawnee Mission area at that time. And I can’t say that I really, at the time I was at Earlham, was terribly involved with those issues of social justice. But then with that background and getting a very conservative educational culture at Kansas, I started behaving much more in the way I did at Earlham rather than what was the expectation of students at Kansas. Including at the end of the first semester we had all of our anatomy and physiology and pathology exams...A very routine thing we had done at Earlham was there was always an evaluation of the professors at the end of the term. The students turned in an evaluation. But we didn’t have that at Kansas. And it seemed perfectly straightforward that we should and I had a major in psychology and had a strong background in statistics and I knew how to put that stuff together. So another freshman and I put together an evaluation of all of our courses and our professors and handed it out to the class and got about an 80% response and scored it and gave it to the administration. And it turned out to be viewed as something of a radical act. So from there med school was just one set of experiences in trying to make some changes. I spent a lot of time at the national level working on projects with an organization that is now called the American Medical Student Association, AMSA. It was called SAMA, Student American Medical Association, at that point. It was our cohorts that essentially took control of SAMA. SAMA had actually been funded and started by the American Medical Association in the early 50s during the McCarthy era. And there was a concern that the student and resident groups were being infiltrated by communists or socialists and wanted to have a more conservative element there. So AMA started SAMA and although SAMA was an independent organization, AMA essentially determined who its executive director was. So our generation of students discharged that individual, hired a new executive director, started getting a lot of federal grants. My particular interest was in educational reform and started in my junior year with a grant of about $250,000 from what was then called the Carnegie Foundation to run a national study with students and medical educators on ways to reform the education system. So I was doing my clinical rotations and running this grant and having meetings at different places around the country and wound up taking a full additional year to finish off some of the writing and publication of that medical education project and also at that point was a vice president in the International Federation of Medical Students. So at the conclusion of medical school, with the Vietnam era and draft obligation, I could have gone into the military or done an internship and then gone into the military. And that would not have been terribly difficult for me to do. In terms of the  issues I was probably a little bit more on the hawkish side than some of the other student activists. But I graduated not really happy with the way I had seen patients forced or mistreated during my educational time. And no particular specialty really called to me strongly; I had had a longstanding interest in psychiatry. That particular therapeutic interaction with patients was something that I found came to me fairly easily and comfortably. So if the script had been you have to go into training and you have to become one type of doctor or another, I probably would have become a psychiatrist. And, of course, at this point there was essentially no presence of family medicine at all. Just in 1969 was the discipline established. But that had no impact on Kansas at that time. But through my work in the student activism projects and already starting to work a little bit with individuals in Washington, DC, originally came to the conclusion that I would spend my draft obligation time by going to work with the National Institutes of Mental Health, which was one of the federal agencies at that point, working specifically on a project to get more behavioral sciences into the medical school curriculum. So that was a natural outgrowth of some of what I had been doing with trying to get curricular reform from the student side because behavioral sciences were something that was just almost not spoken to at all in medical education at that point. And my original assignment was to the NIH and I started there two weeks out of medical school. And as I said, I was a commissioned officer in the U.S. Public Health Service. And I had been doing that for probably a couple of months or so and I got a call from one of the people I had worked with, one of the senior physicians I had worked with in the medical education project who was at that time based in Kansas City. E. Grey Dimond, who was in the process of starting a new medical school in . He had a close friend who had just accepted an assignment in the Nixon administration to be the administrator of the federal agency that did all the health services and research programs. And at that point there were only three federal agencies. There was the National Institutes of Health and the Food and Drug Administration and then this agency that was called the Mental Health Administration at his level. And Grey Dimond’s friend named Vern Wilson had just taken over to be the administrator of HSMA. And Vern felt like this was a great  opportunity – give three or four medical students a chance to see what public policy and public administration was all about. So he created four different types of positions on his staff and was recruiting for young docs who would be interested in doing that. So Grey Dimond called me. The NIMH where I was, was part of his group. He said I’ve got my friend, he is doing this and is recruiting. Would you like me to give him your name? So after just the slightest amount of pondering I said sure. So I interviewed with Vern Wilson who was another MD with an interesting background. He came to medical school late. I don’t think he did an internship. If he did any postgraduate training at all, he only did it an internship. But then also got right into administration. He was just a wonderful federal administrator when I saw him. He came from the University of Missouri. Actually is one of the incorporating members of the American Board of Family Practice. And there is a linkage and a history between him and general practice and ----that you may pick up in some of your other interviews. And he selected me to take the position called the Assistant Administrator for Agency Goals. And I had a series of projects that he asked me to take on, one of which was looking at the health care system in the year 2000, which of course in 1970 seemed like a long way away. And so we had two contractors, one on the east coast and one on the west coast, that were working on that independently. I worked for a couple of years with him trying to figure out whether or not the principles and structure of the Agricultural Extension Service could be used in health care both to get better health in education to the general public and also as a mechanism whereby technology might be more rapidly translated into day-to-day application. And the last portfolio was to be an interface with health profession students groups around the country because this was still a time when there was a lot of student activism boiling around. But it wasn’t just med students. It was pharmacy students, nursing students, dentists, the whole realm. And there was a certain amount of support in the agency to help those student groups to do things to look at better curriculum and get them involved in the community. So it was that part of the portfolio that brought me in contact with Jane because Jane was also working in SAMA and as she became a junior was going to be the national coordinator for a project that was called the Medical Education and Community Orientation, at that point MECO. This was still when there was practically no family medicine, no primary care medical schools. So this was a project which allowed sophomore medical students, before they entered their junior clerkships, to spend a year, spend their summer,  the transition probably between freshman and sophomore year, to spend their summer off in a community hospital. So looking at ways to give medical students an exposure outside of the academic health center to see what “medicine” really is like as you practice it. And so Jane was looking for federal support for this, and that put us together. And we started dating, never lived in the same city, never lived within 600 miles of each other until we got married in 1975. And of course at that point, in ‘75 I had made the transition from the federal government to my first stint with the Academy and was living in Kansas City when we got married. And she went to Houston and started oncology training and I went back to Kansas City and finished off six months at the Academy. So we started our marriage by not living together either – and that will become a recurring them as we go through this interview.\n\nChronologically, you left HSMA in 1973 and then came back to the Academy?\n\nThe connection there was another person that Vern Wilson had brought with him to Washington, DC, a woman sociologist by the name of Marian Bishop. And Marian had been at the University of Missouri and her spouse, Bob Froelich, was there also. And Vern saw this opportunity to take over this huge federal agency. HSMA had only existed for about maybe three years when he took it over. He was not the first administrator. But the administration change from Johnson to Nixon in 1968, a fellow by the name of Joe English had been the administrator under Johnson for a period of time. He may have continued in the Nixon administration but then they turned it over with Wilson. And he just looked at this agency, which is enormously complex, and had everything from the Indian Health Service to the Centers for Disease Control to the Bureau of Community Health Services to just everything going on. So he convinced Marian to come to Washington – and I’ll use my words, not his, I think to kind of describe the culture of that federal agency and the programs that it ran and how they would change over time. And so Marian was there and she didn’t fit in any nice, neat slot on the organizational chart – and, course, neither did I. And we were seated in roughly the same area in the executive offices for the administrator. So we just struck up a casual conversation and started doing some projects together. And, of course, we had very overlapping interests too. She was already connected to the family medicine community at that point, which was still a community I didn’t know much about at all. But she had been working with the early leaders of the Society of Teachers of Family Medicine, Lynn Carmichael and Gayle Stephens and all like that. So she was aware of what was going on in that discipline. And we would talk a little bit about what the impact would be of that discipline on the health care system, because I was looking at the future of the health care system, and what it might do with a new generation of student activists coming along. I signed up originally for a two-year tour of duty and that was over in 1972. So I was having a good time, continued to be interested in what I was doing, so signed up for another year or so. Nixon’s reelection was in November of ‘72 and transitions from one administration to the other are always difficult. But it turned out the transition from Nixon 1 to Nixon 2 was really difficult. He essentially fired all of the Schedule C’s [federal employees] that he had hired. And so one afternoon in mid-December of ‘72 Wilson along with the other agency heads and everybody else had been called downtown to meet with the President. We all went down figuring alright, we are going to get our marching orders for the second term. He came back and was just livid because he had been told to resign. And suddenly the guy I had really enjoyed working with was going to be gone and I didn’t know who else was going to come in and what their philosophy would be or what they would think about the students on staff or that or former medical students on staff. And about that point, Marian had been aware that the Academy, and particularly Tom Johnson who she knew very well...And Tom at that time had a different title than we use now. He was Field Secretary for the Education Division. The educational division of the Academy at that point was very small because as was the , there really wasn’t a lot of educational focus for the Academy. Because now you’re going into this new discipline of family medicine and people are starting residency programs and wanting to start departments of family medicine and are turning to the Academy for assistance and consultation. And Tom was the point. Tom Johnson was a physician trained as a GP, practiced for a number of years, although I’m forgetting exactly what his professional CV was. He worked for the Academy for probably ten years. And suddenly he has this responsibility to go to all of these places and help them start residency programs. He had absolutely the right background and a passion for it. But only one problem, he wouldn’t fly. So Tom literally would get on a train in Kansas City. And the train service back in the 70s was starting to be kind of spotty but you could still get around. And he would be gone for six weeks. He put this itinerary together and he would get around and see people. I remember talking to the woman who was his secretary at that time and she said every week she would get this envelope from Tom that was filled with tapes from a Dictabelt because this was still when we had the 360 degree, kind of three-inch wide Dictabelt tapes that he would dictate his report on. But this was clearly starting to wear on Tom. And so he was looking for an assistant. They had given him the title at the point of the Director of the Division of Education. They had done away with the Field Secretary title. So he was looking for someone as an assistant who basically would be willing to get an airplane and go to these places. And Marian said one day look, this is in Kansas City, it’s your home. This is a really neat organization. They are doing great stuff. You are single. You like to fly. You ought to talk to him. And so I went, it was during the Academy’s Annual Meeting, must have been in ‘72. So some of this is overlapping even before knowing what was going on with Vern Wilson and the change of administration. I went up to New York City and interviewed with Roger Tusken who was the CEO at that point and with Tom. And they said great, you should come work with us. And so February 1st of 1973 I moved to Kansas City as the Assistant Director (the first time they had that position filled) of the Division of Education. I did that for about two or three months and suddenly Tom resigned. He seemed perfectly enthusiastic about me being hired. I don’t know whether he saw me around for two or three months and said this is great, I can get off this treadmill or whether he said oh my God, who did I hire and he just wanted out. But I was there for three or four months and suddenly I was Assistant Director with no Director. Had all of the responsibilities of traveling around doing these consultations. The irony seems to have escaped most people that I was consulting on establishing residency programs in the discipline that I had absolutely no background in. The decision had been made by the Society of Teachers of Family Medicine to have a headquarters in Kansas City. It had been kind of run by Lynn Carmichael out of his home in Miami. So Lynn boxed up all of the records and sent them to Kansas City and that’s where STFM was. The only problem was there was nobody in  to open the boxes. So about the same time that Tom retired, Roger said we would just like you to do something to help as part of your responsibilities and that is be the interim Administrative Officer for the STFM. I think basically what was happening at this point both from Tom Johnson’s perspective and maybe from Roger’s is that they may have figured out that the guy is still two or three years out of medical school, doesn’t really know much about clinical medicine and family medicine but he does seem to know how to administer things and how to run things. So we need somebody to kind of keep order of this stuff. So that’s what I was doing.  \n\nDuring that time period one of my priorities was to find a boss because we really did need to have a Director of the Division of Education. I think it must have been relatively late in the fall of ‘73, and your memory of dates of this is probably going to be much better than mine, I was up in Chicago. We were doing something that was an interface with medical students and recruitment. And a fellow from the Academy’s Membership Commission, Tom Stern, was there. So Tom and I were working together on this project. He was Residency Director out of Santa Monica and I thought he just did a wonderful job in interacting with the people that we were adding. It couldn’t have been an AMSA meeting because it was late in the year and AMSA meets early in the year. So I don’t know exactly what the venue was. So I came back to  and talked to Roger and said we can’t lose Tom Stern. He seems like he could be a good candidate for this division position. Would you mind if I discussed it with him? Roger said feel free but I’ve talked to him a couple of times and he’s really not interested in moving to Kansas City. So at some point I had an opportunity to pursue it with Tom and whatever had been the discussion between him and Roger before, something may have changed in his thinking about the job or what the possibilities were. But it worked out that Tom was willing to come to Kansas City and be the division director, which was just a wonderful arrangement for the Academy.  