{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/d795719k6n/manifest","type":"Manifest","label":{"en":["Dr. Nikitas Zervanos"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Date"]},"value":{"en":["1991-05-05 (created)","1992-03-04 (other)"]}},{"label":{"en":["Type"]},"value":{"en":["Oral History"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. William Ventres (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":["Nikitas Zervanos, MD (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}},{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer: The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}}],"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284028","type":"Canvas","label":{"en":["Media File 1 of 4 - Zervanos_Nikitas_Pt1_91_a.wav"]},"duration":1804.87339,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284028/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284028/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/284/028/original/Zervanos_Nikitas_Pt1_91_a.wav?1754493238","type":"Audio","format":"audio/wav","duration":1804.87339,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284028","metadata":[]}]}],"annotations":[]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284027","type":"Canvas","label":{"en":["Media File 2 of 4 - Zervanos_Nikitas_Pt1_91_b.wav"]},"duration":1788.699,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284027/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284027/content/2/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/284/027/original/Zervanos_Nikitas_Pt1_91_b.wav?1754493236","type":"Audio","format":"audio/wav","duration":1788.699,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284027","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284027/transcript/82285","type":"AnnotationPage","label":{"en":["Dr. Zervanos Interview Transcript (1) [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284027/transcript/82285/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Nik Zervanos\n\nMay 5, 1991\n\nPhiladelphia\n\nQ. - William Ventres, MD\n\nA. - Nikitas Zervanos, MD\n\n___________________________\n\nQ.  I think the, what I wanted to start with was to get a perspective on, really kind of the structural aspects. What you were doing when – or, how you got involved in family medicine, kind of what you were doing, that process first. And then later we can get into what that meant to you.\n\nA.  Okay. I went to medical school at the University of Pennsylvania. I graduated in '62, I always envisioned being in general practice. I really considered no other field of medicine. I came to Lancaster to do my internship with the notion that Diana and I would settle in Lancaster. Her family was from Lancaster, my family was from Reading, Pennsylvania. And that's where our extended family was, both – in either one of those two communities. And then while I was in my internship a number of things happened. I met Ed Kowalewski, who was a family physician from the little borough of Akron, that year he was president of our local chapter of the Academy. I heard him discuss some of the concerns about the future of general practice. That got me particularly interested in my own future, and also some of the political aspects of the discipline, or at least of the – it wasn't even a specialty but of the field. I joined the Academy, and remained very interested in what was going on. During my internship I decided that I needed some more training before I set up practice, I was going to go ahead and practice with a general practitioner in town who is my wife's family physician. And what happened at that point is I got drafted, but I had already, I was already accepted into a residency. Now what happened in the interim, though, I was looking at general practice residencies and they were really nothing more than another year of internship. And so I sort of decided I wasn't going to do that. But I also was rather annoyed by that observation because it occurred to me that when I looked at general practice residencies, there were no general practice residencies in any medical schools around our area, and as far as I could tell there were no general practice residencies in any medical school or university setting. And that sort of annoyed me some more. And it reminded me of what, some of the concern Ed was having too about the future of general practice. And so therefore I was going to go back to Philadelphia, do a year of medicine, then come back to Lancaster and go into practice with Charlie. And then what happened is I got drafted, went into the US Army and the – went down to Washington to get, see if we couldn't ourselves – myself and another friend of mine who was an intern with me – assigned to a desirable location. I wanted to go to southern Europe and hopefully be close to Greece so I could visit family where I, and many of these people I'd never met since I was born in the United States, most of my relatives were still in Greece. And I discovered that there was in fact an opportunity to go to Greece. There was one US Army position there, and I got it. So I – my wife and I were very excited about having that opportunity to go. So while I was in the US Army, stationed there in Greece, I started a letter-writing campaign back to my dean of the medical school and some friends and expressed my concern about what was happening to the future of general practice as I saw it. And I also was pleased, though, that there was activity occurring at the AMA level. I learned about the establishment of the Millis Commission, and that was encouraging. And I also was encouraged by some of the discussions that I had with some of my mentors back in medical school, actually. There was a guy by the name of Louis Blumley, who maybe some, maybe you have heard of him. He was the, just the recent outgoing president of Thomas Jefferson University but at the time he was a nephrologist at my medical school. And Dr. Blumley expressed concerns to a number of us medical students who were interested in general practice or I shouldn't say a number of, because I don't know exactly what his discussions were with others, but I know he was sympathetic about my future. And was encouraging. And expressed concern about medical education in general that we weren't paying enough attention to the production, if you will, of generalists. And so anyway, when I wrote back to Dean Goren, who our dean at Penn, he was a biochemist of all things, and when I told him what I was up against when I was looking at general practice residencies, and he was also sympathetic. He thought that I had a legitimate concern, and he told me I should write to Joel Alpert up at Harvard. Joel Alpert at the time was a pediatrician, associate professor of pediatrics, who was in charge of the Family Health Care Program. This was a program that was developed by Bob Haggerty, who was then a professor of pediatrics at Harvard before he went to Rochester to become chairman there, and Dr. Haggerty founded that program to prepare pediatricians coming out of Children's Hospital Medical Center for community practice, since many of them didn't feel adequately prepared for community practice coming out of the environment of Children's Hospital Medical Center. And so when Joel took this program over, it was at a time when he realized that there was going to be something happening in family practice. I guess he was aware of the Millis Commission and so forth, and it was his idea to take people who were in general practice and offer them an opportunity to come and do a fellowship there and prepare them for careers in the academic arena. I know Lynn Carmichael was one of the first that went there. I guess that was in '64, '65. I wrote to Joel, I was in the Army at the time, of course – and he said when I got out of the Army he wanted to meet me. So I did go and visit with him. And while I was in Boston he, and we had our interview, he offered me a fellowship which I was going to do after actually completing the year of medicine that I had planned to do in Philadelphia at the University of Philadelphia. This first year was going to be at the Philadelphia V.A. I say first year because I ended up spending a second year there, Dr. Jim Weingarden was chairman of the Department of Medicine and I shared with him some of my career goals, and he was rather encouraging, and suggested that I stay on a second year and parti-cipate in some of the ambulatory care experiences that I had in mind in terms of my own preparation for future family practice, which I did. Including one year – during that year I also spent time with Dr. Joel Potash, who was a psychiatrist who set up a Balint seminar that he offered for a number of us who were residents at Penn at the time and there were some people out in the practicing community that participated. In fact it was a general practitioner from our own Lancaster County area who was coming up who participated in that Balint seminar. And that a rather exciting year to have that opportunity. So I learned a great deal from that experience. Anyway, I then went up to Boston in '68 and I was – while I was there from '68 to '69 I got a call from the director of medical education at Lancaster General Hospital, who was brand new at the time in that role, but he remembered me, having done my internship there, and he said that they were thinking about establishing a Department of Family – not a department so much, but a residency program in family practice. Would I mind considering that situation? And of course I was quite pleased with that opportunity, and didn't think that things would work out quite that well. We even considered going back to Lancaster and going into practice, but when this opportunity came up obviously I was quite interested, I did go to, back and look at the situation. I was quite anxious about it, obviously, because at the time there were no residency programs in place, and although I learned that there some pilot programs that were being developed, one of which was at York Hospital, in fact. And they started their program in 1969, and a fellow by the name of Tom Hart was asked to assume directorship of that program. So when I came to Lancaster in 1969, one of the first visits that I made was with Tom Hart over at York, and I saw what he was doing, and then I remembered later that summer or early fall I got a visit from Tom Johnson, who was the Director of the Division of Education of the American Academy of General Practice, or Family Practice now at this point, and Tom was enthusiastic and very exciting and – one of the things we were considering doing is taking the outpatient department that we had at our hospital and converting it to a family practice center, because one of the concerns we all had back then was the problems of the underserved, and the problems of the indigent and we – remember now, this was 1969. And this was a – the specialty of family practice in fact was supposed to be able to respond to that area of need. And it was also going to make a difference in the quality of, not only of health care but the quality of life for the American people. And I found it a challenge to be able to develop a program where we could direct our philo-sophy in the care of people who were psychosocially disadvantaged, I suppose, or at least had psychosocial problems and were socially and economically disadvantaged. So I found this as a real opportunity to try to do something about that. And when Tom came I remember him saying, 'Well, Nik, you know, you got – this specialty is, the way we're trying to do these family practice centers, we'd like the practice to represent the demographics of the commun-ity. And you know, the family practice center really needs to have a wide socioeconomic spectrum of patients.' And so – after Tom's visit we really thought a lot about what we were going to do about this