{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/fq9q23st2g/manifest","type":"Manifest","label":{"en":["Dr. John Geyman"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Date"]},"value":{"en":["1991-05-06 (created)"]}},{"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":["John Geyman, 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: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/159381/file/290369","type":"Canvas","label":{"en":["Media File 1 of 1 - GEYMAN_JOHN_(1991).wav"]},"duration":3708.94658,"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/159381/file/290369/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/159381/file/290369/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/290/369/original/GEYMAN_JOHN_%281991%29.wav?1756933063","type":"Audio","format":"audio/wav","duration":3708.94658,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/159381/file/290369","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/159381/file/290369/transcript/83677","type":"AnnotationPage","label":{"en":["Dr. John Geyman interview transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/159381/file/290369/transcript/83677/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"John Geyman\n\nMay 6, 1991\n\nPhiladelphia\n\nQ. - William Ventres, M.D.\n\nA. - John Geyman\n\n____________________________\n\nQ.  John, today we have an opportunity really, if you want to go off on tangents or if you want to approach things that you think might be interesting, but not sure, or I may stop you at some points and redirect, because we have the opportunity to really explore a lot of different areas today in a relatively short time span....  I guess the first step in the, thing I've asked people to do is to kind of explain how they, and how yourself, how you got involved in family medicine, how you made an active choice at that time to choose to move off in a new area.\n\nA.  Well, to start at the beginning I was not a premedical student in college, I was a geologist.  Graduated just after World War II in the naval ROTC and ended up spending 3 years on a destroyer, during which time I decided I probably wanted to go into medicine.  My dad had been a physician, a radiologist in Southern California, he had been at the University of Minnesota and interned at what is now St. Paul-Ramsey, used to be Anchor Hospital.  And went out in the country in a town of 700 and practiced 2 years, and felt overwhelmed.  Did a good job in a town with two docs, but he went back and went into radiology, the second year of radiology residency at Minnesota, and etc.  So I came from a medical background but I always wanted to do what non-medical things that looked like, but during the Navy I decided to go into medicine.  Actually, a book I read on the ship was Logan Clendening--you may not have ever heard his name, but he was an anatomist at Minnesota, and he was a very colorful writer and I liked his book on anatomy, and that intrigued me.  So I came back and I did all my premed work after the Navy, a year, two summers at Berkeley, and had to take all the courses except for--I think at Princeton in geology I had one year of physics and that's all.  Everything else I had to do.  So I did all that and got into medical school at UC-San Francisco, and I was a little older going there, as at that time a number of people who had been in the service were getting out, were a bit older.  And when I went to medical school, and it's curious, I've been on admissions committees several--each medical school I've been in, now about 10 years, it's always interesting to read applicants' personal statements.  And my personal statement said I wanted to be a family physician in a small town and be part of the community, etc.  And so I went to UC-San Francisco, which today is a biomedical research center and then was a biomedical research center, and then had about 5 percent of its graduates going into family practice, or general practice then, and so it was very atypical then.  But I was one of seven in our class of 84 that went into general practice.  I never changed my mind, I liked everything in medical school, I couldn't conceive of being a surgeon and doing just that, or a pediatrician and doing just that, or--I liked almost everything.  Actually everything.  And so I got out in 1960, I interned at L.A. County, in a rotating internship, then wanted to take, I wanted to prepare myself well because I wanted to go to rural practice, wanted a good training, looked around, and there were--that was the year when there were, I forget the exact number, there were probably 8 or 10 pretty darn good general practice residencies in the country, and maybe another 20 or 30 that were not filling and weren't very good.  But there were 5 or 6 that people talked about and sounded really pretty darn good.  And Santa Rosa was one of them in California.  And so I went there.  As a matter of interest, I looked at the University of Colorado - Denver.  There was only one university program, it had a GP residency.  Am I digressing too much?\n\nQ.  No, you're doing fine.  It's kind of your story about how you got involved.\n\nA.  Yeah.  Anyhow, University of Colorado had a good program, San Bernardino had a good program, Ventura had a good program, Santa Rosa had a good program.  But there weren't many.  You could count them on a hand or maybe get over to the second hand.  