{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/p843r0rs80/manifest","type":"Manifest","label":{"en":["Dr. Richard Roberts"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}},{"label":{"en":["Date"]},"value":{"en":["2016-01-18 (created)","2016-02-11 (other)","2016-03-07 (other)"]}},{"label":{"en":["Type"]},"value":{"en":["Oral History"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. Dan Ostergaard (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["American Academy of Family Physicians","American Academy of Family Physicians President","family medicine","family physician"]}},{"label":{"en":["Subject"]},"value":{"en":["Richard G. Roberts, MD (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}}],"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282876","type":"Canvas","label":{"en":["Media File 1 of 6 - Roberts_Richard_Pt1_16_a.wav"]},"duration":3246.70474,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282876/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282876/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/282/876/original/Roberts_Richard_Pt1_16_a.wav?1752685486","type":"Audio","format":"audio/wav","duration":3246.70474,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282876","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282876/transcript/81719","type":"AnnotationPage","label":{"en":["Dr. Richard Roberts interview transcript (1) [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282876/transcript/81719/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Dr. Ostergaard: Good morning Dr. Roberts.\n\nDr. Roberts: Good morning Dan.\n\nDr. Ostergaard: Please, for the record, state your full name.\n\nDr. Roberts: Richard Guy Roberts.\n\nDr. Ostergaard: And, also, Rich, just to confirm for the record, please, that you are aware that this is being recorded and you have signed the consent form with Don Ivey at the Center for the History of Family Medicine and you are giving your permission or have given your permission to do this interview.\n\nDr. Roberts: Yes, that is correct.\n\nDr. Ostergaard: Okay, Rich, what is your present title? And by that I mean your title at the University of Wisconsin and any other title that you may have that I may not know about?\n\nDr. Roberts: For me the most important title has always been simple country doctor as well as husband and father. But professionally right now it’s Professor of Family Medicine in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health.\n\nDr. Ostergaard: And, Rich, we will get into, a little bit later, to your rural practice in that town nearby as well as your academic work. So back to biography, when and where were you born?\n\nDr. Roberts: I was born in Beaver Dam, Wisconsin, the oldest of five. My dad, who was Richard --, was a Singer salesman, sold sewing machines, and my mother Theresa or Terry was at home with the five of us. At about age two we moved to the Madison area where I really grew up and have identified as home. I think in terms of my formative years, we lived a pretty middle-class life though we hadn’t had anybody in my immediate family who had gone to college. So I wasn’t quite sure what that was all about as I was growing up. I think one of the issues that was always in the background for me was my dad was, in fact both my parents were very avid readers and very bright folks but neither had the chance to go to college. My dad because of World War II, Mom because the kids that came along. And I think my dad always had a desire to go to law school and kind of regretted that he never was able to do that. And I’m sure that influenced some of my choices later in life. But growing up, going through school, one of the things that I did was I was very active in sports, football, track, wrestling, things like that. I was also pretty active with leadership things. You know, class president, captain of the crossing guard, things like that. \n\nDr. Ostergaard: That was a good one.\n\nDr. Roberts: Yeah, that was a good one. Those are things that just kind of happened. But I never really thought of myself or remember myself as being terribly aspirational, seeking these things out. They just kind of happened. Either somebody would say, well, why don’t you go do this or I think you’d be good at that. And so as I came to the end of high school, I had a couple of grant made (?), as they used to be called back then, grant made offers (we call them scholarships) to a couple of the Ivy League schools. You know, play football, go to school. But in those days it was not a full ride scholarship, so the net difference was still substantial enough that … And I couldn’t’ see spending all this money on college, for heaven’s sakes. So I decided to stay close to home where I could afford the in-state tuition. Went to the University of Wisconsin. And started working even in high school. I worked at a grocery and a service station, but kept the grocery job through college. And walked on at the University of Wisconsin, had what I would describe as a brief and forgettable career as a tailback with the Badgers football team. Decided, as I was going through school, that what I really wanted to do with my life was something that was interesting, that I found interesting and challenging, but trying to be of service to others. Those were kind of the