outpatient department, which had a bunch of clinics and they were trying to develop or provide services on a voluntary basis to these indigent patients. And so we came up with something unique. We decided the Lancaster program was going to do something for these people and at the same time we were going to develop our own family practice – we were going to develop the family practice center as required by the RRC, and we were going to put this family practice center actually in rural Lancaster County. We thought it would make a, it would make a real contribution to be able to have a rural center. And we came up with that because we also, as we looked at where we were going to put this family practice center, we also recognized that the most underserved area of the entire county at the time was in this little borough of Quarryville, 15 miles south of Lancaster city. And when we looked at the demographics of that community it had a lot of attractive characteristics, one of which was that the borough of Quarryville was right in the center, right in the hub of a 300-square-mile area, and this borough of 1800 people was also the hub of a lot of activity of southern Lancaster County. We knew that people shopped in Quarryville, most of their services that these people who lived in that vast area down there, that's where they liked to go for their services. And it had at one point six or seven physicians in general practice serving that area. And there were a couple who had retired, there was another one who had just died and they were left with, I think at that point they were left with just three family physicians or general practitioners, one of whom was close to retirement already, and the other one wasn't well. And it was a serious situation. So it just turned out that the person who was getting close to retirement was chairman of our Department of General Practice at the time. His name was Charlie Bear(?), and he says 'Nik, please consider putting your center down here.' And so Dr. Henry Wentz, who was a person who I recruited to join us, and he was one of my real mentors when I was an intern back in '62, '63, I asked Henry whether he would become a part of this new venture, and Henry was caught up with the challenge, and he became the director of our center in Quarryville. And it was a smart move. But what we, before we even did that, we also – I had a medical student, or – yeah, he was a medical student, who I recruited that summer, actually was the summer of '70 to '71, the summer before that I had another interesting medical student, a student that worked with me, who I recruited from Harvard when I was a fellow up there. And this fellow was from Bethlehem. His name was Ed Benz(?). We did something very interesting with Ed. I told Ed, I says, 'Ed, I want you to go out and meet every agency director in this town.' Heart Association, Lung Association, Cancer Society, the various mental health groups, the Office of the – well, we didn't have an office of the aging at the time, but we had groups that represented the Children's Bureau and the Community Action Program, and so forth. It was a whole bunch of agencies. And I says, 'You go out there just like you were a journalist or a reporter, and you just go out there and you interview them. You find out what they do, and what they expect from hospitals like ours, and what would they expect from a specialty like ours? And you tell them what this specialty of family practice is. You tell them that this is a brand new specialty, it was just established and we are committed to providing continuing and comprehensive health care. You tell them that we're going to be producing physicians who will be able to deliver this service and on a highly personalized level, and that there will be a consid-erable amount of emphasis on the prevention of disease. We intend to direct this discipline to maintain people in an optimum state of health and you tell them that we're going to be well-trained and well-educated to manage and treat the vast majority of problems that people experience in their entire lifetime. Now you go out and tell them that and you find out how they feel about that and how they feel they might want to interact with us and how we might be able to work together for the future benefits of our community.' And he did it. And he would come back with a journal every day, and it was a nice experience for him, it was a nice way of us communicating with the community at large about what we were about to do. And I remember one of the agencies that he contacted was a Council on Alcoholism at the time, and there was great concern about the problem of alcoholism in our community, and they also were – that was the agency that was also trying to address the growing new drug problem that we were experiencing in our community too. And I say that too, because that sort of laid the groundwork for some other areas that we got into with our depart-ment and the community within the first year or two of our operation. But in the meantime we were in the planning stages developing this center in Quarryville, but before we did that we had this other student who worked with us between '70 and '71 and in '70 I might add was the first year that we brought in our first residents, we had our – our program was approved in the fall and we recruited and we brought in our first three residents in July of 1970. We were going to phase out the internship altogether, and then we had an internship – I think at that time there were six interns and we were going to phase it out and replace it with our family practice program over the next two to three years. Of course in 1975 all internships were supposed to have been dissolved – free-standing, rotating internships would no longer be able to exist. So that would have been gone by then and we would have a full-standing residen – I mean we would have a full complement of residents, we were planning of having six at that point – in each of three years. But when we looked at our community and did the demographics, we had – this student, he did a remarkable thing. What he did is, he recruited 30 citizens of the southern Lancaster community. And these people came from the Farm Bureau, primarily. And what he did is he met with them, he told them what we were going to try to do in Quarryville, what we wanted to be assured of is that they would support our family practice center. And each of these people were expected to go out and visit 10 homes. So we were intending to visit 300 households. And he did it. He managed to get these people to go out and visit 300 households. And at the end of the summer, when he completed his data, the feedback that we got was overwhelming supportive of our endeavors to establish this family practice center. Because you see in a lot of – there were some assumptions on the part of people that – how would a citizenry at large want to visit a family – a doctor's office who were just staffed by residents.\n\nQ.  In training.\n\nA.  In training, mind you. But the way we envisioned our program, we said that none of these people going, none of our residents who were going to be participating in the center in Quarryville would be interns. They would all be second-, third-year residents. They would all be licensed, because the way we designed our program, and it still is the same way to this day, we said that our residents would spend a half a day a week in the family health service, which is the unit we called it at the hospital. Because we created what we thought was a service in family health care, but service the indigent. And we said that the program at the hospital, this outpatient unit which was being moved incidentally into a brand-new north wing of the hospital, we said that that new family health service was going to provide continuing and comprehensive health care to this indigent populace on a one-half day a week basis throughout the three years. And then our residents would go down to Quarryville beginning in their second year and spent two to four half-days a week in the center in Quarryville for their second and third year. So we thought that was a really exciting model. And the RRC actually liked it. They – at that time we were very open to flexibility, and they liked what we were trying to do. And to this day it's the same model. It has not changed. We operate these two units. And at the time the hospital-based unit, that first year of operation I think we saw something like 5,000 patient visits. And today of course we have 12 residents in each of three years and we're seeing close to 30,000 patients. That's just in the hospital-based unit. And the unit in Quarryville, that first year of operation, we were seeing several thousand patient visits and now we're up to almost 30,000 patient visits in our center in Quarryville, and the demographics of the practice in our center in Quarryville are in fact reflective of the demographics of the community at large. It has a wide socioeconomic spectrum. And it's turned out to be a very, very successful model for us. And being in a rural setting, I think it helps prepare people for overall practice and it turns out that two-thirds of our graduates who left our program and graduated from our program are practicing in communities of less than 30,000 people. So I think the model has supported the rule, emphasis. Now in the meantime what was beginning to happen back at the homebase, if you will, when I'd come out to the meetings, it was a really exciting time, because we would, there was just a handful of us basically back in 1969, 1970. I remember Leland Blanchard very well, Gayle Stephens, of course, was a role model for many of us, even back in those days.\n\nQ.  He was [   ] years old than you.\n\nA.  He was at Wichita, Kansas, at the time, Lynn Carmichael of course was a very important figurehead for all of us. And then there was Fitzhugh Mayo down at the Medical College of Virginia, and Hiram Curry, I remember him so well, and of course Lew Barnett. Just a lot of wonderful people that was part of this movement. And of course Bob Rakel, who we heard from today.\n\nQ.  Was he also part of that group?\n\nA.  Yeah, he came in 1970, he came right in, and of course Bob had a magnificent presence, as he still does, back in those days. We were very fond of each other, all of us who started out. I remember Tom Nicholas, who I felt so positive about back in those days and he became a very important part of the whole movement because after Tom Johnson died – I think it was Tom that moved in shortly thereafter – and of course Bob Graham, who is a Young Turk I guess you might call anybody. Very impressive person who, everybody was impressed with his beautiful mind, and he really did a lot for us. He was part of the Division of Education of the Academy early on, he was, played a very influential role in the development of the Society of Teachers of Family Medicine.  \n\nQ.  You know, I want to stop you at this point just to digress, perhaps. Each of the people with whom I've talked, and before this you mentioned it as well, something was shared in that early time period, and I'm not sure what it was, but people look back on that time as a really exciting time.\n\nA.  Oh, sure.\n\nQ.  And I'm not sure what it is, and I haven't asked this of other people, but what was it in that group of a handful of people? I mean what was going on that generated this excitement.\n\nA.  