So I went to Santa Rosa, which then, it had started in about 1950 and it was a program with four residents in a year and, in a 2-year program, and by the time I got there in '61 there were five residents in each of 2 years.  And we ran the hospital.  We had a full-time director, who was mostly an administrator, and no full-time faculty, and all the consultants in town were the teachers, and they had great community participation and here's a county hospital, 5 miles out of town, 4 miles out of town, an active clinical volume, and we ran the place.  It was great.  Still is not very much bigger than it used to be, but there's so much material there and so much clinical volume and--and the tradition's there with community doing the teaching, medical staff is still strong and it was a good program.  You'd have to make it yourself, but you could make a great program out of it.  So we took I think the equivalent that way, a big hospital rotating internship and a 2-year GP residency of, I think I ended up with an excellent training of, in most areas, it was weak in preventive medicine, it was weak in behavioral science, but it was really strong in biomedicine.  It was strong in things like anesthesia, which I did a lot of in practice, and two and a half months' rotation, and every third night for 2 years we'd do anesthesia on call.  So we got a lot of anesthesia, and it was pretty good in orthopedics and trauma and surgery, and--but weak on behavioral science and weak on preventive medicine.  Anyhow, that's how we trained and that was the best way I could train them, I thought at the time.  Came out in '63 and my wife and I started up the road, wanting to practice in the Northwest somewhere and we got about 300 miles north and ended up actually in the first town we came to, which I had done, I had done a GP preceptorship between sophomore and junior year in medical school in two places: curiously, one was in Santa Rosa and this was set up by the Academy of General Practice in California, and the second was in Dunsmere(??), California, which is just 8 miles south of Mount Shasta.  And so I knew a good friend who I'd preceptored with in Dunsmere, and we stopped to see him, and it turned out that the town just 8 miles north, Mount Shasta, one of the physicians was in the hospital with a glioblastoma(???) forming and was leaving practice, and so I bought his practice and started practice about a week later.  Solo practice, in a little office downtown, and started from scratch, put in a little office X-ray and I was one of three physicians in town, and we had a 28-bed hospital in town, and there were three other communities within a radius of 12 miles that used the hospital, we served 20,000 people in the southern part of Siskew(??) County in Northern California, and there were eight of us, also in that part of the county.  We worked closely together in the hospital.  We all did OB, we all did sections, we all did trauma care, three of us gave anesthesia, and we all covered the emergency room at the hospital.  On a week's basis you'd cover, from Friday noon to Friday noon, as I remember.  And yet we had no call system other than that.  So on Saturdays you'd see everyone there to sew up a laceration a couple, three times, it was a nonsystem that way.  Only two out of the eight of us ever wanted to develop a group coverage of any kind, and it never happened because it was the rugged individualism of mountain doctors, okay?  So anyhow, had a great time in practice, town of 2,500, 3,000, my wife taught school there, we started raising our three kids there.  By then our kids were, when we went there they were 1, 2 and 3.  Three boys.  And so we had a great time there.  We were there 6 years, very much into the community, the kids went to the elementary school and Jean, my wife, was involved in the community as a teacher, and as one of three physicians you're very much intimately involved with the community.  During that time I started a coronary care unit, and for a little while it was the smallest hospital in the country that had a CCU, we set up a two-bed unit, got telemetry set up with Sacramento, 300 miles away, and trained the nurses as volunteers to be CCU nurses, and had that going about 3 years, and when I left I analyzed the, our stats, and we had 8 percent mortality in our patients, which was, as I recall, the national average was 12 to 14 in CCUs then, so we really did pretty well.  But that was the time where, you know, there were breakthroughs and then the challenge was to apply them in practice, and--just as it is today, whether it's OB ultrasound or colposcopy, anything else, so always exciting things to do.  During that time I got involved with medical education.  We had students in our practice, it was my practice, I was so solo, but they--the students would live with us for 2 to 4 weeks and so that was a good experience.  We were a stop on the CME--there was a CME program out of the, what was it, partly UC - San Francisco and partly, I forget who the other sponsor was, but every, in the fall and the spring there was a CME rotation, and three or four communities in northern California, and we were one of them, so we'd always have the--\n\nQ.  Kind of a circuit CME.\n\nA.  Yeah, circuit course, and so I worked with that, and I found myself--it's actually curious.  