And Sandy, you remember, when did Tom and Glad[ys] arrive in Kansas City?  \n\nI’m thinking it was ’74.   \n\nIf my chronology is accurate it’s going to be March, April or June of ‘74 that Tom arrived. And so then he and I had just a wonderful year plus because he knew a whole bunch of things about family medicine. He was really my contact and the point from which I really started learning about not only the discipline of family medicine but the issues about education and undergraduate education. And of course at this point I was spending a lot of time because I was the Academy’s representative to the Residency Review Committee. And I was working with Lee Blanchard on what was then supposed to be the first revision of the essentials of the residency since 1969. I don’t think they got done until about 1975, ‘76. Lee died in the middle of that process which set it back some. I was working a lot with Lynn Carmichael, Gayle Stephens so I had this contact on both the STFM side and the Academy side, which was just a wonderful learning opportunity. And at that point, I had decided when I came back to the Academy, after I was there about six months, that this was a discipline that clinically I could be very comfortable with for all of the reasons that I had not liked what I saw in medical school and the way patients and students are being treated. I really liked what I saw in family medicine. And so I worked out an arrangement with Jack Stelmach. Originally came into contact with Jack because he wanted to start a residency program at Baptist Hospital. And so I went over and sat down and spent a half day with him just doing the usual sort of residency consultation with him. But then we started talking more and more and Jack and I really hit it off. I proposed to he and Roger that over a period of about six years on a half-time basis that I would do a family practice residency because I thought it would be good for me to get clinical training before I got too far away because I had already been out of med school at this point for four or five years. So I got my licensure and everything like that and started this half-time residency. Must have begun that in early ‘74. So I would do a month or six weeks on as a resident. So I was over in the hospital doing what residents do. And I would get done on the nights that I wasn’t on call and I would come back over to the Academy office and I would do dictation and catch-up stuff until ,  at night and then just go back and do the cycle again. And when that four to six weeks would be done then I would leave the residency program and for four to six weeks I would do all of the Academy stuff. Which is fine because I was young and I wasn’t married. But, of course, Jane and I were dating during this time period. And about late ‘74 or early ‘75 we decided that it was time for us to get married. So I just finished off one equivalent year on family medicine. I actually still have the Kansas license which ought to be a precautionary warning to anybody about the quality of our licensure system. We got married in June of ‘75. Jane at that point had done a year’s internship in Indianapolis and had done her second internal medicine residency year at Georgia Baptist Hospital in Atlanta. At that point internal medicine was a two-and-two program, so she was ready for her two years of fellowship in clinical oncology which she started in M.D. Anderson. So we got married in June of ‘75 and Jane went immediately to Houston and I went back to Kansas City to finish off six months at the Academy and then moved to being with her in Houston in the end of 1975.\n\n\n\nCENTER FOR THE HISTORY OF FAMILY MEDICINE  HISTORY INTERVIEW WITH ROBERT GRAHAM, MD  (CONTINUED)\n\nINTERVIEW CONDUCTED ON  \n\nBY  PANTHER, CFRE\n\n\n\nI would like to go back and pick up on two items that you had mentioned at the end of our taping in the last session and I will let you go in whatever order you wish. First is Dr. James Price, whom you wanted to reflect on, and the second was the start-up and implementation of the National Conference for Family Practice Residents and Students. \n\nActually, those two things are related. And I realized in kind of recapping what had gone on in the ‘73 to ‘75 time period while I was the Assistant Division Director that I had not gotten that in there. I believe my memory is correct that Jim was elected President-Elect at the Annual Assembly of 1974. This can be verified in the Transactions and I haven’t had those resources here to go back – because I’m going to describe a one-year period between his President-Elect and his coming presidency. But right after Jim was elected he and I had a conversation. The Congress had voted that there would be membership status for students and residents and although that seems like a pretty routine thing today, this in the early 70s was the first medical professional organization that had decided that they would give students and residents full status within their government structure. And with me coming out of the SAMA experience as a student activist, this was exactly what we had been trying to do. We had been trying to do it with the AMA and just getting absolutely nowhere. So the Academy, once again being very enlightened, looking at what would be necessary to get medical students to go into these newly-formed residencies, said we need to be welcoming. We need to carve out a place for students and residents to be our colleagues. So they were fifteen, twenty years ahead of their time there. And Jim knew my background as an activist and knew that I had been working with student groups when I was with my responsibilities at HSMA in Washington. And, of course, was kind of related to what I was doing with the Division of Education. And he said I want to make sure that by the time that I am sworn in as President, students can be seated as waiting members of the House [Congress] of Delegates. Now that’s where my memory would need to be corroborated in terms of the Transactions. I think we went from the Congress action one year to the students and residents being seated with a vote the next year, it is possible that they were included in the House [sic] but without vote for a period of time. I believe they came into the House [sic] before they were given positions on the Board. That’s all researchable. But essentially this movement for an unusual degree of inclusion of students and residents in family medicine started out by popular support of the Congress. And then they had a President-Elect in Jim Price who said this is something I want to see happen as part of my presidency. Then figuring out well, how are we going to do this, how do we get people seated, where would the delegates come from, etc., etc. What is down the path of putting together the first conference of student and resident representatives? And we organized this out of the Division of Education. I can remember working in particular with one staff member in the division at that time, Pam Williams, who stayed with the Academy for a long number of years. And we had the first meeting out at the old  Flight Attendant Academy called the Breech Academy which is out in the western part of Kansas City. And I think we had maybe twenty to twenty-five residents and maybe the same number of students. And I can’t remember how we contacted them because we didn’t have the infrastructure at that point of Family Medicine Interest Groups at the medical school. But some of the later leaders in family medicine, Alan David on the academic side, Bruce Bagley, a Past President of the Academy, were actively involved in that first session. And we were able to get the presence of the residents and students I believe for the first time in the Annual Assembly of 1975 coming out of the meeting that we had in Kansas City, that small group of students and residents earlier that spring. And then, of course, the involvement of the students and residents has become much more structured and formalized and now the Academy hosts I guess what is their second largest annual meeting every year in Kansas City in August with the students and residents. So I just wanted to make sure that we didn’t miss that piece.\n\nAnd now the attendance is about 1500.\n\nI know it has fluctuated some in past years. Probably a little more on the student side. And I think looking at the newsletters and everything, it’s coming back up. It went down roughly during the time that we have had lower interest on the part of the students in the early 2000s. But last year in ‘08, I think it was up very strongly.\n\nLet’s go then to Houston and pick up chronologically what we were doing. Let’s move you’re your move to Houston and your tenure at Baylor College of Medicine. \n\nJane and I got married in June of 1975. And consistent with our pattern of dating which was we never lived in the same city and what would later become our pattern of marriage of not living in the same city, she went to Houston and I went back to Kansas City. She started her medical oncology fellowship which was to be a two-year training program at M.D. Anderson Cancer Hospital in Houston. And she started in July of ‘75. I went back to Kansas City and finished off the last six months as the Assistant Division Director and the STFM Exec and finished that up in December of ‘75. We recruited Dan Ostergaard. Now at this point, of course, Tom Stern is the Division Director. Tom recruited Dan Ostergaard to come and be the second Assistant Division Director. And also at that point the STFM made the transition from having their executive staffing done by me to hiring their first full-time – they quit using the term Administrative Officer. I believe they switched to Executive Director.  \n\nSo I went to Houston in January of 1976 and started out doing a variety of things. In Baylor College of Medicine where there was a Department of Family Medicine there was also what they called a Program in Health Management. I suppose if it had been named today it would have been an Institute for Health Policy or something like this. So I was not actually in a position in family medicine but had a staff assistant position in the Program for Health Management. The main project I worked on for them was doing an analysis of physician and particularly general and family practitioner population in Texas counties essentially following up on some work that we had started doing in Kansas City with Claudene Clinton who was the first Director of the Research and Information Services Department, starting to try to do what today would look like very back-of-the-envelope calculations about how short of supply are we of family physicians. Because at that time the federal office in the Bureau of Health Professions that was doing physician projections ten and twenty years out was using a model that was very linear and was publishing things, while we were starting residencies and starting the new discipline of family medicine, the federal bureau was saying in twenty years there won’t be any family doctors. So we had started working in Kansas City to try and rebut that. And doing some of that specific work when I was down in Texas. At the same time, because Jane was there for a two-year fellowship, we thought we would probably be in Houston for four or five years, I started a Master’s in Public Health degree at the University of Texas at Houston. And also because I had become kind of interested in a couple of doctor/lawyers that I had seen in Washington (they were relatively rare at that point), an OB/GYN physician from Topeka had just been elected to the [U.S.] Congress, Bill Roy. And he was an MD/JD. A very nice guy. So I thought I’m going to be down here, maybe I’ll just go ahead and get a law degree. So I took the LSATs and was admitted to the University of Houston Law School to begin in September of 1976.  \n\nAnd then Jane and I were at the STFM meeting in New Orleans in April of ‘76 and I got a call from a close friend that I had worked with in SAMA, now AMSA, by the name of David Kindig.  He did not turn into a family physician but he has been a health policy person and has always been very favorable towards primary care. David had been working in the federal government for about three years as the Deputy Director of the Bureau of Health Manpower. This is what is now the Bureau of Health Professions. And had the responsibility for running all of the grant contract programs that supported medicine, osteopathy, dentistry, nursing, everything else. But in particular was where Title VII is located. Now at this point Title VII was being fairly well-funded and was kind of a growth area for the Bureau. And David had been doing that for a number of years but was recruited to go to Montefiore to be the president of the Montefiore Health System. So he was looking for a replacement and he knew of my interest in educational reform. He knew that I had worked in Washington. Knew that I knew something about family medicine and primary care. And so he called while Jane and I were down there and said you ought to come talk to these people, this is just the perfect job for you. It’s time for you to come back to Washington. So Jane and I did a couple of trips to DC and the job looked like it would be an interesting one for me, something that I would enjoy. But it was a little bit more difficult on Jane’s part because she would have to leave her fellowship training in M.D. Anderson after the first year and we were trying to figure out what to do there. And NIH, of course, is a very strong fellowship program in cancer and she felt that would be a decent place to continue her work. And the NIH people said we really like her, we would be glad to have her. But gosh, this is a federal position and we just don’t have a slot, that typical bureaucratese. So we got down to the point where as I was talking to the people in the Bureau, and it was in an agency at that point called the Health Resources Administration, I said we are ready to come but it doesn’t look like it’s going to work out because NIH, the National Cancer Institute says they don’t have a slot. Well, the head of the agency at that point was a fellow by the name of Ken Endicott who had a lot of responsibility in developing some of the health manpower legislation from the federal side. Was a physician but it turns out he was also a past Director of the National Cancer Institute which just wouldn’t happen today because he was not an oncologist. But this was back probably ten or fifteen years before when the  was very small and just getting started and Ken was a career Public Health Service commissioned office and had had a number of assignments at NIH before he took over this agency. And Ken was just kind of a no-nonsense guy and he said something appropriately profane about the bureaucrats at  and they hadn’t changed since he was there. But he said I can solve that, I’ve got a slot – we’ll send it over to . So that’s what he did. So Jane started her fellowship at  on an HRA slot, never been done before. And we moved to Washington and I started as the Deputy Director of the Bureau of Health Professions.  \n\nI don’t know the best way to describe the next several years because you start getting a real intertwining of stuff that was going on for Jane and I professionally. I stayed as the Deputy Director of the Bureau of Health Professions working for a dentist by the name of Dan Whiteside who was an absolutely wonderful person to work for. Just the best of the federal administrator that you could describe in terms of knowing the programs, having a bias towards action, but really getting things done in the right way. So it was a good experience for my first time really being at an operational level. When I was in HSMA I had special projects and I enjoyed working with Vern Wilson but I really wasn’t running anything. Well, this time it was line operation: learning budgets, managing personnel, doing a little bit of work with the Hill, a lot of work with the department. And then after two years the then administrator of HRA, Ken Endicott had retired, was a gentleman by the name of Henry Foley. We are now in the Carter years and Joe Califano is the department secretary. And so Foley had come into HRA as the administrator. And he had a vacancy in his deputy’s position. And for a variety of reasons I ended up moving from the Deputy of the Bureau to the Deputy of the Agency. So that was a nice promotion and now I wasn’t just dealing with health professions but I was also dealing with the Health Planning Program and with the Health Facilities Program. Jane, in the meantime, had finished her fellowship and had been recruited to go on staff at the  as a drug monitor in the Division of Cancer Therapeutics. And the director of that division was a fellow by the name of Vince DeVita. So she was becoming actively involved with monitoring all of the NIH research protocols that are going on all over the country and indeed all over the world and making a wonderful set of contacts and working with people in regional oncology groups. NIH was way out in front of anybody else in putting together what we would call practice-based research organizations right now. But when they had a study protocol it wasn’t just carried out by a group of doctors in one place. It was coordinated and carried out probably in seventeen or eighteen centers and there was a coordinating entity that was regionally organized, eastern, southern, western. So she was interfacing with all of those and dealing with the newest of the drugs that were under study. And so she was having a great time. Vince DeVita was very well-known in the cancer community, a good person to work for.  \n\nAnd so that kind of got us to 1979. A close friend of mine I had actually met when we were both working at HSMA, another physician, had started working for Ted Kennedy and was Kennedy’s Chief of Staff for the Health Subcommittee. Kennedy at this time was not as senior and was not the head of the full, what we would now call Waiver Education Health and Pensions. But he was the chair of the health subcommittee. And this fellow and I had talked on and off over the years and he said at some point you just have to have the experience of being on the Hill and doing legislation. And this is the perfect time because it’s 1979, we are running up to another presidential election, everybody is going to be preoccupied with the election and Kennedy is just going to stay at home and do nothing but get bills developed and passed. And so this is a great time for you to come down because we’ve got lots of things that you can do. There was a little bit of uncertainty in the department about whether this is the best idea. The guy that I was working for wasn’t extremely happy that his deputy was going to go to the Hill. But some other people in the Assistant Secretary’s office got involved and said as a matter of fact we think this is probably a very good experience and we will support it. And so I wound up in the summer of ‘79 with Kennedy’s staff as a detailee from the Public Health Service. And I was there I think for two weeks when Kennedy announced that he was going to challenge Carter for the Democratic nomination. So the next eighteen months we were doing legislation. And I was responsible I think at that point for the reauthorization bill of the National Science Foundation, two of the NIH Institutes, a couple of bills that had to do with international stuff. Got heavily involved with some issues about regulation of infant formula, which is totally different than anything I had done before but was an absolute ball. But also at the same time Kennedy running for president. Well, both as a commissioned officer, and even if I had been fully on the Senate staff, you can’t have any direct involvement in the campaign activities because that’s partisan. But you can take vacation and when you’re on vacation you’re a private citizen and can do whatever you want to do. And there were at that point four of us on staff who were physicians. My friend Larry Horowitz who is the Staff Director, myself, a gentleman by the name of Stuart Shapiro and another by the name of Bob Knauss. He actually had also come out of the Bureau of Health Professions and had a very long history of working with family medicine and primary care. So anybody listening to this tape who is aware of that time period may well recognize Bob’s name also. Because at this point we were just only about ten years just past the last assassinations, any time Kennedy was out in public he was a very high threat target. He had Secret Service protection from the day he started campaigning which was very unusual at that point because at that point the candidates typically did not have Secret Service protection until they were selected by their party as the nominee. And we just decided any time that he was in public one of the four of us as physicians would be with him with a little metal Banyan fifteen-minute medicine case. Because the Secret Service no matter where we are we are never going to be fifteen minutes away from a trauma center. I’m not sure they’re right about that, but that was our planning. So we were prepared. We all went back and did ATLS certification and were prepared to do whatever was necessary for a fifteen minute medicine if we had another one of these tragedies strike. Now a lot of the time that I spent with Kennedy in that arena was around Washington because most of the campaign trips were covered by the staff director. But over the course of the campaign I was probably with him a total of three weeks on the campaign plane which was a fascinating experience just to watch the way an individual who had considerable political skills, although he turned out not to run a very good campaign and really did not come close to Carter in the primary. The way he would organize things, the way the campaign worked. A huge number of campaign stories which are fun to tell but are beyond the scope of this tape. But it was an excellent learning experience. So I had both the legislative experience and the campaign experience. In the meantime, Jane is working for Vince DeVita. And sometime around 1978 Vince is the head of the Division of Cancer Therapy and recognizes that she is a very talented person. Not only a good oncologist but very good at getting things done and people like to work with her. And so he changed her assignment from being a drug monitor to being his special assistant. So she had lots more to do with the responsibility of running the division. And then I don’t remember if it was late ‘78 or late ‘79, DeVita was appointed the Director of the National Cancer Institute. This is a presidential appointment. It doesn’t require congressional action. So when he moved to the Director’s office he took Jane with him and she was a special assistant there for about six to nine months. And when he moved he had inherited an individual in the deputy’s position and that person had been Deputy Director of the Cancer Institute for probably fifteen years or so. And DeVita was a very dynamic, very different sort of Cancer Center Director. And this individual decided it was a good time to retire and he did. And so Vince appointed Jane as the Deputy Director of the Cancer Institute. So she is barely into her thirties and is now the Deputy Director of the Cancer Institute which four years before hadn’t been able to find a slot for. It was a lot of fun to go to some of their functions and watch the people who had made it somewhat difficult for her to get a training position there now work with her as their boss. She never made it terribly difficult for them but it was fun watch.\n\nSo that brings us up to the end of 1980. And the election is held, Carter loses. We are in the Reagan administration. Not only that, the Senate turns from Democrat to Republican which had not happened for a long time. And when you go from the majority to the minority in the Senate, the majority always has two-thirds of the staff; minority has one-third. So suddenly all of these Democratic staff positions that had been there for, I think the Senate had been Democrat majority probably since the Eisenhower years. Maybe one- or two-year period when it switched. It was a real shakeup and people were losing their jobs and everything else. But it’s time for me to go back, it was the end of my detail so I went back to HRA. And I really didn’t know what I was going to do. The fellow that I had been working for had gotten himself fired by not Joe Califano but the Secretary that took over for Califano, Pat Harris. He got himself crosswise with her, so she fired him probably six months before the election. And the new HRA administrator was a woman by the name of Karen Davis who is an economist. So she had come out and started running HRA which is a political appointee. So it was very clear with the inauguration she would be out as the HRA administrator. And one of the people working with her was a fellow by the name of Brian Biles, who is a physician from Kansas. He was one of the cadre of medical students in Kansas that were activists during the time I described earlier. Brian called me probably in mid-December and said Karen knows that he is going to be gone and you were detailed from the Deputy’s position. It is vacant at the present time. Would you be willing to come back as the Deputy? And I said well, that has some attractiveness. But we are going to have a new set of bosses downtown and I’m just coming off of the Kennedy committee. That may not be the smoothest thing. Let me do some checking. Well, it turns out that during the time I was on the Kennedy staff the ranking minority for the Republicans was Richard Schweiker, a senator from Pennsylvania. And actually when Reagan had made his first run for the nomination in 1976 when he was unsuccessful, Schweiker was to be his vice president. And so Reagan and Schweiker were very close together for a variety of reasons. When Reagan ran in ‘80 Schweiker was not the vice president but they maintained close relationships. But Schweiker did announce that he was not going to run for his seat in 1980 and so he was a retiring senator. But Kennedy and Schweiker got along very well and Jane and I, for a variety of reasons, came to have some very close friends on the Schweiker staff. People that worked for Schweiker. So we had as many social friends and relationships on the Kennedy staff as we did on the Schweiker staff. Everybody in mid-1980 had just kind of written Schweiker off. He’s a retiring senator and whatever is going to happen is going to happen with the Reagan administration, etc. Nobody is really paying attention to him. And then Reagan gets elected and one of the first cabinet appointees he announces is that Schweiker is going to be the head of . So now everybody rediscovers Schweiker. And I still knew the Schweiker staff well enough that I called and said here’s the situation: I’ve been on detail. They would like me to come back and be the Deputy of HRA for Karen. Obviously, when she leaves the Deputy is there. I could wind up being the acting administrator of the agency. But I don’t want to be there if you guys don’t want me there. And I recognize my connection with Kennedy is one that may not play well in the White House. They said let us get back to you. And a couple of days later they called back and said we have talked about it with Senator Schweiker and he is comfortable with you being there and you probably will be the acting. Just don’t unpack your suitcase. I said okay, I understand that communication. So I worked with Karen Davis for about six weeks largely on transition issues. Karen went on and has become the president of the Commonwealth Foundation and is still very active in health policy circles. And when the inauguration took place Karen was gone and I was the acting administrator of HRA. So it was a great opportunity for me. Still in my thirties. This is one of the agencies at U.S. Public Health Service. I would say at that point we had 4500, 5,000 staff still doing health planning, health facilities and health manpower. Part of the Reagan platform though was a substantial reduction on all of the domestic programs. Government had grown too large. It was doing things that shouldn’t be done. He particularly did not like the Health Planning Program which restricted the growth of new technologies and new hospitals. Things such as certificate of need was done on a national basis. And so Reagan had some battles with the Congress in terms of his budget because for his first two years the Senate was Republican but the house was still Democrat. The Reagan first budget for HRA was zero [dollars]. The agency would go away, period. Where we wound up was the Health Planning Program was abolished. And the appropriations and the staff support for health professions and health facilities were reduced by probably, I think we wound up at about a quarter cut. One of the places where Title VII funds started becoming reduced. And so beginning in March, April of 1981 one of my major responsibilities as the acting head of the agency was to run something which is called a reduction in force. And that is a process by which you discharge career civil servants from federal employment. It’s a relatively unusual thing to do as government tends to grow rather than shrink. And although the federal work force is not unionized, there are a number of very specific rules largely around seniority about how you get rid of people. What it basically says is the more senior you are, if your job is abolished you have the ability to bump down along your job category and knock out people who are more junior than you in jobs that you are eligible for. We have about 5,000 people in play. The health planning people know their job is gone. But they know since they are career civil servants, they have the ability to bump into jobs elsewhere in the agency that they are qualified for. So if they are a contract specialist that’s been doing health planning stuff, they can bump into a contract specialist in the Health Professions Bureau and knock them out of a job if they have more seniority. And we are doing all of this really before everything is computerized. And so you’ve had these lists of people and you are trying to figure out what the cascade branches are about who bumps who and who goes where. And you’ve got people very nervous and very angry. This has never happened before. A lot of people were quite dedicated to the programs and angry that the President was going to discontinue them. And so we ran a RIF. And for a variety of reasons, using words that we use in management today that we didn’t use at that point, we did so in a very transparent fashion. And I held a number of all staff meetings. Most of our staff in this agency was located in the Washington area, so I could look at them face-to-face. I said I will tell you what I know and I will tell you when I know it. And if you hear rumors bring them to this meeting. Because the worst thing that can happen to us is if everybody starts to listening to rumors rather than what the facts are because we are going to have to deal with the facts. And people responded to that very well. They didn’t like what was going on. But they felt like they were being treated fairly and they felt like they knew what was happening as soon as anybody. Management didn’t have secrets. Management was telling them exactly what the rules were. We got a reasonable amount of support from the Secretary’s office. And they essentially froze positions across the department so that rather than just bumping and taking positions in the agency which was downsizing we were able to outplace people to NIH and to other agencies. I can’t say those other agencies were ecstatic about it but at least our staff felt like they had some places to go rather than just the impact area. And a lot of people did take retirement. We had to early out programs and people said this is a good time for me to be gone. When we finished we reduced our staff size by 40%. But no one lost a position involuntarily. And people were just amazed at that outcome and we got very good reviews from the Secretary’s office about the way it had been done. And they had our management team come down and brief the Secretary’s staff and the Assistant Secretary for Management about how we had done this. And they were very complimentary to the agency. At the same time we were doing this a sister agency, the Health Services Administration, was having to deal with some similar types of things. They didn’t have a whole program that went away. They had major budget reductions. Health Services Administration did such things as National Health Service Corps, Community Health Centers, Maternal and Child Health Programs, Indian Health Service. But they also ran a system of public health service hospitals. At that point we had PHS hospitals in port cities like New Orleans and San Francisco and Seattle and New York. And so the acting administrator over there who was somebody I knew very well from my HSMA times. He had also worked for Vern Wilson. A gentleman who was about fifteen years older than I and had a long history in the Public Health Service running a number of different programs. One of the nicest guys in the world. So he was handling the downsizing of that agency which mainly was selling off or transferring to community groups the title for these hospitals – which took a lot of federal employees off of the federal books. In some of the cases, the hospitals continued to operate as clinical sites but the funding responsibility moved to the not-for-profits, to the community base. While all of this is going on one other thing that we took on at HRA, because we had our health profession authorities, we had been a longtime source of support for a number of minority health profession schools. And at this point minority means African American or I think the acronym at that time was historically black colleges and universities. And one of them that was always in and out of difficulties, Meharry Medical College. And it must have been about May of ‘81, Meharry hit one of their crises. They were running out of money. They had a teaching hospital they were having trouble servicing the debt on. And in just one of these twists of fate, the prior president of Meharry had resigned or retired and they had an acting president. And most of the administrative structure and the board structure of Meharry were African American individuals. But for a variety of reasons, on their board was a white radiologist from Houston. A very strong supporter of Reagan, a very strong Republican. And he was Board Chair and when all this crisis hit he was acting President. And he went to James Baker who was then Reagan’s Chief of Staff two or three months into the administration and said look, we’ve got a problem down here and you guys cannot let Meharry go under. This is a national resource. It’s been around for 100 or more years and there are only two black medical schools in the country. You cannot let this happen. And I’ll tell you what I want, I want half of the VA. Well, the VA was totally controlled by Vanderbilt. This being Nashville and Vanderbilt and Meharry and you can imagine. And so the White House calls