Well, first of all, just imagine, and you're getting into something – virgin territory. Nobody knows really exactly how we're going to do this and do this well. We all had a vision, however, we all knew what family practice was and what it meant to us, and we all wanted to develop what we felt was the need for discipline. You know, general practice was a wonderful way of practicing medicine. But it wasn't the same throughout the country, and it wasn't even the same always in your own community. Part of it is because it wasn't a discipline. We needed to create a discipline that will assure the American people how you personalize continuing and comprehensive health care. We bought in early on to the problem-oriented medical record. We wanted to be able to look at people's problems in the holistic sense of the word, I mean we were particularly concerned about the psychosocial dimensions of patient care, and we wanted to be able to learn how to deal with those problems in the most effective way possible. And we wanted to learn techniques and skills that weren't available to an intern who went from internship right into practice. Those of us who were doing those things, that is, you know, using techniques to take care of people and listening techniques and so forth, we learned them on the job. And some of us did it very well and some of us didn't do it so well. But we felt the need to be able to become as good at it as possible. It was one of the reasons why early on too we recruited people who could help us. We recruited these behavioralists who became a very important part of our faculty resource, who helped us acquire those needed skills. And we felt our mission, and we felt that we were in this together, and we wanted to also – early on I remember how concerned we were about research, believe it or not, and how we wanted to develop a database so that we can really look at what we were doing. We wanted to document our experiences. And I remember that when – I’m trying to remember his name, he was at Rochester – but anyway, there was a gentleman, I think his name was Metcalfe – he went to Rochester and he was, he brought with him – he was an Englishman and he brought with him the Royal College of Physicians [General Practitioners] data retrieval system and it was named after a guy by the name of Eimerl, and that was a system of being able to look at your practice. It was done – at that time it was a manual system, and we were all excited about having that tool. I remember having our meetings and talking about how we were going to be able to document what we do and develop a database, and that was something that we – I remember the people in Rochester getting excited about it, and I – Eugene Farley was sort of leading the charge, more or less. As he's done in so many areas of our discipline. And so we in Lancaster bought into that right away, in fact had a new faculty person who joined us in 1971, his name was Dr. Herbert Tindall, and he became a very active member of the North American Primary Care Research Group. \n\nQ.  NAPCRG?\n\nA.  NAPCRG, yeah. And Herb and our computer people at the hospital, we computerized the Eimerl system and right away we started documenting on computer, right at Day 1 when we started our center in Quarryville, we computerized all the problems that we were seeing based on that Royal College of Physicians system. And of course one of the key people in all of this who was, oh, what's his name, at the Medical College of Virginia, was with Dr. Fitzhugh Mayo, the Englishman who came over with Dr. Metcalf and still here, still is here and he just retired. His name will come to me. But anyway, he was another prime mover...\n\n[tape side ends]\n\n...he was in Fitzhugh Mayo's – and in fact in the early 1970s Fitzhugh Mayo and he and the current chairman of the Department of Family Practice at the Medical College of Virginia, Dr. – boy, I'm having difficulty remembering him, he's the current chairman, he was a pediatrician, trained at Harvard, outstanding fellow, and turned family practitioner. Boarded in family practice. And they wrote this incredible article in the Journal of Family Practice that so many of us quoted year after year back in the early '70s, I guess around '75 it was written, but it was on the – they documented – his name is Dave Marsland – Dave and, anyway, they documented the problems that they were seeing in their six practice sites. And it gave us a handle on what's happening in family practice in terms of the kinds of problems we were seeing. But the excitement had to do with the fact that we were a small group, we were anxious to learn from each other, we were anxious to share everything we knew, there was a lot of support for each of us, and we were excited for one another. But we were growing so rapidly then. I can remember the excite-ment of the '70s, when this specialty was developing quickly, and there were so many programs popping up all over the place. Tom Stern, who came into the scene as a, into the Division of Education, and Tom expressed concern about the quality of our program because we were worried about how we were going to assure excellence in family practice training. We knew now that there was a, quite a variety in programs and some of them that were in the process of developing we weren't quite sure of the quality of their curricula and the kind of training that they were going to be getting. Even though the RRC was approving these programs that we were approving them, recognizing that they're going to, you know, they needed to demonstrate that they could do what they said they were going to do, and now that the RRC was going back and visiting some of these programs, we began to realize that the quality of the programs varied a great deal. So – what Tom came up with in 1975 was something called the Residency Assistance Program. And he invited a number of us, I was invited that first year and unfortunately I had an illness and I wasn't able to participate that first year but I got involved in 1976. But it was, the idea of the Residency Assistance Program was to be able to utilize people now that had some experience already behind them, and have been able to demonstrate that we were doing it relatively well, to be able to utilize us as resource people to assure that programs that were trying, to achieve excellence in their program could do so, and they could have people who had some experience under them assure them that they were either on the right track or they weren't, and help influence the bodies to be at their respective institutions how it has to be done if we were going to achieve excellence in our discip-line. And that's been another exciting development in family practice. I think we continue to make a, I think an important impact on the discipline. I've been serving in that capacity now since 1976 and I think I'm now the, been around as a RAP consultant the longest among those who are still in the system.\n\nQ.  I want to kind of shift backwards to early in your training. Why do you think that you wanted to be a generalist? What did you see in that?\n\nA.  Well, that's a good question, and I think when I decided I was going to become a physician, and I remember it well – it was the third year in college...\n\nQ.  In Pennsylvania?\n\nA.  In Pennsylvania. I was at Albright College in my home town in Reading. When I made that decision it was based on the fact that I always thought – I thought, when I went to college that I wanted to be a chemist, because I was good at chemistry. And so when I thought about what I was going to do, I had discussed this with a relative of ours, and he questioned whether I'd ever consider the medical field. And I really didn't, only because it was a financial problem for me, I wasn't quite sure how I was going to do it. But there was another person in our community who was a, he was a senator, a state senator, and at that time we had what we call senatorial scholarships. And somebody suggested, why don't I go talk to Gus Yatron. He was a member of our parish. 'Cause he thought maybe I might be able to get a senatorial, so Gus was the most encouraging of all, because he said to me, he says, Nik, he says, 'You get into medical school and you go to either Penn, Temple or Pitt, and I'll get you a senatorial.' So with that stimulus I was able to proceed. And I got my senatorial, and it helped a great deal. And we – and Diana and I also then decided to get married at the end of my college, right before we entered medical school, and she also worked in – with her working and my senatorial and some other part-time jobs I had, we were able to do it okay. Now in the meantime, however, one of the reasons – I always thought when I made that decision about being a, going to medical school, I always thought it was general practice, and I did read a lot about what it meant to be a physician. I only discovered, or rediscovered, I guess you – that I had an uncle back in Greece, his name is Hippocrates, who was a physician, believe it or not. My father’s brother. And I guess my father – we really didn't talk much about him because my uncle died early in his life. As a physician, he had a ruptured appendix, in those days back in Greece it was misdiagnosed. At any rate – and I also then discovered that there were other physicians in my family back on the island and they were general practitioners. But that wasn't quite what did it. What did it was, as I read more about medicine, and I read what medicine was all about, and I read a lot about the history of medicine, it always occurred to me that the generalist made the most sense, because I envisioned having a relationship with patients over a lifetime. I envisioned about taking care of people in the context of the family. The physician that took care of us back in Reading was a general practitioner and he was somebody who took care of all of us. That relationship with that physician was an important one for our family. We, my family, always held the physician in the highest esteem, and that need to have somebody who you can, that was your personal physician, was an important part of our family. But not only my family, I grew up in a neighborhood where, I guess a third of the families on this one block that I lived on, were immigrants from Greece. And they were part of my extended family. And we all related to Dr. Levant(?). He was the doctor for almost all of us on that block.\n\nQ.  For the extended family.\n\nA.  Yeah, and it was just an important part of our lives. I mean he would come make house calls, he would – his office was just two blocks from the house, and so he was in the neighborhood. It just seemed like that was the only way to go. I mean it was – I guess not only role modeling, but it was role modeling inside my family. How we viewed the physician and how we viewed that physician was part of our family. So when I made that decision to go to medical school, what also reinforced it is my wife's family physician. Dr. Charlie Frankels was a young guy who had just got out of, he was in practice for only a few years when I got to meet him, but he was very enthusiastic about what he was doing, he enjoyed his relationships with his patients and his families, and he was very encouraging, and that just reinforced what I thought I wanted to do. When I went through medical school, I enjoyed every-thing about medical school. Everything. I might add one more thing. When I entered medical school, half of my classmates, at least half my classmates, were interested in family practice or general practice.\n\nQ.  Oh, really. Which was against the trend...\n\nA.  No, this was 19 – well, I'm talking about entrance.  \n\nQ.  Oh, at the beginning. Okay.\n\nA.  