It took me, I love the, I thrived on the challenge of rural practice, and figured I'd do it for 30 years, but actually--and was working long hours but probably much too long, and had I stayed there I probably would have wanted to break out of the solo practice mode and actually recruit into town a partner and develop a group, which was the non-norm.  There weren't any groups in primary care in that county.  But, so I was starting to get stressed with a very large practice and doing other things on the side in medicine in the community, and I started finding myself going late to the office in the morning.  And I would see--30 patients a day was an easy day.  Forty patients a day was a fairly hard day.  And my record was 56, though I never wanted that.  That's how tough it was.  And that includes the hospital, and usually I'd have three or four anesthetics a week in the morning, and I mean it--compared to what I see graduates doing now, they'd be blown away, they just couldn't do it.  Not that anyone should be expected to do it, and it's not really the way to do it, but it's how we did it, and--\n\nQ.  It probably was somewhat standard, that's the way, not just you did it, but--\n\nA.  It was.  Yeah, exactly.  And it was a real challenge, and it was fun and it was hard work and a lot of blood and guts medicine.  But I found myself starting to do kind of system things, especially after I got so I knew how to do the various things and got more comfortable with doing sections, even though I'd done a bunch in residency, and you know, the things you have to do.  Emergency care and closed reductions and things.  So then I started getting more involved with, with like the CCU and starting that, and then another big problem was we didn't have an ambulance system, so I started working with, we got a committee started, and the four towns each had their local high schools and they compete back and forth in high schools and lead(??) each other station wagon armed by fire department people as a volunteer ambulance, but without really good equipment or great training and no radios, okay?  So each of the four towns competed and there wasn't a system.  So it seemed to me there should be a system with a great ambulance and well-trained people and radio coverage and so I worked with that a couple of years as an example of a systems thing, never got it done while I was there but it happened 2 or 3 years after I left.  But those kind of things would be kind of related to medicine but beyond my individual practice.  And I found myself spending more time with those and so if I were in the hospital in the morning and the office was to start at 9:30 and I had an anesthetic or a surgery and then I'd end up spending time with the hospital administrator and we'd be talking over strategy of this, about the ambulance problem or this or that, and I'd find myself going slower to the office, so about then--\n\nQ.  So this was 1968--\n\nA.  This is '69, about then family medicine became a specialty and a few months after that I got a call in the middle of an afternoon when I was about six patients behind and all the exam rooms were full and I had someone in labor across the street in the hospital, and someone in the--you know, just things were wild as usual, in the middle of the afternoon I got a call from a friend who was on a steering, who was on a steering committee for this new program they were going to start at Santa Rosa, where under regional medical programs they were going to set up a university affiliation between the medical school I'd gone to and the Santa Rosa program for the purpose of developing into a family practice residency from general practice and, etc. etc.\n\nQ.  John, I want to stop you there.  I want to ask you how you first heard of family medicine.  You said it had started up, but at some point you heard of family practice, and what was your response to that, (??)--\n\nA.  Okay.  I was in, I had been in general practice and in California it was a particular debate, is this a good thing to be a specialty or not?  I never questioned it.  I always thought it really was, and very important to do, and some of my friends and that I respect and fellow general practitioners took the other stance, you know, we're general practitioners and AAGP members and we don't need a specialty, we can do it ourselves.  Especially boards, it's just trappings, and you know, on and on.  I always thought a specialty board was a fine idea and very much needed, and that indeed the problem with general practice was it never got institutionalized in medical education and would fail if it stayed outside the medical school and outside the formal GME system.  So I thought it very important to do.  So I followed all that with interest, and I knew about the Millis reports, and--\n\nQ.  What did family practice mean to you back then?  Did it mean doing what you were doing, or did it mean something new, or--\n\nA.  Well, that was interesting.  That was the challenge.  People--it was unformed then.  There were, there was that Essentials for Family Practice, which as I remember was a two-page document which would determine how the new programs were accredited, but, and there were two or three articles, almost--very, very few that were kind of general and kind of the rhetoric of family practice.  But it was a blank slate.  We knew it was going to be a 3-year residency.  We knew--and the rhetoric was that we were going to train people to do comprehensive care, actually all the things we did already.  But more emphasis on prevention and emphasis on behavioral science.  