driving forces in the early seventies when the Vietnam war was winding down. There were still a number of protests on the Wisconsin campus. I can remember having to go through teargas to get to classes on time. And like all of the young people of the day, concerned about issues of social justice, the Civil Rights Movement and the women’s movement. So those were kind of the things that were swirling around me, in my generation. And that came together by my deciding to go into medicine. I think there was one other event or occurrence that shaped that. There was a neurosurgeon, Dr. Fred Kris, who became a very close friend of mine. He had grown up in a hard scrabble west Texas family whereas he described that the boys in the family took to sports to keep out of the way of their abusive alcoholic father and they all excelled. And he went on to become a football player on one of Woody Hayes’s early teams at Ohio State, then went to Harvard for medical school and Michigan for residency and came to -- to practice. So a real kind of up by the bootstraps success story. And Fred and I just clicked. He had helped me with one of my football injuries and also had me paint his house. I was doing some painting as well as my grocery job during those college years. And in the end kind of talked me into medicine in that he would allow me to go along on his rounds in the hospital and also even to scrub in on patients in undergraduate – all the with the permission of the patient, in all of those instances. And Fred was a very remarkable man. A really compassionate physician. I just remember one instance on a Sunday morning, we were doing rounds and there was a man there that had had a ventricular peritoneal shunt and was being revised because he had blocked off. But this man had been in a persistent vegetative state for quite a long time. And we were rounding with a fairly young nurse who was just out of training and Dr. Kris said to us, Would you please get me some more gauze to change his dressing. So we walked down the hall together. And the nurse said to me, What’s wrong him? I said, Well, he just had this shunt replaced because he was getting a lot of fluid pressure built up in the brain. She said, no, no, what’s wrong with Dr. Kris? And I said, What do you mean? Well, he was talking to the patient like he’s really there. He was telling him about the Packer’s score and about the weather. And I said, You have to understand Dr. Kris; he is there to Dr. Kris. That’s how he looks at everybody. Which really had a big impact on me in terms of how you think about people – you know, each person having value. But what Dr. Kris talked with me about was the fact … He was right in the midst of the first medical malpractice crises in    our state and was testifying before the legislature and he was always complaining about those idiotic lawyers that were making health policy that really didn’t understand anything about taking care of patients and wouldn’t it be nice if we had somebody who could speak both languages. And that prompted me to … That really set me on a whole other trajectory. I ended up accelerating. I got through undergraduate as a philosophy major. But I got through college in three years. I was taking an illegal number of credits. Then I went to law school, stayed right in Madison because my wife to be was finishing up her degree one year after mine. So I stayed there and went to law school in Madison. Got through that in two instead of three years, also taking an illegal number of credits every semester. I always started the semester in the dean’s office begging for permission to take extra credits because the tuition was no different and it would save me time and money. But it was really Dr. Kris that had a lot to do with that sort of trajectory and I’ve forever been thankful to him. In fact, one quick story I’ll finish with: When    years later called him up to say that I was choosing family medicine and going into family medicine residency (I was going to Washington, DC Medical School at the time), I could almost hear the disappointment in his voice. He was very polite about it, but I could just tell that it sort of wounded him. It was like how come you aren’t going into something like neurosurgery? And then about twenty-five years later, as I had been in practice for a number of years, he called me out of the blue after he had retired and he said, Hey, could I follow you around? And I said sure. So he came and shadowed me for almost thirty-some hours as I went through clinic, on-call for the night and -- with me a couple of babies with admission to the hospital. The next day in clinic. Then we debriefed that second at a restaurant after we had gone home to clean up after the long day, day and a half. And I said to Kris, What do you think? He said, Boy, you guys work really hard. I said, Yeah, that was a little more, but not too much more. And then he said something to me that’s really, again, had a big impact on me. He said, I could never do what you do. He said, I never realized how many different things you deal with and the complexity of it and how you have to do this in a fairly compressed timeframe. He said I could never do what you do. And that, to me, was very affirming and I still think back to that – it happened just a few years ago.