'Cause we had these discussions, and I had a wonderful class. The best group of human beings I ever worked with, I mean, as a group, by far were my classmates in medical school. They were just a beautiful group of people. I look back at those days with such great fondness. And we had many discussions about medical practice in general. I remember that was the days of the debates between President Kennedy and Nixon, those major, those magnificent debates. And many of us would listen to those debates and that was in the fall of 1959. I remember, I was in medical school '62. And we were in an era of change. You could feel the change coming on. America was feeling its oats at the time. We were really feeling like we were in, doing well economically, we had a good sense of ourselves, and when Kennedy started talking about some of the social ills in our society and how we were going to have to deal with those things and so forth, it was exciting for me, and I could see that I wanted to be a part of that. And of course after he became President he challenged the American Medical Association, some of the things we were trying to do in terms of Medicare and Medicaid, which finally came to be in the mid-'60s, we got a lot of resistance from the AMA and it bothered me that within our own house of medicine that we seemed to be resisting what seemed to me improper. I just thought it was not right that we should be resisting these changes in making health care more accessible to the poor, making health care more accessible to the elderly. And at the same time I also realized as I write more and learn more that there were many people in our country who didn't have access to a physician, especially in rural America. And those communities needed general practitioners. And it seemed to me that the system ought to be moving towards, that is, the system within medicine should be fostering solutions to those problems, and it shouldn't necessarily have to be coming from government, that we should be coming up with the answers. And I remember us having these debates in medical school and so forth. And unfortunately only five of us survived. The socialization process of medical education, as I call it, because you know the role models in our medical school were already now in the traditional specialties. The closest you got to a role model who would be somebody that was close to the family or general practice was the general internist. And there were a few of those around yet. And the chairman of our department of medicine was one of those. Dr. Wood, he was a beautiful person, and he reinforced my own career objectives. But what we realize was happening is that there were so many beautiful role models, the truth of the matter is. I mean we had fantastic surgeons, we had wonderful orthopedists, we had wonderful cardiologists and nephrologists and urologists. I remember these people so well, they were such wonderful people and they were teaching us and psychiatry was another one. In fact the largest number, when we graduated, the specialty that attracted the most of our student body was with psychiatry.  \n\nQ.  Oh, really? That's interesting.\n\nA.  And many of these same people wanted to go into family practice. I remember talking to them later at reunions and so forth, and they would tell me, you know, that's always what I wanted to do and I ended up in psychiatry. And the other area that got most of our, the other large hunk of our student body was internal medicine. And pediatrics. So you see, it was still primary care, if you will, but it was siphoning that group of people who would have gone into general practice or family practice. If the specialty was there at the time, I think we would have attracted – but general practice was not, it was still demeaned. It was a field of medicine that put you at the low end of the totem pole, there's no question about it, it was also at an era when the general practitioner was truly being squeezed out of the hospital setting. The surgery issue wasn't a big issue, but what was beginning to surface as an issue was taking care of your hospitalized patients. The units – back then we were – well, we didn't have CCUs in the early '60s, that came back, that evolved after the regional medical programs were put in place back in the later '60s, but you could see that the general practitioner was still not highly regarded. Now in our community of Lancaster, that was not quite the case. Because Lancaster was still, and our hospital was still the GP hospital. The majority of the physicians on our staff were still, or the largest department, if you will, were general practitioners. But they were dying off and they weren't being replaced. And then of course the payment system was another thing. I mean if you were going to be a specialist, the third-party system rewarded the specialist, whereas the third-party system essentially ignored the general practitioner. And so those signs were there, and I think it discouraged some of us going into general practice.\n\nQ.  But then later on you chose to take really a leadership role.\n\nA.  Yeah, because, I told you what happened. I must admit I was sort of annoyed with what was beginning to happen. It was starting to work on me. I knew what I wanted to do, I still wanted to do it, I still was convinced...\n\nQ.  Some of this stuff that was going on while you were in the service?\n\nA.  Well, it was happening to me during my senior year in medical school and how convinced I still was about what I wanted to do. I was annoyed that some of my friends who were still considering general practice, that that was waning away, and I realized that this needed to change. And people like Ed Kowalewski encouraged me to take on a leadership role. I felt that I wanted to be a part of a change. Part of that also happened when I was in the Army. I'll never forget the words of John F. Kennedy. We all probably remember this wonderful quote from him, when he asked us, 'Ask not what your country can do for you, but ask what you can do for your country.' That had a lot of meaning for me, because it was good timing. Because here I was thinking about these kinds of issues, and I saw the Millis Commission being established, I saw there was an opportunity coming up. And of course after Kennedy's death it was, it moved me to want to even more so become a part of something that I could make a contribution in this area. I was excited about the vision of a new discipline. I was excited about being a part of it early on. It also scared me, yeah, because when I was up in Boston and I was trying to make the decision about whether I was going to take on this position in Lancaster, I was also looking at practice opportunities. I was up at Concord, New Hampshire, I was over at Hyannis, Massachusetts, and I looked at practice opportunities even back in Lancaster, I was still considering going into practice with Charlie. I looked at all of that and just the idea of starting a new residency program was scary. But I remember what Joel told me, I'll never forget it. While I was up there he said something else that helped me make a decision. He says, 'Nik,' he says, 'Don't let your anxieties drive you to inaction. Go with it.' And that was something I needed to hear at the time. It helped me make the decision to go to Lancaster. I felt the anxieties that I was experiencing were entirely appropriate and also helped create the kind of energy source that I feel it inside me to be able to weather the storms. Because there were some storms. And when I got to Lancaster there was a lot of mistrust, and they didn't know what I was up to, there were some people in the community that – here we are talking about the need for more general practi-tioners and I was hearing when I was in Lancaster, 'we don't need more general practitioners.' I was hearing stories like – one senior member of the staff who didn't know what I was up to said, 'Look, we never needed you, we don't want you here, and don't expect any support from us.’ And he was a senior member in our department of general practice. He saw what I was trying to do in the clinic and didn't understand what I was trying to do in the clinic, in terms of meeting the needs of the indigent. He thought I was going to try to do something radical and that it was going to change the face of medical practice inside the hospital, that suddenly the hospital would be loaded with all kinds of poor people or something. Later on, two or three years after it, he came up to me and patted me on the back, put his arm around my shoulder and complimented me on what a wonderful job I was doing, and how pleased that he was that I stuck with it. And so he became one of my strongest supporters. A lot of nice things. Some of the subspecialists, one of my wife's relatives said, 'Nik, you're on the wrong track here. You ought to just pack it in, go into practice, there's a lot of people out to get you, this is not going to be easy.'\n\nQ.  Were you doing something radical? I mean you're talking about going against the grain, all these folks...\n\nA.  Well, it felt radical to some people, it didn't feel radical to me.Q.  It didn't. Why not?\n\nA.  Because I really – it was like motherhood for me. 'Cause how could, what we stood for, do anything but a lot of good? The philosophy of family medicine was the philosophy of medicine. When we looked at the kind of physicians that we were trying to – when we used the philosophy of family medicine and talked to medical students about what we were trying to do in terms of the kind of product we were trying to produce, that's really what I think medical students went to medical school for. And when we talked to those medical students back in those days, we were able to relate to all of them. Anybody who would come into our door and hear what we had to say about family medicine, they couldn't help but get turned on by our discipline. And there was the '60s, remember, late '60s, early '70s. It was the language of the times. It was what people needed to hear. We were part of something very, very good, and we got a lot of support from the students.  \n\nQ.  You talked about a vision during that time. Where's your vision going now for family medicine?\n\nA.  Well, to me it's still the same vision. I think you know, we heard about Sisyphus today and about that stone that keeps on rolling up and rolling back down, but I still think we're moving in the right direction. I think we've made a lot of good. When I look at Lancaster County, I mean that's where I get the excitement, and that's where I get the reinforcement. Lancaster County, 40 percent of our graduates are practicing in our county. The largest department in our hospital is family practice. When I look out into my commun-ity and I see the good that is coming from the care and the practices of these physicians, it is extremely heartwarming. When I hear the feedback from many, many people who live in our community, patients as well as organizations, these same organizations that we were introduced to way back in 1969, it's all positive, it's all exactly the way we said it was going to happen. It is, it's meeting our goals. And I can just see the good that's happened in Lancaster County, I think it can happen throughout the state of Pennsylvania and throughout the United States. I'm just entirely encouraged by those positive developments. Now we are dealing with another force that is working against us, and it's not so much working against us – well, it is working against what we're trying to achieve, and that is we're trying to get more medical students to enter our discipline because we need more family physicians. Clearly. But what else is happening is that the payment system is going haywire and it has created these incredible imbalances in the system and we have unfortunately just too many physicians making highly attractive and lucrative salaries and incomes. And...\n\nQ.  And this discrepancy is more than existed...\n\nA.  Oh, my goodness, yes. It's far more dramatic now than ever. And I don't think it was ever intended to be that way. It's, even the people who created these payment systems never envisioned something like this happening. But it has happened and we have taken steps in our society to correct this, and RBVRS is certainly part of that, and I think we will see some positive developments, and I think it will eventually create a correction in the course. We'll get back to why people really go into medicine – because they really still think people go into medicine for the right reasons. And the right reasons are because, we go into medicine because we – it might sound trite – but we do care a lot about people and we want to do something very meaningful and worthwhile for another human being. And medicine creates one of the best opportunities that society offers to do good for others.  \n\nQ.  I'm cognizant of the time, in order to get you to this banquet. Is there anything else that you wanted to bring up that – talking about in a sense your relationship with family practice, something that – I mean this is actually very interesting for me.\n\nA.  There's some things that also happened that I think are positive. I'm impressed with the kinds of people that we have been able to attract to the specialty. Not that there aren't a lot of wonderful people in the other specialties, because I know many of them, I'm equally impressed with so many of those others. But I do know our people very well. And I'm excited about the people that we continue to attract to our discipline. I'm encouraged by that for the future of our discipline. I just finished my 22nd year of interviewing medical students, and at this point I think I've interviewed in excess of 2,000 medical students in my professional life. And it was as good a group of medical students as I've ever interviewed. I'm really impressed and pleased with what we're being able to attract into the discipline. I'm encouraged by this for the future. I think we're going to see a lot of good things happen over the next 10 years. We're going to see the payment system change dramat-ically, and it will put the generalists very much in the forefront. I would see, whether we like it or not I think we're going to have a universal health insurance. When you have 35-40 million people underinsured and there are no other viable solutions, there's got to be a way of making health care access-ible to them and the only way that I can see it happening at the moment is through some kind of universal health insurance program. So that's going to happen. And when that happens, and the more the government, if you will, or the public has to say with how the dollar flows into the system, it will elevate the value of the practitioner, of the family practitioner. We've demonstrated it over and over again, the importance of family practice in making health care available and accessible. We're the only ones that make sense, that you put in a community of 900 or 1,000 people or a community where the catchment base might be several thousand of a 20- or 30- or 40- or 50- or 100-square-mile area, it's the family physician that fits in those settings. And we have many, many such settings all over this country. We also – and the family physician is the one that fits that setting the best. But it turns out, when we looked at the National [Health] Service Corps and we look at the experience of the National [Health] Service Corps and we look at it right in my own community...\n\n[tape ends]","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284027#t=0.0,1788.699"}]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284027/transcript/82286","type":"AnnotationPage","label":{"en":["Dr. Zervanos Interview Transcript (2) [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/154866/file/284027/transcript/82286/annotation/2","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Telephone Interview by William Ventres of Nik Zervanos\n\n(Tucson to Lancaster)\n\nMarch 4, 1992\n\nQ. - William Ventres, MD\n\nA. – Nikitas Zervanos, MD\n\n________________________\n\nBarb:  Family and Community Medicine, Barb speaking.\n\nQ.  Hi, this is Dr. Bill Ventres. May I speak with Nik Zervanos, please?\n\nBarb:  Hold on, I'll see if he's in his office....Go ahead.\n\nQ.  Hello, Nik?\n\nA.  Hi.\n\nQ.  Hi, this is Bill Ventres.  \n\nA.  How are you?\n\nQ.  Okay, I'm sorry I'm calling late, I had...\n\nA.  I was expecting your call, so...\n\nQ.  ...some problems in clinic this morning and I had to come across town.\n\nA.  No problem. Hold on a second, I think I just need to get [    ]. Okay, go ahead. Did you get all the stuff that I sent you?\n\nQ.  Yup, I got it. \n\nA.  How is it?\n\nQ.  Looks fine. I really like your talk about – it will be interesting reception you get down at the Keystone – is this actually going to be a journal, or is this a talk?\n\nA.  This is going into the journal.\n\nQ.  This is going into the journal.\n\nA.  Yeah, Keystone Physician is the name of our monthly periodical that goes to all the family doctors in Pennsylvania.\n\nQ.  Oh, okay. You have a monthly...\n\nA.  Hold on a second.\n\nQ.  Okay.\n\nA.  Go ahead.\n\nQ.  Okay. [    ] ran across town, but...\n\nA.  So where do we start?\n\nQ.  Yeah. I guess, Nik, the places that I wanted to start with are the things I mentioned to you last time. I read through your article and obviously being in Pennsylvania and in Lancaster's been real important to you. I was wondering if you could comment on, first on your own personal life but then in the broader sense of family medicine, what community, what this community has meant to you or what community in general has meant.\n\nA.  Okay.\n\nQ.  You know, you've stayed in the same community for quite some time.\n\nA.  Well, that's obviously a good question, but let me start at a personal level.\n\nQ.  You can take it in whichever direction, we can expand on different ways.\n\nA.  Well, first of all, one of the reasons why I am in Lancaster is, has a lot to do with community. And when I think of the word community, what I keep getting reminded about is you were talking because the word koinonia came to mind for some reason, and koinonia in Greek is the word that has to do with communion, as opposed to community. And the reason why I thought about that is because immediately I thought about my roots here in Lancaster with my wife's family who immigrated from Greece, came to Lancaster, my other – my own family came from the same island and they immigrated to – originally, my father came to northern Lancaster County and then moved to Reading and so, which is 30 miles from here, so most of the Greeks actually that came from the same island are from either – are either here in Lancaster or in Reading, and so when I was, when we were talking just a few minutes ago, the word koinonia came to mind because when the new specialty of family practice was established in Greece, back in 1985 when we all went over to Greece with the Society of Teachers of Family Medicine, they were establishing this new department in the new medical school on Crete and they were going to call it the Department of Family Practice, the Department of Commun – well, they use the word Koinonia, which has to do with communion. And the word communion has some very special meaning in Greek Orthodoxy because it has to do with the actual religious communion that we take as Christians. And it has, the word has to do with a bonding that takes place at the deepest levels in a relationship, the spiri-tual level where you have a feeling of closeness that you have with your fellow man, but extending beyond that to the people in your own family, to your relationship with God and so forth. So I couldn't help but think about that as you were asking about what does the community mean to you, and it has a lot to do with these very close connections that I have with my roots here in the Reading-Lancaster area. The – my own family is, I mean I can count them, I can count all the Zervanoses that live in America, that's how close we are, I mean there are about 28 of us, they're either in Reading or Lancaster and now in Harrisburg. And we're very, very close. The extended family that I refer to as my extended family really refers a lot to not only my relatives that are on both sides of my family and my wife's family, but then that really gets into the, almost to the entire Greek Orthodox community that's here in my town. When I came to Lancaster I knew I was going to have a small practice in view of my position here at the hospital as the residency director, so I chose to adopt as my patients those people who were Greek-speaking and were immi-grants primarily because since I knew the language I was going to be able to add, to do them added service. So it turns out that that practice of mine, or my practice as it has evolved, has made me even more closely connected with this community that I just made reference to because not only did I get to know them through my connections through the extended family, but through the church and so forth, and then I get to know them very intimately as, and through my practice. And I've enjoyed in fact developing these fascinating pedigrees, you know, these trees, the family trees that I've created through my family, in my patient's charts, because that gives me an opportunity to see how this one family I'm taking care of is so well-connected to so many of the other families, not only here in Lancaster but through my relatives back in Greece, and if not blood-related through marriage and so forth. So it's just been fascinating, when you talk about community the entire experience of living here, developing a practice and getting to know these people as I have has really been very much an experience that underscores the word communion as I've just described it to you.\n\nQ.  In, you know under other residents, or the residents that worked under you, how – they may not be Greek-speaking.\n\nA.  No, that's for sure, what [    ], we have had a few.\n\nQ.  What – how do you take that image of community or communion and what do they take from that?\n\nA.  Well...\n\nQ.  That's not very clear, but...\n\nA.  Well, I understand what you're saying. The role modeling that I think that is so evidently portrayed by my relationship to my patients and to my community, my community as I just described it, I think, is very evident to my residents and I think they can see how fascinating it is to develop a close connection with people in your practice and then of course through a, through my own subculture, if you will. But I think too, just the, our own philosophy of family medicine so strongly underscores this idea of the bonding that we all enjoy and experience as family physicians and they see it happening to the faculty's practices but they see it happening to their own practices, and it underscores for themselves how wonderful it is to, after a period of time that you're here as a resident, to have those special relationships that they experience and that how they can impact on their patients' lives in such a positive way. It's always quite an experience for me to see outgoing residents from our program have these beautiful experiences of, well, I call it beaut-iful but it's sort of a painful experience in a way, where the patients demonstrate how much they appreciate them with gifts that they get with these wonderful notes that they get from their patients and how much they appreciate what these doctors have done for them during the time that they've been here. But it's very heartwarming to see these kinds of things happening to our residents and underscores of course how important our specialty is and how wonderful family practice is and how it impacts some people's lives.  \n\nQ.  You know, you – my guess is, as I mentioned, a lot of the other folks that I'm interviewing are university programs and you're not. And my guess is that in the past you've had an opportunity or could have taken opportunities to go to university programs.\n\nA.  