Schweiker and says do something. So Schweiker called us and said you guys have been handling this, do something. And so suddenly I found that I was the Chair of the White House task force on Meharry Medical College. And that task force had representatives from , Treasury, Education, Veterans Administration, Department of Justice and we had six weeks to find a solution. What we wound up doing worked out and it was just a crazy time period. Nobody was willing to take on Vanderbilt and actually tell them they were going to lose half their affiliations because VA affiliations are just tremendous sources of income for medical schools. And Vanderbilt just would have had a fit. If it would have been done, it would not have been done in six weeks. It would just have been a bloody battle in Nashville. And the White House had no taste for that at all. But the Veterans Administration was perfectly happy to find another teaching center. So about twenty miles down the road from Nashville there is a place called Murfreesboro. And they had a VA and never had any teaching programs at all. Murfreesboro was just delighted to become a teaching center for Meharry. And so we created a new teaching program in Murfreesboro and identified a source of funds that would start flowing to Meharry as part of that VA affiliation. We figured out a way working with the people and Treasury to do something that I never knew was possible. And it’s a very technical term, but you can diffuse one set of bonds and buy another set of bonds and basically allow you to pay off a mortgage. And so we did that and paid off the mortgage on Hubbard Hospital which had really been the critical element of this crisis. And so suddenly Meharry was in good shape. This was actually when David Satcher was just coming on as President of Meharry. And so we put this proposal together and went and briefed Secretary Schweiker. He said will this work. And not all of his staff was really enthusiastic about it because it was government involvement in solving the problem. And we said we think it will work. And not only that, we think it’s about the only way you can get out of this without having another civil war in the medical community in Nashville. And the leader of the insurrection is going to be a close friend of the President’s. And so he did a couple of phone calls to the White House. They said is the VA okay with it and they said they’re fine with it. They said is the DOJ comfortable and the Justice said it’s all legal. The Treasury said it’s all legal. And so we did it. So this had been going on also while we were running the RIF. And we come to the summer I guess of ‘82 and we’ve got two much smaller agencies right now and they had to decide what to do with them. So they decided to put them together. So that’s where the current agency of HRSA, Health Resources and Services Administration, came from. And the Assistant Secretary at that point, Ed Brandt, another physician, a wonderful administrator, a great guy to work for. Also very supportive, very favorable to family medicine although his clinical and administrative background was not in that. Somebody who was also a very close friend of Marian Bishop’s. Because at this point Marian is down at Oklahoma, Ed had come originally from Oklahoma although he came to this job from the University of Texas. Brandt sort of looked at the acting administrator at HSA and me at HRA and just made a pick between us in terms of who would be the administrator of HRSA. My suspicion is that he probably had a conversation with the guy over at HSA because he was senior to me. And that guy probably said I really do not enjoy that type of role. Bob and I can work perfectly well together. I don’t mind being his deputy. So my feelings are not going to be hurt if you pass me over. And so Brandt went to Schweiker and said I think we ought to have Graham be the head of HRSA and John Kelso, who is the guy over at HSA, be the deputy. But you need to know that he worked for Ted Kennedy two years ago and I don’t want to take you by surprise. And Schweiker said I know that and my people are comfortable with him and he sort of helped us out on the Meharry thing and the RIF went pretty well – but let me check it with the White House. And the way I am told the story, because I was not present there, about 6:00 at night Schweiker’s phone rings. He was not there, his Chief of Staff was there and picks it up. And it’s Jim Baker in the White House saying we understand you want to appoint somebody who used to work for Kennedy for one of your agencies. Do you really want to do that? And the Chief of Staff apparently said well, you know we’ve worked with him quite a while and you remember that Meharry thing and he was sort of in charge of working that out. We are pretty comfortable with him and Ed Brandt thinks it’s just fine. And Baker said okay, that’s fine, go ahead.  \n\nSo I guess at the age of thirty-eight or thirty-nine I’m now the head of HRSA which was a wonderful experience. HRSA did not have the most money in the Public Health Service. NIH and CDC were by far and away better funded than we were. But we had 15,000 people because we had the Indian Health Service. The Indian Health Service at that point had a head count of about 11,000. And we are doing business all over and there is a staff member in every state and almost in every county, in the Pacific, doing stuff in the Marianas and Polynesian Islands because we’ve got 80% of all the commissioned officers. We staffed the medical needs of the Coast Guard. It was just a fascinating responsibility. And at this point I am the Administrator of HRSA, Jane is the Deputy Director of The Cancer Institute. Both of us have dinners together and say is this really going on. So it was a very good two or three years in terms of professional growth and opportunity.  \n\nAnd then about in ‘84 we are taking one of our usual late summer walks on the beach trying to figure out what do we do next. And both of us came to the conclusion what we are doing right now is really exciting, really very professionally rewarding. But both of us are at positions where the only way to go up is to be a very political person and we’re not. We are independents. We have as many Republicans on our Christmas card list as we have Democrats. So we are never going to pass the real witness test of being rank and file loyalists, either side. So we are not going to become the head of the Cancer Institute. We’re not going to become the Assistant Secretary for Health. And as things inevitably change, I think when we had that conversation we didn’t know whether Reagan would win the second term, although certainly he was in a very strong position. Eventually the leadership changes. And we have been working with some really good people, with Ed Brandt and Vince DeVita and they’re supportive. But there is going to be a new Assistant Secretary at some point and they may not be as supportive. Or Vince isn’t going to be the Cancer Center Director. And so it’s probably time that we think about doing something as a next stage in our career that is not Washington-based. And Jane had a longstanding interest of doing something in academic medicine. Had always been interested in the possibility of being a dean or a VP for health affairs. And it looked like it was probably a logical time to look at that. But there was no clear way forward for us at that point. And another one of those peculiar ways that life works out – within about two weeks, it may have been even the same week, I got a call from the people at the Academy in Kansas City because the prior CEO, Roger Tusken, had left the Academy and they were starting their search process. And apparently the Board at that point had decided that the priorities for their candidate is they did want to look at having a physician, which would have been the first time for the Academy. They did want to look for someone that could raise the profile of the Academy in Washington in policy circles. And they did want somebody that had demonstrated that they had some management ability. And I scored reasonably well on those criteria. So the head of the search committee, and I don’t remember who the first contact was, said would you be willing to talk to us. And I said yes, this is not a bad time. I would definitely be willing to do that. It’s going to be a factor whether or not Kansas City works out for Jane as well as me. But there’s no reason not to keep my name in your hat. Well, Jane got a call that week from the Executive Vice Chancellor at the University of Kansas and he had decided that he wanted to establish a position in his office which would be a Number 2 Associate Vice Chancellor. He had met Jane at some AAMC function. Actually, he knew both of us but did not know we were married because we had different last names. In fact, he told Jane later on when they got to know each other very well, he was originally a little bit concerned about contacting her because he knew she was married. But he had seen her with me and he thought we were really inappropriately friendly with each other. \n\nSo in December of ‘84 I went out and had what turned out to be kind of a bizarre interview with the search committee for the Academy because we had arranged to do it on one of these fly in, fly out same days. So I was flying non-stop. At that point  was still an airline that was flying and it flew nonstop from [Washington] National to Kansas City. And so I was supposed to get into Kansas City let’s say at","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153003/file/281609#t=0.0,600.0"},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153003/file/281609/transcript/81601/annotation/2","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"in the morning and we were going to have an airport conversation and I would go back to Washington at 3:00 in the afternoon. It wasn’t real ice and snow but I got on the airplane at Washington and we flew for about thirty minutes and they said this is unusual but we are going to make an unscheduled stop in St. Louis because we have head winds of more than 200 miles an hour right on our nose and we don’t have the fuel to get to Kansas City. So we all thought that was a good idea to stop in St. Louis. Then it was just one of those things that happen when you are traveling all the time, nobody was expecting us there. This was not a plane that is supposed to stop in St. Louis. It was not the  hub at that point and they had maybe three or four gates. And so we sat on the ground in St. Louis for two hours to get fuel. So I got to Kansas City at 1:30 and was supposed to leave at 3:00 to meet with the search committee. So it was a very brief conversation. They said if you’re interested we are going to try to work this out with you. We’re not even going to interview anybody else. And I said I’m interested. I knew that Jane had talked to Kay Clawson who was the  [Executive Vice Chancellor] at Kansas. I said I’m not for sure that there is something for Jane but I’m a lot more optimistic than I was when I first got the request to interview. And I am perfectly happy to continue this conversation with you. And for where I am in my career and what I really care about, working for the Academy would be a wonderful opportunity and I am extremely interested. I’m not sure it’s fair to your process that you only talk to me. You know, there is always a little bit of a danger that for some reason we don’t work it out or things don’t work out for Jane and I don’t want to leave you hanging. But that’s kind of your business. And if your question is am I really interested, I am really interested. It was not hard at all for me to come to an arrangement with the Academy. It took a little bit longer for Jane to work things out at KU. But in the end it worked out and she started there in September of ‘85 as Associate Vice Chancellor and I started as the EVP of the Academy.\n\n\nCENTER FOR THE HISTORY OF FAMILY MEDICINE  HISTORY INTERVIEW WITH ROBERT GRAHAM, MD (CONTINUED)\n\nINTERVIEW CONDUCTED ON JANUARY 21, 2009 \n\nBY SANDY PANTHER, CFRE\n\n\nWe are starting now with your career path in the Academy. And I would like if you would please share with us those early years as Executive Vice President. What your vision was for the organization, the style by which you were going to accomplish that, the greatest accomplishments. And then also as part two of that, if you would continue on with Jane’s career and how it interacted with you in those years. \n\nGoing back to what we talked about just briefly on the last time, the search process, the Board at that time I think had decided that they wanted a couple of things in the next EVP of the Academy. And one of them was an individual who could increase the Academy’s advocacy visibility in Washington in policy circles. And I think they had also reached a determination at that time that it might be the right moment to go to physician leadership of the Academy. And I was not privy, obviously, to any of those Board discussions leading up to the formation of the search committee or the contact with me. But talking to folks later, as was true for most organizations or most member-based organizations, there was some ambiguity. That’s not the right word – there was probably a little hesitation about what the implications were for having an MD. In one sense we were seeing at that point more and more professional associations go to physician leadership. There is a sense that this is a doctors’ organization and it ought to be headed by a doctor. But at the same time the nature of the Academy then and I think still today is it’s an opportunity for a continuous cycle of leadership development among the volunteer members of the organization. The folks that have worked their way up through state chapters and commission leadership and Board leadership. And the spokesperson for the Academy is supposed to be the President. I’m sure there were conversations about well, if you have a doctor leader and a doctor President is the public going to be confused about who the spokesperson is. Who really speaks to the Academy? And as I’ve looked at my tenure there and certainly watching the tenure of other physician execs in similar member-based organizations, that is at least a source of small tension at all times. And then depending upon the individual and their relationship with the Board and what the issue is for organizations, it’s no big deal. Or it may become just kind of a preoccupying issue around which there are real struggles between the executive and the Board. I would say for the vast majority of my time with the Academy this was not a big issue with me and the Board. Now the Board, of course, is always made up of fifteen people and they change on an annual basis. And there were times I know when there were Board members who may not have been a majority on the Board but who felt maybe the public was seeing a little bit too much of Graham. Particularly this could become an issue as it intersected with that other objective they had which was raising the visibility of the Academy and the policy of Washington. Because one of the reasons I think they approached me about being interested in the position was at that point I’d had about ten or twelve years of service in Washington. I was leading the largest of the Public Health Service agencies. The largest in terms of number of positions. Unfortunately not in terms of budget. And I knew a number of individuals on the Hill on a pretty much first-name basis having served a couple of years on Senator Kennedy’s staff. And so I would say on most years there would be a time when I would have a discussion with the Board Chair who was the individual I always interfaced with primarily in terms of my relationship with the Board. But the Board Chair, the President and the President-Elect. We had this invitation from committee X to present testimony. Who is the best person to get our message to this committee or this particular venue? And sometimes depending on the committee, the issue and the temper of the Board at that point, we would think it should be the President and it should be the Board Chair. And that was generally my inclination and my lean. But from time-to-time we would also say this issue is before a committee that knows Bob very, very well. It’s a type of issue which is somewhat technical and complicated, so I would do a reasonable amount of that type of testimony. And I think in one way it’s just a proxy for the types of issues that associations are always going to have when they select an exec where there is an overlap between the interest and the skill set of the exec and the elected members in terms of exactly what the role is of the exec and of the members in terms of leadership of the organization.  \n\nYou asked particularly about what vision I had for the Academy. In one sense if we had been discussing it just as I came on board, I would have tried to use a different term than that. Because I think the legitimacy of a member-based organization comes from the direction and the energy that the members put into it. And really it is the elected leadership that should be articulating what the vision is. At the same time I had a prior term of service with the Academy in the early 70s. I had been fighting the family medicine/primary care wars in a number of different venues and I was and am a very strong advocate for the discipline and for the role of the Academy. And so part of my objective was and was in total agreement with what the discussion was with the search committee is I wanted to see a greater presence of the Academy and the point of view of family medicine inside the beltway in Washington where policy decisions were being made all the way from the type of coverage decisions and payment decisions for what was then called HCFA. Now the Center for Medicare and Medicaid Services. The annual appropriations battle over how much money would go for family medicine education. And so at least on the programmatic side the vision was how do we move family medicine front and center to make clear that the individuals with this type of training, with this type of practice style are something that the American healthcare system needs more and it needs to be recognized and it needs to be supported. On the interior inside style I probably had some more clearly articulated feelings about what we need to do with the Academy. I was coming back to an organization that I thought very highly of, that I thought had been very effective. But I also thought I was joining it at a time where we probably needed to change and evolve some of our operating procedures and some of our management styles to better be able to take advantage of the opportunities that we hoped to create in terms of public policy. Every time you get a new CEO and every time that CEO may have a little bit different operating style there are periods of turbulence and uncertainty. And I was coming from an organization that had 15,000 people to an Academy which at that point I think was probably around 250, 270 staff. And both philosophically and operationally I had a style and a view that you operated an organization through a series of strong staff members with specified responsibilities to whom there was delegated a lot of authority and responsibility and that they shared the accountability with the CEO for what the outcome was. So I think when I got there, if you look at my direct reports, and I think if I remember correctly at that point there were four vice presidents who were direct reports. There was no deputy position at that point. And then there were somewhere between eleven and fourteen division directors. The style that Roger Tusken, who was the previous Executive Vice President for about twelve years, had had was probably a little flatter than my style. Roger had been in the organization a long time. He had been there working when Mac Cahal, the first EVP was there. And I think Roger probably had a style of more one-on-one relationships not only with the VPs, the direct reports, but also with the division directors. And indeed probably had much closer one-on-one personal relationships with a lot of people in the Academy because he had been there from the time that the Academy maybe had seventy or eighty employees. So knew a lot of people on a one-to-one basis. With the advantage of hindsight, I think probably the first six to eighteen months that I was there, there was some adjustment and some feeling on the part of particularly long-time staff at the Academy and at the division director level or above that I was more structured, perhaps more aloof because I would tend to work and deal through the vice presidents rather than directly with the division directors. And also during that time my performance expectations in terms of just what the culture of the Academy was were probably a little bit different than they had been five or ten years ago. The Academy had always described itself and I think took some pride in the fact that it had a great feeling of a family type of organization. There was a lot of informality. We were still at that point observing at least officially something that Mac Cahal had started at 3:00 in the afternoon – there was Tea Time. And when I was with the organization in the 70s it was still small enough that pretty much everybody on staff could go down to the coffee room and have a fifteen-minute break together. Some groups played cards and some groups sat and chatted. Some groups were smokers. We still had smoking inside the building at that point. And so it was a very casual type of atmosphere. Then we were starting to grow away from that. Tea Time was still on the books but people mostly didn’t all gather in one place. Smaller groups would take their time together and not go down to the lunch room. And so the culture was changing. And there were some folks who had been there for a period of time that I think they said gee, this EVP is just not what I’m used to and I’m really not comfortable with the way that he is managing and the expectations he has. And some of my expectations were we needed to be a little more professional, a little less casual about some of the things we did. And so although we did not have a huge turnover in the first two or three years I was there, you did see some changes at the senior staff level as people just decided that was not an environment that they were as comfortable in. And to some extent I was probably the one making them not comfortable. And so we started getting different types of people into the organization. And that on an operational sense in terms of vision I would say is very much something that I thought needed to be done. When I got there we did not have a Director of Human Resources. And I thought in most organizations that that was a particularly critical type of function that you needed to have somebody who really had a professional background so that not only were you recruiting and looking at the right types of people to come into the organization but you were retaining them, that you had a strategy in terms of professional developing, that your procedures were both contemporary and legal. This is when we were getting into a lot more concern about things that you can and cannot do in the workplace in terms of discrimination and harassment. And the Academy really had no policies about that and I thought that was a vulnerability for us. And so we did recruit our first Director of Human Resources. Several years later we had the individual who had been the Comptroller of the Academy for a number of years retire and rather than replacing him with an individual with comptroller skills, that’s the point at which we went to a Chief Financial Officer model. And the difference let’s say between those two skill sets is the Academy, the Comptroller had done a perfectly acceptable job in the Academy. There was never any question about where our money was. We had an audit every year. We always got clean audits. The books were well maintained. And that was the responsibility of being able to tell us exactly where our resources were. What I wanted in a Chief Financial Officer is somebody to do all of that but also to advise the Board about where your assets should be five years, ten years down the road. You know, what should be your reserve policy. What should be your investment policy. We had done mostly self-management of our assets in terms of the financial markets. It was during this period when we got a Chief Financial Officer that we started using investment managers and getting professional assistance. I guess the third thing, the structural thing that I did was decide that the organization was emphasizing complexity and the responsibilities of the Executive Vice President in terms of representation...And to do my job usually in most years I was out of the office about 120 or 130 days a year. You really needed a clear line of responsibility with a deputy. There should be a shared responsibility in the executive leadership of the organization. And so I think at one point when Mac Cahal was there someone may have carried the title of Deputy EVP. And Sandy, you were around there. Did Chuck Nyberg have that title?  \n\nI think it was an informal. I don’t think he ever carried the COO or Deputy [EVP] title. I think it was informal.  \n\nAnd when I was there Mac was not there. Roger was the EVP. Chuck was still there. It was sort of understood that when Roger was out of town or something needed to be done, you could go to Chuck and he would be comfortable in doing that. But it wasn’t that formal. And I wanted it clearly understood that in the absence of the CEO that the Deputy is in charge. And so Mike Miller was legal counsel at that time. He carried two titles. He was Director of the Socioeconomics Division and actually was one of the Vice Presidents and was General Counsel. So I had Mike become the Deputy. And it was a very comfortable relationship because Mike had a long tenure with the Academy, twenty-plus years. People had absolute respect and trust in his judgement and his integrity. And he and I were very different in terms of style and that was complementary. There were things that he could do that I knew he would see differently than I did that would watch out for my blind spots. Things that I would do that I thought were strategically important for the Academy where he would sometimes think I was nuts. But he was always very supportive. So those types of changes were part of my intentional plan for the Academy. And if you said what is just a one sentence description, I would say I really felt that the Academy needed to become more professional in its approach to the multiple tasks and that we needed in a number of our skill positions to have individuals with very specific types of skills that we hadn’t had previously. That we had been more of an association model. Small association model where lots of people did very different tasks that they had learned over time but didn’t necessarily have the specific preparation there. Now at the same time and bringing a close to this particular part of it, after I had been there a year or two and partially in discussion with our new Human Resources management, we decided that one of the priorities that we needed to have in the organization was staff development. That if you really want to have a positive culture in an organization, you need to decide what you want to look like, how you want to behave and then you need to start giving people the experiences and the training to get there. So we started out with a staff development program that ran for the rest of the ten or eleven years that I was there. And I think it did a lot of good things for us in terms of helping understand different work styles, different communication styles, how to constructively identify and resolve conflict, how to do better strategic planning with a particular focus on execution. And also how to get feedback. So it created an environment where people became more and more comfortable. They got more comfortable with me. I was no longer the new guy and they would see me around. But they could give me feedback and say you know, sometimes you are too reserved. We don’t see enough of you. And you need to get out and maintain some relationships with folks other than just the vice presidents. And so as a result of that I started changing some of my operational style. And we used staff meetings differently. I started meeting at least twice a year with every division for a couple of hours so that I had one-on-one contact with everybody in the Academy. And we could talk about what they were doing and talk about specific ideas or problems that they had identified. Which I came to find to be just enormously useful and would say that was a great learning experience for me. But we had to create the environment first where people were comfortable in giving that type of feedback and where we all acknowledged that yes, that’s a particular responsibility of every individual in the organization, to figure out ways that they can do things better and figure out ways that they can provide constructive feedback so other people know what impact they’re having on the organization.  \n\nLet me give a pause there and see if I’ve hit on things that you want me to pursue or that I’ve missed.\n\nNo, when I said your vision and the changes and your style to get there, that pretty well covered the first two or three years that you were there when you were really intricately involved in setting the course and changing it from that family atmosphere into what I would term a small business or a family-owned business atmosphere into a Fortune 500-type company with a strategic direction. \n\nDuring this time was Jane with you or was Jane elsewhere? \n\nThe first seven years that we were in Kansas City we were perfectly traditional. We lived together and lived in the same house. She was at that point at the University of Kansas. She had come back there to be the Associate Vice Chancellor for Health Affairs. So there was one individual, Kay Clawson, who was the, I guess they called it Executive Vice Chancellor at that point. And so he had all of the deans of the health professions reporting to him. And Jane was the Number 2 physician in his office. She wound up doing a number of things while she was there at KU. At one point in the late 80s they had had a dean search which went fine, they got a dean. But it turned out not to be a good match and he only lasted for about a year or a little bit less. And so they suddenly had another opening and asked Jane to be the acting Dean. And so she had about a year and a half of serving as the Dean of the School of Medicine at Kansas. Now somewhat a reflection of both the times and Kansas, she was a candidate for the permanent Deanship and both her boss, the Executive Vice Chancellor and the President of the University of Kansas at that point, Gene Budig, were very complimentary to what she was doing as Acting and encouraged her to be a candidate. And the search committee determined that her background was not adequate to even be interviewed. So you kind of look at that and say okay, that’s just the way this institution is. I guess that was probably in 1990 when we had that particular turn. Also, when that didn’t work they did get a new dean and she was asked to take on more of the responsibility of starting their Comprehensive Cancer Center. But in late ‘91 she got a call from David Kessler who was the head of the Food and Drug Administration at that point, and David said I want to bring in somebody to be the Chief Operating Officer of the FDA. It’s such a big, complicated operation. He basically was looking for a Deputy for Operations. And Jane originally had said why in the world would I do that? She hadn’t had...with her NIH base it had been much more on drug development, not approval. And most of her interactions with the FDA had been not terribly positive because there’s always that stress between the agencies in terms of what should be approved and what shouldn’t be. But she visited with David and I think properly viewing that having an opportunity to have more responsibility at Kansas was at least in the short term not going to be good just because of that sort of search committee attitude of why would we want a woman here? She went back to Washington and was Deputy for Operations for about two to two and a half years. At that point we thought that living apart was temporary. And so we kept the house that we had in Kansas City and tried to visit each other every couple of weeks. Then in ‘94 she was asked to go to the University of New Mexico as their first Vice President for Health Affairs. They had not had a VP for Health Affairs model before. At that point we said this commuting is not just going to be temporary. You’re going to be in New Mexico for four, five, six years. At some point Bob is going to move to Albuquerque. And every year when Jane was not living in Kansas City, part of my performance appraisal discussion with the Board was we’ve got this circumstance and you need to know what I’m thinking. And at that point my relationship with the Board was very good. I liked the Board. They seemed to be happy with what I was doing. Didn’t express any real anxiousness to have an opportunity to go out and search for another CEO. And so they just sort of said we understand it must be difficult. Let us know what you plan. But in the meantime we’re happy to have you here for as long as you choose to be. And I always had my contract with the Academy a rolling two-year contract. So any time I came up for a performance appraisal there was only one year left in the contract. Now I did that so that if the Board was ever unhappy with something and they could say we think it’s time for a change then we had a year and had plenty of time for transition and change. Or if I felt like it was time for me to move I could give them a year’s notice. I always intended that transition when I did leave the Academy would be planned. And it had been so traumatic both when Roger Tusken left and Mac Cahal left, both of those transitions were very, very abrupt. For a variety of reasons, the Board and the EVP just got to a point where something snapped and the Board said that’s it, you’re out of here. And I didn’t want that to happen. So always had the contacts where I could have a discussion with the Board and they could say whether or not they were satisfied with how things were going, I could tell them what I was thinking about doing, what Jane and I were thinking about doing and then we would go on for another year. When Jane moved to Albuquerque, and this is in ‘94, I told the Board that I thought after a couple of years I’m probably going to move down there. This was the first time she had been the VP for Health Affairs, first time the University had had one of those. I said take a couple of years to make sure this is going to work out because I really like what I’m doing right now and I’d feel kind of dumb just to leave this job, go down there and then find that Jane was ready to leave in a couple of years. The Board was very generous and flexible at that time and said to make this a little bit easier for you, in computing your official travel that the Academy covers either Kansas City or Albuquerque is your home. And so if you go from Kansas City to Washington on a