None of us knew much about behavioral science.  And by the way, I wasn't--in practice I was trying to train myself in behavioral science, I noticed a lot of people were depressed and I treated them I think reasonably well, although I'd do it a lot better today, but at least I knew it was there and important.  But then a lot of people had marriage problems, and so I got the book, the classic book of the day, and read that, and then started having Saturday morning times for, to do marriage counseling.  But then I noticed it never went too far because both parts of the couple wouldn't come in.  In our logging town the women would come in but the men wouldn't, and anyhow so I wasn't resistant to all that.  But it was unformed as to how you would teach or learn behavioral science, and what you'd put into the residency and how you would do it was all unformed.  So--but that was the challenge of it.  So here I get this call at 3:30 in the afternoon, will I consider being an applicant for this new position of director of this program, and it's under regional medical programs, and etc. etc.  Set up the affiliation in San Francisco.  So I would consider it, but you know, I really liked what I was doing.  So over the next month I gave it quite a bit of consideration.  I went down once and talked to my friend Ed Neal, who was a year behind me in training, and practiced in Heelsburg(???), California, and the bottom line was I finally decided to do it.  Actually pretty quickly decided to do it.  And a month or two later we left.  And--in a way we left--we'd built a house out of town, couple of miles out in the country--\n\nQ.  Out of the Reading area, or--\n\nA.  Mount Shasta.  That's where we were for 6 years.  And anyhow, when I say we left, we did physically but we kept our house for 18 years, we kept taking the weekly paper for 18 years, and it was only 3 or 4 years ago that we sold the house.  So a lot of our rootedness and connectedness to a community were goes back to the Mount Shasta years.  We were there from 1963 to 1969.  But I feel that we knew more people and knew more people well and were more connected to a community than we've ever been before or since.  Anyhow, so now in August or September of '69 we go down to Santa Rosa as a family, young kids now in grade school, and I'm the only--I'm the director of the residency, and the only full-time faculty member for the 2 years I was there.  And we started writing on the slate, and so we developed the curriculum, developed the 5/5 program, became a 6/6/6 within a year, set up the, built a family practice center, set up a continuity training there, set up a behavioral science program, set up electives, and tried to retain many of the strengths of the traditional rotations and tried to add on the things that were not there.  So, and actually I wrote an article which was in JAMA which describes the conversion of that general practice residency to family practice and what stayed in and what was added on and what changes were made, and it was one of the--there were a number of programs that were GP residencies that converted, though there were many more that were started de novo.\n\nQ.  Sure.  What kind of time was that for you?  Was that an exciting time, a challenging time, a fearful time?\n\nA.  Well, it was both.  Not fearful, but it was exciting--again, I loved it but in thinking back on it I had my losses too.  And one of my losses was, I'm being quite candid with you, one of my losses was as a clinician.  Because my identity was so much as a clinician in a community, that all of a sudden I wasn't a clinician in a small community, with all that, all those strokes and all that sense of what you've accomplished today, and now all of a sudden you're working with paper, you're devising curricula, you're working with people, with residents who are complaining about their call system, and--already--and you don't have any peers.  You're the only full-time person in this program and you don't have other full-time faculty.  Everyone else is in practice in the community, and so they're not really your peers.  And so kind of lonely from that perspective, and it was so busy, as the only full-time person having to build a program that I didn't have my own practice.  I did some teaching but I didn't have my own direct patient care.  So from very active direct patient care in a community where you knew what you, who you were and what you did, all of a sudden to zero direct patient care and all this other stuff, including, are you going to get the next grant or the first grant or not?  And, including all the organizational stresses, I found that was a loss, and what I found I did is kind of interesting, I--and if it wasn't for my loss I might not have filled it in this way, I had written two or three papers in practice, just case reports, and so that's the only writing experience I had, but during this first year in Santa Rosa as director, I spent nights and weekends and wrote a book about family practice, and it was the first book written about what family practice is.  And it's not a great book, but there weren't any.  There weren't any.  And so that was my project and that actually gave me a lot of structure, etc.  So that's really the origin of my writing interest pretty much, and actually was my connectedness to a publisher that subsequently became the publisher of the Journal of Family Practice.  