Yeah, that's happened to me a number of times. I often wondered when that's going to stop, because I thought by now that I reached a point in my career where people would probably give up on me. But it continues to happen and it's obviously very heartwarming and reassuring to me that people are still interested in, at least having me explore opportunities. That doesn't necessarily mean that I would have gotten the job if I went for it, but the reasons why I've stayed here in Lancaster have a lot to do with what I've just described to you regarding my connections, my very strong connections to the community and my strong family ties of course. But in addition to that is that this hospital has been tremendously supportive of what I believe in, and has been tremendously supportive of this particular residency program. It's one of the five busiest hospitals in the State of Pennsylvania, it's got tremendous resources, it's, it can certainly, has the capacity to support a number of residency programs. We're the only residency program here. There are some transitional residents as well here at Lancaster, but we're the only categor-ical residency at Lancaster General. It's, one of the things that we did when we started back in '69, we wanted to operate these two ambulatory care centers, the one family practice center in rural Lancaster County, and then this program that we developed at the hospital, which we call the Family Health Service, to service the indigent patient population, and I've been really pleased to see how our program has made a very substantial commitment of service to this population group. And we've really elevated the quality of care we have really made a difference in terms of community service. Now the fact that, you know, we operate out of what I consider attractive facilities, the hospital continues to support our various endeavors, for example in the last three years we have made a commitment to really enhance our obstetrical program and they have put a lot of resources and money behind this effort. We have contractual relationships now with members of our OB department, we've added four new faculty to support our obstetrical curriculum, these are family practice faculty, we have a new relationship with one of the members of our Department of Obstetrics and Gynecology who functions as our liaison, and he's now part-time faculty with us – so this is an example of the kind of support that we've been getting here at Lancaster, so every year it seems like there's something new, a new challenge, a new opportunity and the hospital is there to support it. I can tell you that I know we have a good program and I've, there's no question that the reason why we have a good program is the kind of support that this program has been fortunate to have from our hospital. And that's one of the reasons what keeps me here.\n\nQ.  I hear that loud and clear.\n\nA.  Yeah.\n\nQ.  Especially, I mean coming from a university program that, you know, they're looking for a new department head now and I think the reason, what they're going to do is try and, sadly, the other forces, I don't know if it's going to happen, are they're going to try and eliminate family practice.\n\nA.  Yeah, that's sad.\n\nQ.  It is.\n\nA.  But the hospital, on the other hand, recognizes this is a very important program and it, they have been, you know, not only do they tell me this but their behavior clearly demonstrates that they value this program as helpful to the hospital as well as development. Forty percent of our graduates are practicing in Lancaster city and county. Many of those doctors who have practiced in our community utilize this hospital primarily. It's tremendously beneficial to this institution. It helps not only the hospital in general, but specifically it enhances the practices of many of our specialists and so forth.\n\nQ.  Nik, I'm going to change a little bit.\n\nA.  All right.\n\nQ.  And I want to ask you about your program at Harvard. I mentioned that before. Tell me a little bit about what you did, what you learned, what turned you on there in terms of that program.\n\nA.  Okay. When that program was developed by Bob Haggerty it was intended to prepare graduates from the pediatric residency program at Children's Hospital in Boston for community practice. And they, these physicians coming out of their residency program being trained in a strong academic research-oriented program, these people, many of them did not feel comfortable in going into community practice. So that's why Bob Haggerty came up with this program. When Bob left to go to Rochester, Joel Alpert took the program over and this is about the time that it looked like there was going to be something new happening in the area of family practice. And Joel had a vision that he thought that this Family Health Care Program could easily accommodate general practitioners who might be considering a career in academic family medicine, or what might be academic family medicine. And one of the first people that came to his attention or perhaps it was vice versa, was Lynn Carmichael. And Lynn went up there, I think it was in '63 or '64, and spent the year with Dr. Joel and it was a terrific experience for both of them, and sort of laid the groundwork for others of us who had similar interests to pursue a fellowship with him. And what Joel offered when I applied to the program was an opportunity to acquire some administrative skills in graduate medical education to understand how curriculum is designed and implemented, how to utilize the resources of an academic medical community, and also to be exposed. In one year's time it was difficult to actually perform research, but we were able to participate in some of the research activities that were ongoing as part of the Family Health Care Program. So we had the opportunity to at least acquire some knowledge and familiarity with research skills and research techniques and the other part of that whole program was to have the opportunity to do some exciting kind of teaching, because the Harvard medical student in my opinion was a special breed and having exposure to people like them was exhilarating for me. It turns out the year I was there, Michael Crichton was a medical student.\n\nQ.  Oh, really?\n\nA.  Yeah. And he was one of the, you know, the fascinating people that came through the Family Health Care Program that year. And in fact one of my lifelong friends has, was one of those students who I had personal experience with, his name was Ed Benz(?), and Ed in fact was offered a student clerkship with me in the summer of 1969 when they came to Lancaster. He was between his first and second year of medical school and he had a terrific experience with me and I likewise with him and Ed today is deputy chairman of the Department of Medicine at Yale University. And somebody who has been a, I look up to Ed as somebody who's really got a wonderful, accomplished a lot of wonderful things in his life and continues to influence me to some extent. He has been an active faculty member, if you will, of our family practice review that we operate with Temple University every year.\n\nQ.  And he's maybe 10 years younger than you.\n\nA.  Yeah. So anyway, that was the, basically the gist of it. We were in Boston – I was at Boston actually in an interesting time in our history, that was the year '68 to '69 when there was a lot of money being pumped into the system through the Comprehensive Health Planning Act, we had also some acti-vities going on in the Boston area from Housing and Urban Development, and they were putting a lot of resources into trying to expand primary services to low-income people and one of the observations that I made while I was there that underscored some of the difficulties we were going to be experiencing when – in time because of our, because of the way a university like Harvard felt about general practitioners and family doctors at the time, they were operating, they were involved in operating some of these facilities. And it made a, I guess the one program that I'm making reference to now is actually one that was operated by Boston University, but the point is that they were operating with all kinds of people from medicine, pediatrics, ob/gyn, psychiatry, there weren't people who were trained in general medicine operating in any of these centers and it turns out that the system was highly fragmented and very, very expensive because to take care of one family required really the services of at least three or four physicians. And it was, it demonstrated to me at least one way not to do it, and underscored again the importance of our specialty. And it was sort of good timing because we at, in the family health program were trying to demonstrate actually to the family, to the Harvard community up there that this specialty was really worth something and that they really ought to put more of their resources and support behind it. Unfortunately it never really did get much support from the university itself. When Joel left to go to Boston University a couple of years after I was there to become chairman of the Department of Pediatrics, the program basically folded.\n\nQ.  The Family Health...?\n\nA.  Yeah, the Family Health Care Program. You know, it was considered one of the first 15 pilot programs when family practice was established as a specialty, and the year '68-'69, sort of that transition year, there were a number of programs in the country that were declared as pilot programs.\n\nQ.  Right.\n\nA.  And that was announced somewhere in December of '68 while I was in Boston, and I remember that the Harvard program was considered one of them. It didn't seem to make very much sense, but of course maybe then, since so many of the programs that were in evolution that were, we didn't really have a clear enough idea of what we wanted these programs to look and behave like and maybe there was a lot of hope too that the Harvard program might really take off. But it didn't, unfortunately.\n\nQ.  It sounds like it was an exciting, invigorating year for you. \n\nA.  It was an exciting, invigorating year. It was particularly useful for somebody who was contemplating a career like I was. It wouldn't have been a particularly useful year for somebody who might have been considering going into practice because it's not what you needed. For me I know that what I got from it was very, very useful for what I tried to do in Lancaster when I got here in '69. But it wouldn't have had much application in a private practice setting. Which is one of the other options that of course I obviously considered at that time.  \n\nQ.  Right. You know, one of the images that I have, listening to you talk about this relatively, well, developed program at Harvard versus going to private practice and having, you know, reviewed kind of what we talked about, at that time, you know, what was the difference between what people thought of as general practice and what people were, you know, thinking about or envisioning as family practice?\n\nA.  Yeah, well, I think that's a good question. What I think we were really focusing in on in 1969 is that we were going to be creating a discip-line. General practice before 1969 was not a discipline. You got out of your internship and maybe you did a general practice residency, and then you went into practice. And what you did is you learned on the job the training that you had at the graduate level wasn't the kind of training that really prepared you for what you were going to actually be doing let's say in the office set-ting because almost all those programs, you know general practice residencies, they were almost all hospital-based.\n\nQ.  It was like another year of internship or...\n\nA.  Exactly. And they weren't relevant to our needs. He had, that was the way, you know, it wasn't really thought out. It wasn't very well thought out. The family practice residency programs that were being conceived were really for paying somebody to enter what was viewed as the discipline as family medicine. They were going to get training in a family practice center in addition to the experiences that we needed in the hospital and the office settings, and that experience of providing, you know, providing our residents a panel of patients that they were going to be responsible for over the period of their residency years and also to model for them how a practice can run. And...