Wednesday and do Academy work and then go to Albuquerque on Saturday, that’s our nickel. And then from Albuquerque, if you go back to New York that’s all Academy work. If you go from Albuquerque to Kansas City, that’s your nickel. And that just made things a lot easier. So it was very clear when I was going back and forth between Kansas City and Albuquerque, that was personal travel. And anything else that I did was Academy travel. And it just made it a lot easier. And in that environment I was with Jane almost every weekend. And by the time we had done that for a couple of years, I was about ready to (I guess this would have been the performance appraisal of ‘96) raise the issue with the Board of going into transition using the next year as a transition period. And at that point Jane got her first call from the Clinton White House about the possibility of coming back to be the Commissioner of FDA. So once we knew that was going to go on, I told the Board we’re just going to have to watch this one play out. But it changed my plans to go to Albuquerque. And it turned out that the process of getting her nominated and confirmed just took a heck of a long period of time. Part of it was the Clinton White House having to make up its mind who they wanted to nominate. And within the administration there was some difference of opinion about whether they wanted to nominate Jane. The acting head of FDA at that point was very well-regarded and there were some folks that wanted to see him nominated. And they finally had to get that resolved and they nominated her in June of ‘98. But then this was right when Clinton and the Congress were getting into a variety of issues. And by the time her confirmation hearing took place in September, she went into the confirmation hearing, the Chief of Staff to the chair of the committee said we’re doing this as a courtesy to Senator Kennedy because he’s on the committee and he supported your nomination but we don’t intend to ever vote on your nomination. We’re just going to have this and we’re not going to go any further. You’re not going to be confirmed. And it turned out that she was little bit ---- than they had anticipated. And one-by-one both during the confirmation hearing itself, there were two Republicans during that hearing that based upon her responses said I’m satisfied, I’ll vote to forward your nomination to the Senate, which was very different than what the Chair had thought. The Republicans had a one-vote majority on the committee at that point. And so when two people said they would switch as long as the Democrats all voted for her, she would go to the floor of the Senate. Actually, she got voted out of the committee I think with only three or four of the Republicans voting against her. But then it got to the floor of the Senate and there were a number of holds. Her nomination literally became the last item of business for the Senate in October of 1998. We were watching this on TV on C-SPAN from Kansas City. Of course, she was in New Mexico, I was in Kansas City and we were watching this. I’m trying to remember the Senate Majority Leader. I don’t think it was Bill Frist at that point. It may have been Trent Lott and Daschle was the Democrat. And you would go through this business where the two of them were standing in the well of the Senate and one of them offers something and the other says I hear no objection. Well, of course there’s no objection; there’s nobody else in the Senate chamber. The President of the Senate is sitting right in back of them who is a Republican, [Mike] Enzi. And what was going on that we didn’t know is that there were still a couple of holes on her nomination from conservative Republicans because she had said in her nomination hearing that it was not her agenda to see that RU 486 was approved but that if the science was behind it, that she intended to follow science. And that was not an acceptable answer to them. And so originally she was supposed to be approved at say","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153003/file/281609#t=600.0,600.0"},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153003/file/281609/transcript/81601/annotation/3","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"in the morning (I’ll just make up a number) when they started doing this last business at the Senate. But they pulled her nomination because there was still one hold they had been unaware of. And when that happened a couple of the Republicans who at that point were working to get her approved were able within the party to figure out who had the hold on her, were able to get a hold of that individual. And for a variety of reasons that individual said okay, I’ll release the hold. And so they came back and just with five minutes left were able to approve her. And so in November of ‘98 she goes back to Washington and she is the Commissioner. When I do my performance appraisal with the Board in ‘99 I say it’s time. We had been commuting for about seven or eight years. And so we went into the transition period then and were able to do a search, identify candidates. The Board was able to make a selection and offer the job to Doug and I transitioned out in August.\n\nThat takes us up then to the Academy time. Is that correct? \n\nYes. A couple of notes that I would say – for that tenure what I think went really well and what were some of the rough points.   \n\nI was just talking about Jane because I’m back into the Academy.   \n\nYes, I’m going back in. I think probably some of the things that worked best for us is the staff development activity I think that we engaged in really did provide a lot more skills and changed the culture of the Academy in a way that made it a much more effective organization. And particularly got us pretty good at working across boundaries. It’s always difficult in an organization because you’ve got very specific delegated tasks. You know, we talk about silos and everything else. But if you’re going to be effective you’ve got to work across those. And I think this gave us good skills in doing that. We were at a fortunate time in terms of our financial performance. The magazine/journal [AFP] was doing well because of advertisements. It was a time when pharmaceutical companies were marketing fairly aggressively to primary care. And so our reserves grew from probably around $20 million to a little bit over $80 million and on an operating budget of – at the time I left I think the operating budget was around $75, $80 million. We also had good timing in the real estate market. When I got there we were in the building that we had moved into in 1974 and had really outgrown. And it was an old building. We were the second or third occupant of it and it was antiquated. Didn’t have enough storage and the heating and air conditioning and everything else were substandard. All of the parking was outdoors. And we went into the market and started looking for some alternative sites and a real estate company in Kansas City had gotten into difficulty and had gone bankrupt and their headquarters building, which we could see from our building, it was three blocks away, suddenly was on the market. And we were able to position ourselves to gain control of that building. To actually bid it in a partnership with another real estate developer in the city. And that was the 8880 building on Ward Parkway. And that was a good building. It was nice and new and modern. It just kind of seemed like we moved up three or four steps. And we were there from’88 until we decided it was time to move and invest again and that was the Tomahawk Creek building that is the headquarters right now. And the timing was such on the transaction, we made money when we moved from building No. 1 to building No. 2 and we made money when we moved from the 8880 building to the new building. Actually, when we entered into an agreement to build the new building with the understanding that we were going to be tenants in it. So the builder was actually building it with the expectation that we would have tenants. But we were wise enough when we entered into the contract with them that we had a provision in there that allowed us within six months of the closing of the deal, occupancy of the building, that we had a one-time election where we could opt for a price specified in the contract to become owners. And the real estate consultant that we had been working with in Kansas City was a wonderful guy. He and his partner, Roger Cohen, has subsequently died and his partner, Tim Schaffer, I think is still working with the Academy on some things. They just gave us marvelous advice. And I can remember them talking to the Board and saying this is a good provision to have in the contract, you’re smart to do it. But we really can’t imagine that you would ever want to be the owner of the building because you are a membership association, you’re not a real estate association and there are all sorts of issues about owning the building. So then we got up to within six months and we looked at what had happened to the market and we looked at what the price was. Roger Cohen and I sat down over lunch and I said Roger, to me we ought to buy this thing. He said I never would have believed I told you this but you are absolutely right. It’s a no-brainer. You are leaving millions of dollars on the table if you don’t buy this building because you’ve got a specified price in that contract and the market has just gone wild. So we went into the building as owners. I know the market has fluctuated in Kansas City now but at least at that point it was just an excellent deal. So on the financial side, we just had ten, twelve really good years. And a CEO always wants to take credit for that. But I would say most of those are circumstances where you’re not creating it, you’re just trying to be a smart enough manager to take advantage of it.  \n\nThe other thing I think happened in about ‘99, which I do feel more personally associated with, is we took a long strategic planning look at what was going on with our membership and what was going on just with the general demographics of the country. And I wrote the Board a long memo which is somewhat atypical for me. I rarely try to give the Board policy advice. I would much more frequently give them my analysis of what I thought the pros and cons were of the policies that they had pending before them from the Congress of Delegates or commissions or committees trying to tell them which way I thought might be better to go. And rarely did I come to them and say look folks, this is something that I think we need to do. But I gave them a long memo and it was on diversity. And I had been particularly struck looking at what I thought happened to organizations when the demographics of their rank and file changed but their leadership did not. And I just thought it was inexorable that eventually your organization comes to look like your rank and file. But so many organizations, the leadership resisted that and so the only way you got there was through a very tumultuous process where things just built up to boiling point and then finally the new people broke through and threw out all of the old people and the organization just had a lot of trauma. And I said this is what the United States is going to look like in 2000 and 2010. Half of our members are going to be women. We’re going to have 15-20% of our members that are going to be African American, Hispanic. I actually underestimated that both because of the growth in Hispanic and because of the in-migration of physicians. Our leadership really doesn’t allow for the participation of younger physicians. You look at the Congress of Delegates and there’s a lot of gray hair on males out there. And so I made a proposal to them that for a period of time that we create particular positions in the Congress of Delegates for women, minority and new physicians. And that those positions be time limited, that the Congress look at them from time-to-time based upon how good we were doing in terms of bringing those perspectives into the mainstream of Academy leadership. And we started the Conference for Special Constituencies. We started the Student and Resident Conference that I spoke about two tapes ago that had grown into a great opportunity for leadership development. And we had student and resident members in the Congress of Delegates but we didn’t have these others. That was a little controversial among the Board for awhile. But to their credit and to the credit of the Congress, they did it. And I think one of the reasons why the Academy in the late 90s and the early part of this century has been one of the first general medical associations to have an African American president, a woman president, more than one. You look at the makeup of the Board of Directors and depending upon the year you’ve got three or four women there. I think one of the reasons that we were successful in doing that is because we did something affirmative before there was a critical mass and a feeling of frustration and disenfranchisement of these growing diversity groups. As the Academy did in the early 70s when we reached out to students and residents and said even before you ask the question, we will invite you in. We did the same thing with those three groups. And seated in the Congress and had the opportunity...once you start participating in the Congress you’re part of the political process and just the normal dynamics go on and it’s easier for people coming from those backgrounds to be considered as leaders in the Congress, to be considered as potential Board members. And you don’t get to be President of the Academy unless you’re on the Board of Directors. And we started having a development process which we have seen reach fruition in the last ten years or so with people from different backgrounds coming to be President of the Academy. And that’s something that I was really pleased with the way that it worked out. And not just because Bob had an idea but because of the receptivity of the Board. I could have written that memo and the Board would have looked at it and said that’s an interesting idea, why don’t we think about it for a couple of years and come back and talk about it? But they looked at it and said by-and-large this is probably a smart thing to do and they found a way to do it. During that time I think our advocacy efforts in Washington were doing better. Our DC office expanded. We actually bought a townhouse in Washington so we had a presence there. I thought that would give us a different profile than all of the other groups that just sort of rented space in a law office someplace. An idea that I had almost from the time that I got to the Academy, having spent so much time in Washington as I had, is when all of these discussions and policy discussions take place there’s nobody with the perspective of family medicine or primary care. And I always wanted to set up sort of a policy center where we would have people who were totally dedicated to the vision and the values of family medicine who would look at things and would be part of the city in a way that I knew how it worked. There’s a small community of health policy people in Washington and they know each other, they go to the same meetings. And if you don’t live there and do that, you don’t know what that community is. And I just wanted our people to be in that community because I knew that they would start influencing the discussion. And we talked about it at the Board level probably two or three times. And generally the Board said that’s a good idea, we ought to think about that. And one of the times that it came back up in the mid to late 90s, we were in the midst of having these very good returns in terms of our investments and in terms of the growing assets. It was a time also right in the mid 90s when student interest in family medicine was as high as it’s ever been. We got up I think one year to 16-17% of all MD graduates went into family medicine. And the Board sort of looked at that swell of interest, the optimism that came with it. Looked at the checkbook and saw that it was in good shape. And said okay, why don’t you do that policy center. So Rosie Sweeney and I worked for a couple of years to identify somebody to lead it. We knew pretty much from day one who we wanted to lead it and that was Larry Green who was the department chair out in Colorado. I think our negotiating skills weren’t very good. We talked to Larry a couple of cycles and said we would love to have you do this; we think it takes a five-year commitment. And Larry said I would really like to do that but I don’t think I can commit more than two years. So Rosie and I went back to rethink it and came back and forth. Finally the light went off in one of our heads and we said Larry Green is the right person – get him here for two years and see what happens. And so we made the deal with Larry. He came and he was absolutely the right person to start the policy center off. He was having so much fun at the end of two years he didn’t even want to talk about going back to Colorado that point. And, of course, he stayed five or six years. So it’s a real lesson on how to accomplish negotiation by being smarter than you are when you go into it. \n\nSo those are the kind of things if you say after eight or ten years out what do you really think you feel best about in terms of those years? On the downside, really very little. I was fortunate in having a relationship with a succession of Boards which with the exception of two or three years, pretty much early on where I think we were sort of switching cultures, I respected the people that I worked with, I enjoyed being with them and I felt like they respected what I did at the Academy. They always made Jane and I feel welcome. We had a bumpy period with the Board and with the membership in ‘93 and ‘94 during the Clinton Health Reform because our Board was pretty much feeling that although the Clinton plan wasn’t perfect we needed health reform. We really needed to change the healthcare system. We needed to reintegrate the values of primary care. And the Clinton plan had more of that in it than anything else that we had seen. And so on a spectrum of medical organizations we and the American College of Physicians started off kind of being more positive than anybody else. AMA was even positive to start with. And then as the Clinton plan got more and more complicated and people got more frustrated and the Clinton popularity started going down, AMA just abandoned the whole idea entirely.  