Through that association they published my book and so anyhow, here everything seems to relate to these things.  This is how we live.  So anyhow, those two years there were very busy, did get the program organized, and on track and then about that time, it was only--less than 2 years later--I was starting to look around, well to fill in a little bit more, so we've been talking about this period of '69 to '71.  And I remember in '69 when I first got to Santa Rosa I, first I went around and here's this blank slate, see.  So I took 2 or 3 weeks and my wife and I went around and saw eight or nine places in the country and in Canada to see what these quote family practice residencies were.  And we went to Oklahoma, which was an early program, we went to South Carolina, Hiram Curry's program was a new program, where else did we go?  I think we went to--I'm not remembering all of it now.  We went to Hamilton, Ontario, and we went to Rochester where Gene Farley was.  So we went to four or five programs, spent 2 or 3 days each place.  And it was being done in a different way every place.  And I came back and kind of wrote up a--\n\n[tape side ends]\n\nQ.  --may have been doing the same thing, kind of, putting things together.\n\nA.  Well, they were.  It was a small group of programs and--\n\nQ.  I guess my question is, what are the, what were the new things that struck you about each of these programs with their differences?\n\nA.  I went to Miami, too, that's right.  Well, that's kind of hard to answer.  Rochester had its emphasis on behavioral science and they had a strong department of psychiatry, so they had their own ambience.  Oklahoma had kind of a community medicine flair.  Each place was different.  Charleston had, was developing its own academic traditions and was a highly academic program, I felt.  They were all somewhat different, though, and just because the curriculum might say the same rotations, they were all totally different.  So then also early on I probably went to the, I know I did, the first STFM meeting I went to was probably '69, and it was a pretty small group.  But that was, those were the questions.  What is the curriculum of this new program we're building, and everyone felt like a pioneer and it was exciting, and it was a small fraternity, and a network, and you'd know about the other programs and people involved, and a lot of sharing and so--but what I was getting too, though, now we're up to '71 and I started realizing that the problem is really not to start residencies in community hospitals, and that's where all the main emphasis was at first, except for a few medical school departments that were forming up, but it occurred to me pretty soon that you really got to get to the medical school.  And so I started being open to moving into a medical school department, and about that time the University of Utah was looking for its first chair of the Division of Family Medicine in a Department of Community and Family Medicine, and I went over there to look, and I ended up going there.  So we moved over there for about a year and a half or so.\n\nQ.  Why was it important to get family medicine involved in university settings?\n\nA.  Well, I think it was crucial.  If you think about it, general practice did develop some residency programs in the '50s, and yet the whole effort failed.  They were isolated from medical students, they were isolated from academic medicine.  And from medical school.  And it was obvious to me, the pipeline for medical education is in medical schools and its affiliates.  So you have to have a visible, strong academic presence in medical school for family medicine to survive.  So it was obvious to me that's where the action had to be.  And was kind of the, a real challenge.  You have to do that, if you fail doing that you would fail.  So anyhow, bottom line is I ended up going to the University of Utah and was the first of a long line of chairs of divisions of family practice in a department of family and community medicine.  And [interruption] I won't go into those details.  It was basically a good experience, it was my first involvement in medical school, and, you know, my first learning about how medical schools and departments in academic medicine work.  And 2 years later I went over to the University of California at Davis as a professor of family medicine and as vice chair, not the chair, and as coordinator of the residency network.  And we developed a number of programs in central and northern California there.  And that gave me more experience with predoc education and a lot of experience with development of a network of affiliated programs and how would those interact with the medical school and with the department, and then in the end of '76 I accepted the chair at Seattle and have been there since.  So we've been a number of places, and my wife would have preferred it to be a few places less, I think.  But they were all learning places and they were all actually part of the development that I think was necessary for me to do what I've done and frankly, being in two other departments helped me to be a better chair of a department.  I avoided some things that I had seen that I didn't think should be modeled, and I saw some things that were, I thought should be continued.  