\n\n[tape side ends]\n\nA...your community but how to utilize those resources in your hospital to help you take care of your patients. And you know, for that matter not only the hospital but the entire medical community. That was so, you know, so obviously important, and you know what's so neat about it is that, why wasn't that conceived of a long, long time ago? It made so much sense. The...\n\nQ.  It almost was conceived as a reaction rather than...\n\nA.  Yeah, it was conceived as a reaction rather than something that, it should have been part of the way you train a physician 50 years ago, you know? When we started even thinking about graduate medical education. Or 50 years before this specialty was created. But it's, I can tell you though that family practice really works. It's a tremendously useful graduate medical (education care) experience in preparing people for what they actually do in their everyday lives. It just makes so much sense. \n\nQ.  Why is that, you know, 50 years before that – I’m not sure if it was a rhetorical question that you were asking, or...\n\nA.  Well, you know, if you look at, if you look at the history of medical education, you know, you go back to the 19th century and the, you know, we had the apprenticeship system for the most part and medical students would spend a lot of time with their mentors and actually a lot of their training action did take place in the doctor's office setting and so forth. But when we created the new model of medical education, primarily evolving out of the experience in Baltimore at Johns Hopkins, you know, that really sort of changed things. It was a great model for training people to learn about disease and to learn about, you know, people who get very, very sick and it was invaluable and it continues to be a very important part of our education. We need those experiences to learn about diseases and how to take care of people who are very, very sick. But what we also needed along the way, and it didn't happen till many years later, was more opportunity to take care of people with more common problems and get an opportunity to take care of the patient over time so that we can know about the patient more holistically and as a person. And you know, pediatrics I guess you might say started to incor-porate much of that in their training programs, I guess in the '40s and '50s, but they went both ways, you know. Like I said, if you look at the Children's Hospital experience up in Boston, they went so far the other way that they realized that they weren't preparing people for community practice. And you know, the problems of internal medicine have been gradually more and more subspecialization. And anyway, we – the graduate medical education system when family practice was being conceived was going so far away from looking at the patient more holistically that something had to happen. You know, almost all the teaching that we had as medical students and as residents in most specialties, certainly in most of the so-called (bedded) specialties were at the bedside. And internal medicine is one of those specialties, but yet those people who are coming out of their residency programs and entering practice found themselves spending a good portion of their time not at the bedside of the patient but in the office setting in dealing with problems that are very common to that setting but no – they had no experience and had to learn it. Certainly those of us who came out of internships and general practice resi-dency programs had the same experience. So anyway, I can tell you that I was, it was extremely satisfying to see how our specialty evolved and the family practice center has become such an important model for graduate medical education, preparing people for community practice.  \n\nQ.  You know, again to switch a little bit. In your, this Keystone paper, Keystone Physician paper, it was interesting to read a little bit about the political things going on in Pennsylvania. And I was kind of wondering if you could comment, reflect on what was the political climate, or what were the political things involved either in Pennsylvania or in the country at large back in the '60s that might have contributed? You mentioned more recent ones primarily in your paper.\n\nA.  Well, first, well, what was clear of course was that there was a very severe physician shortage in Pennsylvania, it's a particularly dramatic situation because Pennsylvania is the most rural state in the United States. What I mean by that is that we have more rural communities in Pennsylvania than in any other state.\n\nQ.  You're kidding.\n\nA.  I'm not kidding, that's a fact. And the bottom line is that we've had many, many, many communities throughout Pennsylvania, especially in these rural settings, now, that once had physicians that no longer had physicians. That was very, very serious. It may well explain why Pennsylvania has more residency programs than any other state in the United States. And there is not a penny of state dollars that ever went into family practice education. Do you know that?\n\nQ.  I didn't know that.\n\nA.  Yeah. And the need for more family physicians was probably as much felt here as anywhere. What's interesting, though, is that even though we had all these programs, we have currently 29 programs, I guess maybe California might have 30 or 31 programs, but the attrition continued right straight through to 1976. It wasn't until then that the numbers began to change and that we've had, start to see an increase in the absolute numbers of family physicians in our commonwealth. Just like perhaps we've seen in the rest of the country. But you know, in our state we have, one-third of the counties have less family physicians than we had in '76. And that's a very serious problem. But to go back to those days, we were in a very aggressive mode and we wanted to see a lot of these programs established in our commonwealth, we wanted to see as many of these people of course stay in the state as possible, but we had no particular incentives, financial or otherwise, to keep them here, but we've managed to keep actually about two-thirds of our graduates overall in the state of Pennsylvania. The, you know, the Academy, the Pennsylvania state Academy at the time when the specialty was established was very supportive but it wasn't strong in the sense that it didn't have a lot of resources, it didn't have a very effective administrative structure to be able to help push for further support from let's say our legislation and so forth that might have enhanced our development in Pennsylvania, and I suppose that may be one of the reasons why we've had an unfortunate situation in our state where there isn't strong support from our medical schools, aside from let's say Jefferson, there really hasn't been a substantial number of students going into family practice from our schools. Overall the numbers are like 10 percent in the country, 9.9 percent last year, in Pennsylvania it's less than 8 percent of our graduates going into family practice. We have schools like Penn and Hahnemann that have like 2 percent of the students going into family practice.\n\nQ.  In a good year, probably.\n\nA.  In a good year. I tell you, it's sad, but what we've done about it more recently now that we have a much stronger organizational structure within our Academy, and that we've decided to put more of our energies and resources to promote family medicine through the efforts of our state chapter, we have made some inroads, and we are beginning to see some legislation now that are at least on the books, and we're hoping to get them through our state legis-lature. But at least we've written the legislation and we hope that we will have little forgiveness programs like other states do. And that we will have some incentive money going to our medical schools to help those departments, those medical schools that have departments to expand and enhance their respective programs and in those medical schools that don't have departments, and we still have four medical schools without departments in the state of Pennsylvania, that we hope that we can encourage them through incentives and so forth to develop such departments. And I think we've done a pretty good job in our state to help make that happen and the fact that we've even had, more recently the governor of Pennsylvania, Governor Casey, has expressed in his new budget some support for family practice. We're hoping that that money can stay in the budget now that it's going through the, you know, the cuts that obviously that such budgets have to undergo. We're hoping that that will be sustained.  \n\nQ.  You started to talk about some issues in the more rural aspects of Pennsylvania. Is that still going to be an issue?\n\nA.  Sure. Yeah, it's still an issue because we are, we haven't been able to, we haven't been able to keep up with attrition. You know, if you look at the statistics nationwide, we have actually witnessed from the early '60s to the current time we've actually seen a decline in the absolute numbers of family physicians, let alone percentage of graduate, percentage of the pool, you know, the percentage of the pool currently is running somewhere around 13 percent, 12 or 13 percent. But when you look at the absolute numbers, even though that we've seen some increases in absolute numbers since, let's say '76 when we had an all-time low, if you compare our numbers to the early '60s, we've actually [   ] that loss. So you take like our state, we – there’s not a county that doesn't need many more family physicians. We're in pretty good shape here in Lancaster County thanks to our own residency program, but also because it's an attractive area and we've been able to bring in a lot of other people from other programs as well to practice here. But there's not a year that goes by that all our graduates coming out of our program do not have opportunities to stay here if they want to. Every year. I mean I've been told back in 1980, we were told that, ‘You know, Nik, the success of your program's going to drive you out of business because you're just putting too many of your graduates into the community.' Well, that's just never happened. In fact we, we were stimulated at that time to actually write an article in our own Pennsylvania Medicine, which is the Pennsylvania Medical Society journal, to actually look at that very issue. And we were responding also at that time to the GMENAC Report, Graduate Medical Education National Advisory Committee, which predicted a doctor surplus by the year 1990 and even to the year 2000 that we would even have an oversupply of family physicians. Well, as you and I both know, that's not the case.\n\nQ.  They missed the boat.\n\nA.  Missed the boat completely. But we, we were able to predict with the, just looking at our data that we had, when I first came here in Lancaster in 1969, and the data that we had available to us in 1980, that we were able to show that despite the extra number of doctors practicing in our community from our program and other people coming in, that we were barely keeping up with attrition, let alone population growth.  \n\nQ.  That's interesting.\n\nA.  So it was, you know, it was a time when I felt that clearly that we were running behind and we had to have much, many, many more people going into family medicine if we were going to make a dent. In my opinion, the most underserved county in Pennsylvania is the county that has more family, more physicians than any other county in the state, and that's Philadelphia County. If you talked to any HMO director in the greater Philadelphia area, they are desperately in need of family doctors and have to use other physicians to function as the primary physician in their system because they don't have other, they don't have enough family doctors to serve as their gatekeeper or whatever you want to call them in these managed care systems.