\n\nDr. Ostergaard: That’s a great story. And the fact that he wanted to come back and shadow you is something I don’t think I’ve ever heard of before from a neurosurgeon. And his compassion of talking to the patient even though unconscious, as if he were there, is great. Rich, let’s go back to a little bit more bio data, if you will. And then we’ll come back to the early days (?) of going to law school and all that. Tell me about your family. When did you and Laura get married? How many kids do you have? How old are they at this point?\n\nDr. Roberts: The way I like to say it is like many great romances, ours began in a car. In that, in our high school the desks in the amphitheater where you took your big classes for lectures were two people to each desk. She was a Richardson, I was a Roberts. We ended up sitting next to each other as sophomores in high school and we’ve been together ever since. We got married when we were both twenty-one, been together since we were fifteen. Had our first child when we were twenty-nine years old, Matt. And that was when I was in training in Los Angeles, so he was born there. Then the other three children – Ben, who was born in 1988, and then Maggie (?) in 1990, then Alex in 1992. They were all born in Madison. I joined the UW faculty, the University of Wisconsin faculty by that point. So we had four kids, three boys that are men now, and one woman – and they’re great kids. \n\nDr. Ostergaard: Kind of an aside: So Laura grew up in Madison too and you’ve been together since you were sophomores in high school. And her family is there, too, right? \n\nDr. Roberts: Yes, she’s the middle of seven children and always reminds me that middle children never make trouble, so she was always the well-behaved one, unlike the ones at either end of the spectrum of children. But hers especially has been a very close family. The siblings are all in the very nearby area. And her mom and dad were very much a part of our lives and our children’s lives. They recently passed away. I say that because some of the things I was able to do later in life in terms of international work and being away from home as much as I was, was only because I had this amazing network of aunts and uncles and grandparents and others that were always available. And it was kind of a mutual thing too. One of my brother and sister-in-law moved across the street, so if I was away and one of my teenage sons needed a kick in the butt, my brother-in-law would come over and help with that. And sometimes I would do the same for him when he was away. You know, it was just one of those things where you always felt like you had your back covered and your family would still be kind of supported and looked after with this kind of amazing network. And the other joke that I always tell about our family is that I always felt like I was feeding half the county because you’d come home almost any time, day or night, and there’d be half a dozen adult and a dozen kids running around. We were always feeding people. And it’s been chaotic at times, but it’s also been a great part. And we still do stuff together, whether it’s going together for vacation or things like that. That’s just a really important part of … In fact, Dan, you will remember during the Academy years, a running joke between – Rockefeller (?) and me was, you know, how many people are you bringing this year, Roberts, to the board dinner with your family? Because the summer meeting was usually the family meeting. And there was always some outlandish number because I was bringing not just our immediate four kids and my wife but also a half dozen or more of the relatives because that gave them a chance to see a bit of the world too. \n\nDr. Ostergaard: I certainly do remember. (Inaudible.) Let’s go back to your decision to go into family medicine. You had that great role model, a neurosurgeon. And I did not know you were a philosophy major in college. And you have indicated that service was and is a great part of your sort of persona and goal. But why family medicine? What happened? Was it somebody in Wisconsin or was it just the beginning of family medicine? It was almost the beginning of family medicine, so why did you want to be on that …\n\nDr. Roberts: It was almost dumb luck. And what I mean by that is having grown up in Madison, Wisconsin, it’s one of the most over-doctored communities in the U.S. I think only Rochester, Minnesota with the Mayo Clinic has a higher physician to population ratio than Madison does. And growing up as a kid, I saw a pediatrician and everybody always went to specialists. But even though our department of family medicine was developing here, it was just in its beginnings and had a long way to go. But when I was finishing law school I also sensed that it was time for me to kind of move on, to get out of the area, to see the bigger world. Laura and I had grown up our entire lives in the Madison area basically. And I was also interested in going to a medical school where I would get really good clinical training. I wasn’t all that interested in research. I mean that was fine, but my passion was really about learning to take good care of patients and making the health system better. So it became kind of a logical choice for me that I’d go to a    place like Washington, DC where I went to George Washington