But the composite of that I think was very useful to me, namely community practice experience plus community hospital residency experience and setting up an affiliation with the medical school, plus being in three departments, very different ones, and so I have enjoyed that whole process during which I started the Journal of Family Practice, again with the same publisher that did my book.  And so I've had a very interesting experience and have enjoyed every bit of it.  And it's a moving, a moving development, well it's a continued evolution of our field and it's fun to see it develop as it has, and--\n\nQ.  Do you see stages in that development, or do you--\n\nA.  Yes.\n\nQ.  --I'd be interested in where, especially in terms of the broader context of what family practice has meant, where has it come from and where do you think it's going?\n\nA.  Right.  That's--it's hard to give a short answer to that.  You can look at it a whole bunch of ways.  There are definitely stages, and I'm sure you can categorize them different ways.  And I even wrote a paper, too, about phase ones and phase twos, but one way to look at it, I think, is to say that Phase One was to, well first of all our heritage is general practice.  So what we used to do is unboarded, before there was a board, community and primary care physicians, whether your label is a primary care physician out of a military board, or primary physician, whatever that was, or personal physician, or a family physician.  Much of that predates any boards.  I see a long continuum with hundreds of years of excellent primary care physicians, some of whom became excellent by the way they put things together from their training and experience, others of whom never did become excellent.  But it's not like this is a brand new field that started in '69.  I don't think it is.  And our heritage is general practice.  You look at John McPhee's book, Heirs of General Practice, that's an important book, and he's on target with that.  So you start with there.  But then after family practice became a specialty, Phase One I think is probably the development of teaching programs, both for medical students and for residents and involving departments of family medicine and medical schools and setting up affiliations, and so it would seem that Phase One is probably--what's that involve, it involves the organizational efforts to have it happen, it involves setting up clinical services, both in family practice center and inpatient teaching service, it involves setting up predoc and residency training programs as well as CME programs, and curriculum development, evaluation, all that goes with that.  I think that's where the initial efforts of the field went.  We developed STFMs, we developed RAP(???) programs, and if you look at the, from '69 to where we are now, you see most of the residency positions were developed by early '80s, I think, the first 12 years or so just about developed as many as we have now, and much of the curriculum development was done by early '80s.  We're still refining and fine-tuning, but I would say Phase One is the organization work and development of education programs, but no research, or minimal research.  Phase Two is probably starting to develop the academic discipline, largely through research, and I think we're still very incomplete in there.  Our research is much more than it used to be, nowhere near where I'd like to see it, nowhere near what it needs to be, our literature of record is much better than it used to be, it used to be zero and now it's pretty good, but nowhere near where it needs to be.  So any number of ways of categorizing, but those might be the two big chunks as of right now, and then one would ask well, what about the future and what's next, what has to be next, and for me, where are we now?  I think we have good organizational development, this kind of an organization is really quite sophisticated, it's very active, it's very dynamic, we have RAP programs, we have, the Academy is well-developed in many areas, the Board of Family Practice has done a great job, we have--organizationally, I think we're quite well-developed.  The literature, we have a number of journals, we have enough in the field, starting from not having anywhere near enough.  We have clinical departments of family practice in I think 80 percent of community hospitals now in the country and departments of family medicine in what, about 100 of 130 medical schools, something like that.  So--and I think our education programs are really pretty strong.  We have a recruitment problem now with the incentives and the perspectives and perceptions of people entering medicine today, wanting to go into other things, but that's going to turn around.  I think that's temporary.  But--so we have some problems, but if I have to look ahead at the next 20 years, what I--seems to me the most important things is, number one we've got a terribly sick health care system, as has been pointed out by a number of people.  I think it's falling apart.  I think part of the solution is a very healthy and dynamic family medicine or maybe an enlarged primary care community of providers.  I think general internal medicine and family medicine have quite a bit in common, they're not identical, if you took away all the political apparatus and all the organizational apparatus and looked down from Mars, you'd say, 'Why don't they get along better?' and 'Why can't you teach internists how to take care of kids?' and 'Why can't you show them how to do, you can give them ballot(??) groups and you can give them minor surgery and some gyn and some derm' and 'Why can't we work closer together?' and 'Why can't we learn from them a little bit more about what they know a little bit better?'  