\n\nQ.  What – you mentioned several things, but I guess I wanted to broaden it, if there are other issues or crises or, what other things are going on today that, and into the future, that family medicine is going to tackle and wrestle with?\n\nA.  I'll tell you, you know...\n\nQ.  And educational or political or just whatever.\n\nA.  When you talk – what I was telling the medical students this past few months through the recruitment period, I got thinking a lot about that issue because one of the things that was a big issue back in the '60s, when our specialty was being developed, was the problems of the poor and the elderly. And interestingly enough, when we talk about health care issues today in terms of population groups, again it's the elderly and the poor. Back in the '60s, the difference was that the country was flush with money and we were able to feel confident in terms of putting a lot of resources and money to help solve some of those problems. You know, we created Medicare and Medicaid and so forth, and many other programs, the Comprehensive Health Planning Act and the Community Mental Health Act, the Regional Medical Programs, the Housing and Urban Development Health Care Initiatives, the OEO programs and the neighborhood health centers, and we created health systems agencies, we created all kinds of programs to respond to the needs of the people in this country, particularly the underserved and in that group of underserved primarily the indigent patients, and we were doing a tremendous job in reaching out. Today of course the same population groups get our attention. The problem is that what's different is we're not flush. So we don't have quite the same kinds of resources available to us as we had back then. And you know we've been struggling with some of these issues in the current political campaign, and you know, people are hesitant to really talk about nationalized health insurance, universal health care plans, and so forth. We do talk about them but we're very careful about how serious we are because of how expensive it would be to implement any such kind of program. And yet we have this enormous population of people in our country that are underinsured or uninsured and it won't escape us. We're going to have to deal with it at some point. And I, my prediction is that we're going to have some kind of universal health plan within the next few years. I think the next administration will have to tackle it. And we will have something. That's obviously going to alter to a large extent the way we deliver health care services in this country. I think regardless of what system we adopt, you know, in terms of whether it's going to be government-run or a partnership between government and the insurance industry or some other kind of corporate structure, that's going at least to be government-influenced regardless, we're going to, the family physician is going to playing a very important and primary role in the development of that system and in the implementation of that system. We're going to – the demand for family physicians is going to intensify. We've got to do a better job in getting medical students interested in our specialty. I realize it's a multifactorial issue and it involves the medical schools, it involves the payment system, and it involves the political structure – the medical political structure – in our communities, and – but all of us are going to have to work together to improve the pipeline because we have the capacity and the capability to train and educate the family physicians. We just need to have the pipeline improved sufficiently so that we can get the students into our programs. And RBRVS is certainly a kind of program that can help. I'm not sure why it's viewed so negatively by some at least – I like to think that we can work out its bugs and that the family physician can benefit from such a program and that will enhance its image and that the family, the medical students worried about where they fit in the hierarchy will see that such programs enhance the family physician's not only income but also his image in the system. I think that we have to have strong departments, not just departments of family practice but departments in every medical school. I would like to see the Liaison Council [Committee] of Medical Education make it a requirement that every medical school, to be accredited, has to have a department of family practice and that family practice curriculum time has to be incorporated in all four years of medical school. There are some medical schools that are doing it, and in those medical schools that are doing it we are seeing far more interest in family practice. I think every medical school should be developing a physician who is well-trained as a generalist. I think those schools that insist on producing academicians and researchers, etc., I think that's important that they do that, but we need those academicians and researchers also in family medicine and we need those people to be prepared for careers in general medicine. They should be very committed not only to producing the high-tech specialist but they also should be producing the academician who's going to be running our programs in family medicine or general internal medicine or pediatrics. We need that kind of strong commit-ment. Every commission, every task force, every committee in recent years that has addressed the issue of physician manpower that involves the medical education system indicates that family practice requires more support and that we need more family physicians. And yet somehow, even though these reports state that, we haven't been able to get our own act together, our system if you will, to develop those appropriate mechanisms to assure that that happens. You know, the AMA and the AAMC are two organizations that I think support in principle the development of family medicine and that they should be strongly supported. Dr. Petersdorf recently in the editorial...\n\nQ.  Right, I saw that.\n\nA.  ...[   ] medicine supports that idea strongly, it seemed to me, and yet we haven't yet seen the...\n\nQ.  The AAMC?\n\nA.  We haven't seen those two organizations take really, what I call real substantive action. They're the two organizations that make up the LCME to a large extent. They, those two alone could actually mandate through the LCME that every medical school have a department of family practice. I see no reason why that shouldn't be done. I know that there is this notion that not every medical school needs to produce a generalist. Well, I think that's hogwash. I think when you go to medical school, if you talk to the average medical student, I don't think they go to medical school to become a specialist, they go to medical school to become a doctor. And a doctor, when you come out of the system, should be well-trained and well-educated and oriented towards the whole patient and have a good understanding of all areas of medical knowledge as it relates to the care of that patient. Now we will have obviously a good number of these people who would choose specialty careers and subspecialty careers, and that's fine, but the system itself, while you're in medical school, let it be oriented towards making sure that these people coming out of the system were broadly educated and trained.  \n\nQ.  Yeah, I – pretty threatening, though, to the powers that be.\n\nA.  Yeah, to some. I think we're winning a lot of our battles along that line, by the way. You know, it's – I understand why it's so difficult, of course, you know, our medical schools really are made up of a lot of bio – made up of people who are trained and educated in the specialty direction and they're the role models, they're the people who – you know, they want more of themselves being [   ], it's understandable, but you know, if you step back and you go at a higher level, whether it's the LCME or whether it's some of our leaders that make up organizations like COGME and so forth, I think they can set the direction. That's what the leadership has to come from, and they – that will trickle down into the medical schools and, you know, we will comply. As threatening as it might feel to some of us, we will comply. We will have to go along with it for the greater good. It has to happen.\n\nQ.  This is a question – the LCME?  I'm not aware...\n\nA.  Liaison Council [Committee] Medical Education.\n\nQ.  Okay.\n\nA.  That's the organization that accredits medical schools. That's the body that does the accrediting. It's a powerful body. You know, we in Lancaster, by the way, submitted that as a resolution through the Pennsylvania Academy of Family Physicians several years ago, that – this idea of having every medical school have a department of family practice, and we got that through the Pennsylvania Medical Society, and then from the Pennsylvania Medical Society it went to the AMA. And when the AMA got it, we were pleased at least they didn't reject it. What they did is they did make some require-ment, they did incorporate a requirement that every medical school require curriculum time in family practice. So that that's now a requirement that has to be at least offered to the medical student. I can't remember exactly the exact wording of that, but it does allow for us to assure that medical students get exposure to family medicine. But it doesn't, the idea or the notion of having every medical school have a department was rejected. But it doesn't mean that we can't try again.  \n\nQ.  Right. I think we've talked about a whole...\n\n[tape side ends]\n\nA.  Well...\n\nQ.  We really hit on several.\n\nA.  Yeah, the, you know, what Paul Tsongas has said sort of comes to mind. If we don't straighten out our economy in terms of doing something with I guess our, well, not only do I guess but we have to obviously reduce our huge debt. We have to put corporate America back on top, and that not only are we competitive but we are, we are bringing a lot of fresh money back into the system, into our economy, and that it's not going out of our economy but actually coming back in and unless that happens it's going to be very diffi-cult for us to solve a lot of our, some of these major health care issues, problems, our educational problems, our crime problem, and so forth and so forth. I believe that this country is so resourceful and so ingenious and it's got the leadership and the vision, it's there, and I predict that it will come forth in the not-too-distant future and I think you'll be able to see that we will get back on top in a lot of these areas in terms of our economy, and if that happens, our health care problems will be solved. And not solved in the absolute sense but will be in the, solved in the sense that we are going to be, see some of the more serious deficits corrected, like our underinsured and uninsured people having access to health care and that, bottom line is that I feel very confident about where family practice is going to be in all of this. And I think a lot of the leadership that we're looking for in medicine is going to come from our specialty. And I have a feeling we're going to be playing a primary role in developing a universal health care plan or some kind of new way of improving access to health care to the American people.  \n\nQ.  Good. This is great, really, it's a little different over the phone, I realize, but it's wonderful listening to you.\n\nA.  Thank you. Well, I appreciate the opportunity to talk to you, Bill.\n\nQ.  I wanted to just check on a couple of things. 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