gradually shifted over to not being so enthusiastic. And we were still there saying it is not perfect but it is better than what we’ve got and we need to make some of these changes. And that was the one time when I was there that the Board actually got spontaneous communications from the members saying what in the devil are you doing? This is not my Academy. If you’re going to do that I’m going to drop my membership. And that put pressure on the Board. And to their credit, the Chair and the three Presidents at that point were really pretty strong and they didn’t say we can’t take the heat, we’ve got to change our position. They did say we’ve got to find a better way to communicate with the members and we don’t want to lose members. But at the same time, we’re in this to prosecute the values of family medicine.\n\n(Interview continues.)\n\nBob, would you please continue with the Clinton health years and then the transition out of the Academy in the next seven or eight years, of what you have been doing. \n\nThat was the one really rocky time when the Board felt...there are always issues between the Congress and the Board where the Congress may wish the Board to go one direction or another. But this is when it got into the rank and file. And this was before we really had email. And I remember sitting at the desk and for a period of three or four weeks, every day or so there would be five or ten letters that would come in. I would open them and read them and figure out a way to get them displayed for the Board. We spent particular time during the Annual Assembly with briefings of the delegates. By and large I would say the delegates were probably closer to where the Board was than the individual members that we heard from. I think although there’s undoubtedly a political spectrum of Republican and Democrat and Independent represented in the Congress, when you come to questions about changing the healthcare system so that family medicine does better and primary care does better, that’s one where there’s a lot of consensus regardless of what your political persuasions are. And it was just as much as anything the complexity of the Clinton Bill and then the contamination of the way people came to feel about Bill Clinton and some of the other things that made it easier for people to kind of lash out at the Board.\n\n  \n\nTalking about transition, I left the Academy in August of 2000 and went back and Jane and I were living together again, happily, in Washington DC. For a year I served as a scholar-in-residence at the Policy Center which the Board had been kind enough to name for me at the last Board meeting that they had. Which led actually to some very humorous circumstance where I would be sitting there...the Policy Center, at that point, had a very small staff. I would be sitting working and our culture was if the phone rang whoever was available would answer it. So I would answer it and say “This is the Robert Graham Center.” And occasionally a caller would say well, who am I talking to and I would say “This is Bob Graham.” And that was usually followed by a very long silence. People just really didn’t know what to say. But that allowed us, the Center took a lead that year in putting on Keystone . From the Keystone conversations came a lot of the impetus for the Future of Family Medicine discussion. And the Future of Family Medicine discussion I think was absolutely timely because it positioned the Academy and the discipline to take advantage of all of this interest in Patient-Centered Medical Homes – and none of us would have seen that developing at that point. Jane, because she was a presidential appointee with the change of administration from Clinton to Bush, there was actually a fairly strong push from some of the Republicans, Senator Frist and Senator Hatch, to have the new administration keep her on at FDA at least until such time as they had their own commissioner. But the electoral politics and her involvement with the RU 486 approval was just too much, and so she was out as of day one of the Bush administration. We had a period of time for about five or six months in early 2001 where we weren’t really sure exactly what we would do next. And I had a conversation with an individual that I worked with in the past, John Eisenberg, who was then the Director of the Agency for Healthcare Research and Quality. And he had a position, one of his Center directors were an individual retired and that Center had a lot of responsibility working with professional groups. And he wanted somebody that he could put into that position pretty quickly. John had been diagnosed a couple of months before with a very malignant brain tumor and he just didn’t want to get tied up in a year-long search. And since I was still a reserve officer in the US Public Health Service, he said if you can pass a physical you can start in two weeks. So I went back into uniform and back as a Center Director for AHRQ. With John’s death I wound up being the Acting Deputy Director of the Agency for about three years. Jane in 2003 was invited to come to Cincinnati as the Vice President for Health Affairs and Provost, essentially running the Health Sciences Center here. So we started commuting again. She came here in 2003. Because AHRQ had always been kind of a vulnerable position, as a policy research agency it sometimes had findings that people in the healthcare industry thought were not good for their business plan. So there were all these people trying to put AHRQ out of business. I did not want to leave the agency while there was a presidential election going on. So worked it out with the Director, Carolyn Clancy, that I would stay as Deputy through the election of 2004. And at the conclusion of that I moved here to Cincinnati in January of 2005. Very fortuitous timing in that the Department of Family Medicine here had just completed their work on establishing an endowment in the name of the first Chair, Dr. Robert Smith, and they were looking for someone to occupy that endowed chair and they specifically had decided they wanted somebody with something of a national profile in family medicine. And I think had done that really independently of thinking about Jane being there or anything else. So suddenly I show up in town and they had me give a presentation. We had lunch after that and the Chair said would you be interested in joining the department and being our first Endowed Chair? Since I was already there I said that seems to me to be a pretty easy conversation to have. So I had been on the faculty of the Department of Family Medicine at the University of Cincinnati since March as the Robert and Myfanwy Smith Endowed Chair. Have really focused my activities on three areas: leadership development, organizational change and universal coverage. And I spend about a quarter of my time out of Cincinnati. I direct the Bishop Fellowship Program for the Society of Teachers of Family Medicine. I’m the Chair of the selection group for the Robert Wood Johnson Institute of Medicine Health Policy Fellowship which is based in Washington. And am also on the board and the chair of something called the Alliance For Health Reform which is a Washington-based organization established by Jay Rockefeller to provide better information about what are the necessary antecedents for a sound reformed healthcare system.  \n\nThe organizational change part has led to a real focus and development on what are the elements of high performance organizations and how do you train people to work in that way. And some of this is drawn from my Academy experience and very consistent with some of the staff development things that we did there we have talked about here over the last ten to twelve years while I was there. But we found a curriculum that we can take groups through, twenty, thirty hours, that really does change the way they work as teams and the way they work in organizations to make it much more constructive. So Jane finished her tenure, five-year contract as a VP for Health Affairs in January of 2008 and at that point found that she was working with the president of the University of Cincinnati who really didn’t think that they needed a Health Sciences Center. Her operational style was to have everything report to the President. So Jane declined to renew her contract, so she is now on faculty. And at some point in the middle of 2008 we sort of looked at each other and said you know, this is the first time since we’ve been married that neither one of us is running anything. I don’t know how long it’s going to last. Her phone rings and people continue to think that maybe she ought to go someplace and do another job and she may well do that. But in the meantime, we’re both faculty members and not trying to do line administration but still very interested and having a lot of fun with what we’re doing. And that is as of January 21, 2009, happy new administration.  \n\n\n\nCENTER FOR THE HISTORY OF FAMILY MEDICINE  HISTORY INTERVIEW WITH ROBERT GRAHAM, MD (CONTINUED) \n\nINTERVIEW CONDUCTED ON FEBRUARY 26, 2009 \n\nBY SANDY PANTHER, CFRE\n\n\nDr. Graham, the last time we ended our session I had asked you a question about your successes and you wanted to go back and pick up on one additional item. So if you would like to do that now. \n\nThinking about things after we hung up, I think if somebody had visited the Academy in 1980 and then came back in 1990 or 1995, there would have been something very obvious to them that had changed that just didn’t occur to me to mention. Can you imagine what I’m thinking about?\n\nNo, I cannot. \n\nThe composition of senior leadership. We went from a point, and I think fairly typical of most associations and probably most organizations at that point...when I arrived all the senior leadership was male. And by the time we got to the early or mid 90s half of the senior leadership was female. So when I got there the vice presidents were Bill Myers, Mike Miller, Walt Kemp, Dan Ostergaard, and Gary McMahan was the head of the Foundation. And by the time we got to the early to mid 90s the vice presidents were Mickey Schaefer, Rosie Sweeney, Clayton Hasser, Dan Ostergaard, Norm Kahn, Mike Miller was the deputy and you were the head of the Foundation.\n\nSo actually that is even, isn’t it? \n\nIf you count you in the Foundation it’s a plus one. And I didn’t go back into the files but I remember in the mid to late 90s during one of our senior management retreats when we had all of the VPs, the division directors and the assistant division directors which is usually a group of about thirty to thirty-five people, that the majority of the leadership was female. All organizations are somewhere along that trim line right now but I think in terms of the specific individuals and the responsibilities that we had and certainly acknowledging that the Academy’s workforce has always been preponderantly female, the ability to be able to promote and place just excellent people who happen to be women in those positions really was a very significant change for the Academy. And I think what triggered it is when we talked about some of the other things that I thought had gone well for us, we talked about the Special Constituency Conference and the fact that the Congress of Delegates was trying to affirmatively manage the governance change recognizing that an increasing number of family physicians were women...I think it was important for us as the women in the Academy’s leadership started showing up in the Congress of Delegates and then we started having women on the Board, certainly had women on the Board as student and resident members before we had anyone elected, that they would be able to look at the staff side of the Academy and see the same type of changes taking place.\n\nAnd I think it is and it has maintained. Currently it is still being maintained with senior leadership being well-represented by women. \n\nYeah, I think if I know the people correctly now, they have two VPs. Rosie Sweeney is still there and the woman who has taken Membership whose name is going to escape me right now.  \n\nDonna Valponi. We lost two because the publication [Publisher] is now male and the Foundation is male. But we still have the two women. \n\nAnd as we go back and look at it in five or ten years, that may just be a reflection of fluctuation rather than a trend away from it because I was particularly fortunate when I got there that as we started making change in the VPs or having had the opportunity to do that, there were just very strong, well-qualified women. Only Clayton Hasser was a recruit from outside of the organization. Mickey Schaefer, Rosie and you all moved into those senior positions from other responsibilities in the Academy. So they were already there.\n\nIt will be interesting to see in the future. It will probably maintain the same percentage.  \n\nSo I just wanted to go back and capture that one. Because as I say, in terms of everything else that was going on demographically in the United States and certainly within the leadership of the Academy on the member’s side, that was just such an obvious thing, and it just escaped me.  \n\nWell, thank you for that addition. Now let’s move into the Foundation. Historically you came on board the Foundation in 1988. And if you can discuss a little the politics of that decision and then the process through to 1997 when the new EVP was announced. \n\nI certainly can do that in outline. And this is the point where rather than being an interview we may get more into a conversation. Because I have not gone back into my notes and tried to reconstruct things from ‘88 to ‘95. But my general recollection is when I got there, and the Foundation was not a top issue for me for say the first year and year and a half. I was focusing in the first year to year and a half just on the normal amount of transition coming in and learning a new job. At the time that I arrived Walt Kemp who was the VP for Publications had been very recently diagnosed with a brain tumor. And Walt died probably within three or four months after I was at the Academy. So in addition to being the Executive Vice President while I was searching for a new head of Publications, I was also serving as Publisher of the American Family Physician which was an absolutely fascinating experience just because of the complexity of that operation. But I wasn’t looking at some other particular projects and that was also the period of time when we were making arrangements to make our first move from the 1740 West 92nd building to the 8880 Ward Parkway building.  \n\nIn the midst of all of that though one of the issues that was troublesome to the Board because of the interlocking membership that we had between the Academy’s Board of Trustees [Directors] and the Foundation Board of Trustees was that the Foundation was struggling. And by struggling I mean particularly it was a period of time when pretty much every year on a year-end basis the fund balance at the Foundation was declining. And that was largely attributable to the play-out of a very specific strategy which began early 80s to try to strengthen the chapter foundations. And I would have to say that certainly looking at it today, in almost every circumstance the strategy worked very well. But it was an arrangement by formula where funds being collected by the Foundation in Kansas City were shared back to the state. But the formula worked in such a way, and the state chapters were very smart, the states basically could get more money than their members ever put into the pot. And I wasn’t around for the conversations in the early 80s but I can’t imagine that the Foundation said let’s find a way to build up the strength of the state chapters and let’s do so even though we recognize we will be eating away at our own corpus of funding, but that’s the way it worked. Now, Sandy, you were around there. Was there the recognition that that formula could possibly turn out to have that event?\n\nNo, it was presumed that if shared with the state chapters part of our revenues both from an individual standpoint and 75% of the corporate donations that we would build up the chapters to make them self-sustaining and able to hire qualified individuals to run their foundations which in the end would bring in more money, not less money. And that simply did not work.