And so I think it's a little arbitrary.  But when I came into this, what we used to talk about in 1970 was having 25 percent of the country's physicians in family practice.  What have we done?  We've done 10 percent.  That's not good enough.  That's terrible.  And so I think Phase Three, and I'd probably look at it as a 20-year phase, maybe, is to, family medicine needs to become the foundation of a health care system that's totally reformed, that has to reform around a strong primary care base.  I think family medicine is the strongest answer to primary care.  I think we could work more closely with general internal medicine, and a lot of them in our area we find want to come over and do family practice, so why can't we teach them what we know about areas that they need, and why can't we learn from them and general peds--that's harder to say.  We have two examples in our area I know of that are doubly boarded in peds and family practice that have learned how to do OB and have become excellent physicians, so it can happen.  Organizationally it looks like bigger gap, though, and I will guess that peds is going towards some specialization long-term.  And that, but if you come back to the 10 percent thing, being 10 percent of a system is not good enough.  We should be, I think we should be 50 percent of the system.  But 25 is a better goal than 10, but I'd like to see 50 percent, like Canada.  But that might take some kind of alliance with general internal medicine, that's where all the residency slots are.  If we think here today in 10 or 20 years we can have 25 percent of the residency slots in the country, there's no way.  The only way we could do it is to in effect co-opt a lot of the internal medicine slots, or work with them.  They've got most of the slots.  So number one, I think a lot of things I'd put into Phase Three, if you want to simplify it to just two or three phases, one is to set up a strategy whereby 10 or 20 years from now we are at least a quarter of the physician manpower in the country, and the base of the health care system, and all referrals come through family medicine or the primary care physician, and we're the central role and not a trivial role in any way, at least as strong a role as we have today, and a more limited and probably rationed role of the subspecialist.  We don't need transplants for everyone.  Callahan gave us some directions on that.  My mother's 91 now and she just got out of the hospital with a popliteal graft, which the surgeon was very excited to do.  \n\nQ.  I'm sure.\n\nA.  And I think it put her down a notch functionally.  If you have a hammer, every problem you see is a nail.  So we can't build a system like that.  So Phase Three, we need to not become a 10 percent option, that won't do.  So we need to revise our educational strategies and build new coalitions and new alliances in medicine and develop many more residency training positions than we have today.  Many more.  Recruitment?  That's going to come.  I know it looks bad now, it isn't bad, it's just a problem.  And there are 35,000 unemployed physicians in Italy--35,000!  Seventeen thousand unemployed physicians in France.  And still we have all these medical students running pell mell into subspecialties in this country and they're going to hit a wall out there.  We're going to have underemployed physicians.  We have to.  And we may end up finding ourselves with more specialists pounding on our doors, 'Can I get a one-year update and get board-eligible in family practice?  Can I take 2 years--I made a mistake and I went into pediatrics.  Can I come back and take 2 years and get boarded in family practice?'  And I think we should be open to those things.  I should we should develop retread programs and new board eligibility programs for people that made the mistake of going into other specialties.  So okay.  Priority one, 20 years from now we need to be 25 to 50 percent of the system.  Priority two, we need to develop the real academic base of primary care and particularly of family medicine, based on research of our own clinical experience, then standards of care are derived from that, not from studies in non-primary care populations or edicts from other specialty societies, as continually happens.  And in three--that gives you your, the number two thing, the research gives you what you teach, it also gives you standards of care, and it also gives you the way to build your more rational health care system and the way you allocate your resources in that system.  So what are the dimensions of research?  Everything that we do in primary care is open for research, but we should know what the cost benefit of anything we do diagnostically or therapeutically is, and I think as the most generalist field in medicine, we should have a lot to do with reorganizing a reformed health care system.\n\nQ.  I want to stop there and kind of go back, go back to let's say the first, maybe that first 10 years, when as Phase A programs are getting established, what was the impact that, if there was one, or what was the meaning to a medical specialty of this new or continuation of general practice expansion into family medicine?  What did that mean to--\n\nA.  Depends on who you ask.  