\n\nIt is always easy to critique a decision and strategy with ten or twenty years of hindsight. But when I got there I think the realization was starting to dawn certainly the Academy Board members’ part that the strategy to build up the chapter foundations which everybody supported was working. But it was working so well in a way we hadn’t anticipated that the strength and the vitality of the national Foundation was starting to come into question. And so there commenced a series of back and forth between our Board and the Foundation Board which got kind of testy at one point. And at that point I was solely on the Academy’s side and was giving the Academy Board the best advice I could in terms of what I thought needed to be done. And, of course, we had a shared constituency there. Anything that the Academy Board would push to do that would affect the chapter foundations, the chapters who are the basic constituency of the Academy could come back and say we’re not happy about that. So it was playing out both at the Board level and occasionally with resolutions of the Congress of Delegates. But we came to a decision at the point that one of the steps that we needed to take was to align the management of the Academy and the Foundation. And so the Academy Board members, through their position on the Foundation Board, made the decision that the Executive Director of the Foundation, Gary McMahan at that time, rather than reporting to the Foundation Board, would report to me as the EVP of the Academy. And as I say, there were several members of the Foundation Board and at that point the senior members of the Foundation Board tended to be Past Presidents or past officers of the Academy. The governing structure of the Foundation has changed at least twice, maybe three times since that. But on the other side of the table, there were people that had a lot of seniority with the Academy, had a lot of experience with the political background with the Academy. And they weren’t necessarily very happy about that change and they let that be known. And that was one of the issues that we had to manage with the Congress of Delegates. And each year when we had our conversations with the past officers at the Annual Assembly that came up. So starting in ‘88 I became much more directly involved with the operation of the Foundation and particularly working with Gary trying to determine different strategies that we could undertake to stop the significant decline in fund balance for the national Academy [Foundation] while at the same time trying to continue to be supportive of the aspirations of the state chapters to continue to grow and get assets into their corpus. Obviously, about the only lever that we had other than just raising lots and lots of more money – which at this point you were Director of our Corporate Relations and it was a time period when you were having a lot of success in terms of establishing relationships and raising funds from the corporate sector. The membership giving went up a little bit every year. I think it was probably during that time period where we initiated the checkoff on the member dues statement. I don’t remember what year it was but...\n\nIt fell in that timeframe because that was essentially what brought us up, if you recall, from a negative budget to a fairly substantial positive budget.\n\nWell, we were getting there. We didn’t make the negative to positive change just based upon the checkoff. We did it by doing at least one round, and I think it took us two rounds of changing the formula of money to the chapters. And the second change in the formula did not take place until we got down to the lowest level that we had which resulted in doing away with Mr. McMahan’s position. And that would have been ’94.  \n\nEnd of ’94 [sic].  \n\nSo we were at a place at that point in terms of the continued deterioration of the Foundation’s fund status. Even though I think we had the checkoff in place, we needed one more round of change in formula. But to get there over a twelve to eighteen to twenty-four month period the only solution that I could see was to downsize the staff. And as I recall, we deleted Gary’s position and I believe we deleted at least one other and maybe two other positions on the staff.  \n\nYes, we did. And I think one was in Individual Development and one was in the Library function. \n\nThat sounds right because I remember any time we deleted the position I met with the individuals and talked it through. And I just remember it was a conversation more with Gary. One of them is a young lady. And I can see her face but I can’t bring a name back.  \n\nSo we had a period of time there where I then became serving much more directly as the CEO of the Foundation. And we went through a period which I know the Board of Directors thought I was absolutely nuts but I asked you and Pat Gibson to essentially alternate every three months. Was that the cycle?  \n\nEvery three months of the first year. Every six months for the second year. \n\nI couldn’t be in the Foundation everyday so I couldn’t be doing what a CEO would have been doing. I felt that we would at some point reestablish the Chief Executive Officer of the Foundation and I thought that both you and Pat would be very reasonable candidates for that position although you had very different backgrounds. And I wasn’t willing to make that choice at that point. And also I wanted to use some of the leverage that I felt that I had as the CEO of the Academy to work through with the chapters and the Board the necessary politics to make that second revision in the allocation formula. And so we had eighteen to twenty-four months where we...I’m trying to remember what the term was – Administrative Officer, Operating Officer. Do you remember?  \n\nAdministrative Officer.   \n\nSo that you would do three months, Pat would do three months. And as I say, I know the Board, and the Foundation Board was still involved, I was relating to both Boards, sort of looked at me like I was a little nuts. Now if I’d have been as smart then as I have learned hopefully to be now, there was a literature citation for what I was doing, I just didn’t know it. But it turns out that it is fairly common in Fortune 100 companies where a succession to the CEO much more typically is done on an internal basis. That what boards will do when they feel that they have two or three candidates that they want to look at for the CEO position is they will specifically give those candidates special projects or special tasks over a year or two years, look at how they carried them out and use that as part of their assessment as to who should become the CEO. Once I discovered that when I was reading some of the management leadership after I left the Academy I said good, so I wasn’t nuts – other people are doing this. But I wanted both to have the opportunity to see how you and Pat both would approach the responsibilities of being the coordinating point during the times that you had that responsibility and also get through the necessary turbulence to do those things that I thought would result in the Foundation having a healthy bottom line. We finally got there in ‘97. Was that the point of transition when you became CEO?  \n\nJanuary 1st of 1997.    \n\nAnd it was at that point that I felt like I had enough experience, that the finances were stable. We actually were starting to do some things that you carried out and brought to full fruition that had just turned the Foundation totally around. It wasn’t just the corporate although you continue to be very successful with that. But we started being much more aggressive about planned giving, much more aggressive in terms of reaching out to the members that we knew would be at a point in their career, at a point in their life where they would be much more likely to be looking at legacy gifts. You started doing the Heart to Heart which wasn’t a huge fundraiser but gave the Foundation visibility. When did you do your first auction at the Assembly?  \n\nThat must have been ’99, 2000.   \n\nIt seemed like you did one just as I was going out the door and I left in 2000.  \n\nIt was Dallas.   \n\nYou and I had talked about it but I wasn’t there to see it because I left in August of 2000 and did not attend the 2000 Annual Assembly. And I think we also because of some of the governance changes were starting to get a Board of the Foundation that I really liked a lot. It was a combination of sitting directors of the Academy, directors from the state chapters and kind of a smattering of past directors or officers of the Academy Board. But not everybody who wound up on the Foundation Board with prior AAFP Board service was a Past President. We had some who got there just because they were interested in the Foundation but they had not been successful in being the President or hadn’t sought the presidency. We had some who had been President. And two people I identify that I thought were extraordinarily effective Foundation leaders and were at the right place at the right time as we started to make some of these changes were Harry Metcalf and Bill Coleman. And Harry must have been President middle of the term when I was CEO, I think. But that’s when we started becoming much more focused on trying to have specific programs that we thought we could raise money for, so we started the Resident Repayment Program, which I thought went okay. It never brought in the level of funds that we thought that it might. But it was visible as a profile. We were able to point to successes with residents who actually had a benefit from the Foundation and I think started getting younger family physicians and residents-in-training with the recognition that the Foundation was there and meant something. I attribute a lot to Harry Metcalf’s leadership in saying we need to do something like this and task some of the staff to come up with ideas. And then Bill Coleman came in, I don’t remember whether I was still the CEO or whether he was one of your first Presidents.  \n\nMy first President was Jerry Keller. So my second President I think would have been Bill Coleman then.\n\nAnd Jerry really had a passion for Foundation and for fundraising. Didn’t happen to have been a Past President of the Academy, lost the presidential race. But served for two or three years. What was the President’s term at that point?  \n\nTwo years.   \n\nAnd then what I remember Bill doing that I thought was so effective and classically what leaders are supposed to do and that is have a vision statement – Bill came in and said I have a vision. We are going to have a fund balance of what was it, $1 million, by such-and-such a date. And at that point that would have been five times the fund balance that we had.  \n\nWas it fund balance or was he the one that came in and said he wanted a $10 million endowment by 2006? \n\nYou were closer to it than I was so I’ll take yours.  \n\nIt was $5 million by 2006.   \n\nAnd you hit it.  \n\nWe hit it in 2004. \n\nI just remember when he made that statement based upon where our balance sheet was, looking at $5 million was just how in the world are you going to get there? But all the literature says leaders have vision and the goals have to be stretch goals. And that was a vision of the stretch goal.  \n\nAnd it was and, by golly, he was right.\n\nYes. Going back to the first part of the conversation. If the charge that was given me by the Board in 1988 was to get involved in the Foundation, do what was necessary: #1 to stop the declining balance of funds; #2 to find a way to get stability of good leadership; and #3 strategies to start building the fund balance; we came out pretty good.  \n\nYou were highly successful.  \n\nIt is one of those things, I have to say though, looks much better looking back on it. Because if you had taken a biopsy of opinion in about 1994, I’m not sure everybody would have given me very high grades.  \n\nBut you rectified the situation which allowed it to go forward without a lot of publicity. The change was made and people give to successful organizations and people really were unaware of that 1994 change. I mean they knew Gary was no longer there but there was no brouhaha about it. So it really had no bearing at all on the revenue generation. \n\nAnd I think by and large we got through that with the state foundations still being in pretty good shape. At least those that had made any significant commitment to developing their own fundraising strategy and to having at least some portion of a dedicated staff to do it.  \n\nAbsolutely. There are five states that are highly successful now because of what we did. And they never used our funds and then just let them sit in a bank account. They actually were proactive in doing good things for their…\n\nYou mentioned something that I had forgotten but was certainly one of our frustrations in this middle of this process. We were seeing a lot of our funds go out of the bank account in Kansas City and go into state bank accounts and just doing nothing but building up the balance sheet.  \n\nThat’s right and never spent a dime. Some of them still have that same fund balance.   \n\nI think that about covers the Foundation. You have received honors and appointments (that I consider honors also). I would like you to list those, if you could, that were most important to you. \n\nIn 1990 I was elected to the Institute of Medicine. This is a voluntary organization in Washington, DC. It’s election only. Within healthcare generally perceived as one of the more prestigious groups that you can be invited to join. And family medicine, I think we have maybe thirty family physicians in the Institute right now. When I was elected we were probably still around ten or twelve. Family medicine has always struggled a little bit to have any visibility there. And it was a nice feeling to be elected into the  and it’s totally attributable to American Academy of Family Physician members who were already in the  putting forth the name. It’s a very competitive process because they usually have five or ten times the nominations each year for election. The STFM provided me with the Marian Bishop Award late in my tenure. And that was very nice because Marian was still there and presented the award. She and I were able to be together at the podium talking about this a little. Earlier in our interview I noted how Marian and I made an acquaintance when I was just working in HSMA before I had gone to the Academy the first time. She was really the person who made the connection between me and the Academy. And a lot of people in the STFM audience knew that Marian was one of the founders of the specialty but didn’t realize that she and I had that relationship that went back that far. And then I guess the other that comes to mind is the Academy’s Board deciding to name the Policy Center in Washington for me – which I had no appreciation what that would mean when they did it. There are relatively few times in my life that I have been totally surprised and that was one. Having a Policy Center in Washington, DC that could participate in and form the debates I’d always felt so strongly was a key part of our strategy. Not just the advocacy strategy but the strategy to get people and policy environments to say you know, whatever we do we need to think about family practice and primary care. And we look and see what that Center has done over the last ten years, they have just done extraordinary work under the leadership of Larry Green and now Bob Phillips. I can’t take a bit of credit for that work. The only thing I can take credit for is making arrangements with the support of the Board to provide the structure where that work could go on. But it is just a remarkable experience when you have something which is dynamic named after you and you’re still living. The downside we discovered is that you get something named after you and everybody thinks you’re gone. We had a running joke in the office while I was still in Kansas City, the Board made this announcement maybe two months before I actually left the Academy. Marge Downey, who was my secretary, and Jo Rockufeler, who was the Executive Assistant there, I would hear them having phone conversations and they would hang up and then they would sort of get together and laugh about it. And I finally said what’s going on. They said we’re getting a series of phone calls where people just always are beating around the bush and what it comes out to be is gee, I didn’t know he was sick.  \n\nSo now I’m two careers past the Academy. I’ve worked another five years in the federal Public Health Service as the Deputy of the Agency for Healthcare Research and Quality. I’m five years into being a tenured Professor of Family Medicine at Cincinnati. And this Robert Graham Center is there in Washington and continues to turn out superb work. And everybody thinks I have something to do with it.  \n\nIt does do superb work because they are highly respected not only by the government but by industry because they do quality work with quality outcomes. So it is an adaptation not only to what you did to have your name attached to it but also the quality of the people who currently hold those positions.\n\nAbsolutely.  \n\nIs there anything else as we close these series of interviews that you would like just a general reflection? \n\nI can’t think of anything right now and am aware that we are probably two or three minutes left on this tape. So I will make reference to the fact that Dan Ostergaard is doing a somewhat parallel set of interviews but with a different focus. Dan and my conversation is focusing a lot more on some of the policy issues and policy administrative things that we got into when I was there. And a couple of times on that tape I’ve made reference to these interviews. So what I’ll do in these interviews is make reference to that. So if somebody is listening to these tapes or reading the transcript and wonders if there’s something else they might want to look at or think about, go to the other transcript.\n\nI appreciate your taking the time and effort to do it, Sandy.  It is nice to be interviewed by a knowledgeable inquisitor.  \n\nIt has been my pleasure totally to do this interview. 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