If you--I think behavioral science is kind of an example of getting different answers.  Some family physicians were very tuned in to behavioral science and became very good at working with behavioral scientists and helping with curriculum strategies and development and teaching methods, and others were frankly not enlightened about it, or didn't understand it, or it was low on their priority list, and their responses might be kind of a direct extension of their roles as general practitioners before.  Many of the initial program directors came from active general practice, so it's only natural that many of them didn't grow too far beyond what they knew.  So it depended on who you asked as to--\n\nQ.  The kind of impact it had.  What--\n\nA.  But I think there was pride in having a new specialty, in the challenge of developing the educational structure of that specialty, of working with other specialties to develop a new visibility and a new image for the field, and a new way of relating to other specialties, and a challenge also in starting to add our own knowledge.  But this was only perceived by a few.  And it was relatively low priority in those Phase One years.\n\nQ.  Was this something that you felt, that you perceived as pride and challenge and--\n\nA.  Oh, sure.  Sure.  But quote research was not seen as a high priority for a lot of the early people.  Because they were (???) and the word research is still kind of a turnoff to many people in family practice, and if you look at readership studies of what people in general and family practice read, it's a little bit disappointing, they don't read with high priority a lot of the original work which is developed in their own field.  Instead, the usual reading preferences were relatively easier to read CME articles.\n\nQ.  How about in terms of the larger community?  What impact or what impact did family medicine have outside of the medical community on populations or in the country, or has it had much of an impact at all?\n\nA.  I think it has.  I think the idea of family practice has captured the public imagination.  There's always been a lot of public support for family practice.  It's been evidenced a lot by state support of family practice programs through funding, of people in health policy circles knowing that primary care and specifically family practice is really important to the country.  The federal government policy people have known that.  So I think there has been broad appeal, but also I think the public is enamored with high tech and in a way they've moved on to the higher tech glitz.  And so I'm not sure family practice is the first thing on people's lips any more.  \n\nQ.  But at one time it may have been, or it was?\n\nA.  I think it tends to have public support where it's raised as a public issue.  Now there's so many issues it's hard to hear, to have it come forward as a major problem necessarily.  I think public images or perceptions of medicine is it costs too much, they often like their own doctor but they don't like the cost of medicine or the problems with AHCCCS or the frustrations with the system.  And physicians are overpaid anyhow and don't we have enough of them, and in fact even the policy people are starting to say, 'We have too many of them, don't we, and they don't go to the right places.'\n\nQ.  You know I've heard that you are returning somewhat to practice now.\n\nA.  Right.\n\nQ.  What are the reasons for that, or what are the satisfactions that--it's in a sense unusual.  Maybe it's not so unusual, but what are the things that you sense in it now that's encouraging you to return?\n\nA.  Right.  Well, it's pretty personal but basically I've always loved the process of taking care of people and I've always missed my clinical roles, especially in rural practice, and I've missed the connectedness that one has in rural practice, which there is a connectedness in medical schools and in institutions but it's different, and it's--so actually as I step out of the chairmanship in that role, it's really exciting, and I could have done just dozens of things that would--and still can--that would be very fulfilling and interesting and fun to do and maybe a contribution too.  But as it turned out, and actually I developed a list a year or two ago of some of the things that I might want to be involved with, and you can't do all of the above and so you have to pick and choose, and I actually ended up shortening my list because of needing to maintain some role as a residency coordinator or a network coordinator on an interim basis during the transition and then looking like there were certain needs in the department when I came back.  So it turned out that on my brief sabbatical of a few months I ended up doing a clinical update as my main priority.  I had thought of doing some other things.  I think my, probably my major interests are returning to a clinical role to an extent, one--two, looking at GME and especially in the nonsense of it and what can be done about getting a larger proportion in primary care and family medicine, in effect reforming the GME system, and three, the whole problem of reforming the health care system is still out there and we should be part of the answer as it falls apart.  So those are probably three themes of my interest, but again you can't do--\n\n[tape ends]","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/159381/file/290369#t=0.0,3708.94658"}]}]}]}