University. And I had a great experience there. I really felt like I got excellent clinical training. And it gave me a chance to work at very high levels of government, and we can talk about that later if you want. But that’s important because GW, at the time, didn’t really have a department of family medicine. They did later for a while, but then that shut down later too. But what we did have to take in our third year was what was called an ambulatory medicine experience. Well, we were living in suburban Maryland at that time, so it was about thirteen, fifteen miles from where we lived into down D.C. where the medical school and hospitals were. But we always tried to live where Laura was teaching. She had a degree in physical education, she was coach. And we only had one crummy car between the two of us. So we always tried to live close to her school so she could walk to school. And that’s what she did and I always drove to wherever I was able to go. And it turned out that I was really sort of sputtering at the point that I was about to do my ambulatory medicine clerkship and there happened to be a guy about a couple of miles down the road from us in Silver Springs, Maryland, named Ed Richards, who was a family doc and practiced out of his home. He had just, about a year or two earlier, stopped delivering babies but still saw patients in the hospital. And in many ways the first floor of his home was almost like a neighborhood community center. People were dropping by to drink coffee. The kids would sometimes get dropped off and wait there for a while for Mom or Dad to come by. It was a really interesting thing to watch. And I fell in love with what he was doing. I mean he was part of the glue in that local community and practiced there for many years. I didn’t know, at the time, and actually was a bit of a surprise, but Ed was active in the Academy. I think he was a delegate for the Maryland Academy of Family Physicians to the AAFP Congress of Delegates. But we really didn’t ever get into that. He was just showing me family medicine and showing me his whole breadth and depth and connections and community and all the things that are important in our discipline. And I fell in love with it. I probably, up until then, if you had asked me what I was going to do, I was probably going to go with ophthalmology. I have congenital strabismus, right estropia with amblyopia and as a result don’t have all high levels of stereopsis or depth of field. And I spent part of one of my summers of pre-medical school working with one of the ophthalmologists here, a very famous gentleman from Syria who had glaucoma (?) and he had to work through binocular scopes to do this. And he was a very smart guy, also another specialist who had an influence on my career. He said to me, You know, you’re really smart and you’ve got good hands. But you’re going to be frustrated, it’s going to be extra hard for you to do the kind of work that ophthalmologists do because everything you do is through scopes and you basically have monocular vision. And he was actually right, if I tried to do that. So that was another person along the way that had, I think without me realizing it, a big impact on me. So I think it was probably a coming together of realizing that the thing that I was tentatively interested in was probably not going to be the best career fit combined with this wonderfully, sort of almost transforming experience with Dr. Ed Richards that then made me want to go and do family medicine. Which was not a terribly popular choice among my professors as (Inaudible). You know, people were saying, gosh, a family doctor? Are you sure you want to do that? You know, many of us hear that, you’re too smart for family medicine. But I didn’t care about that. It was what I was interested in. And as I said, my ambition had been to be of service, which clearly Dr. Richards was, and to do interesting, varied work, which clearly family medicine was. So for me it was really, by happenstance, a terrific kind of event in my life that set me, again, on the course for being a family doc. \n\nDr. Ostergaard: And instead of staying in D.C., even though there wasn’t any family medicine at George Washington, there was some beginning ones in the area, Franklin Square or other places up there, you went back to Madison. Why?\n\nDr. Roberts: No, I actually did not. \n\nDr. Ostergaard: You went to UCLA.?\n\nDr. Roberts: I went to UCLA Santa Monica Hospital, yeah. I had, I don’t think I mentioned this in passing, but one of the other reasons I was sort of interested in D.C. was the chance to    work a bit on health policy. So, for instance, I got involved with AMSA, the American Medical Student Association. I got involved with the AAMC, Office of Student Organizations to represent as OSR (?). I got involved with the Medical Student Section which was sort of the successor to the AMA’s medical student group that you have been involved with. And I was active in all those groups helping to draft legislation, public law 94-484 (?), which was the Health Profession Education Systems Act, and things like that, in the mid to later seventies while I was a student there. But I also had a chance to work through the Public Health Service -- program, doing health policy stuff with undersecretary Telafano (?), in what was then HEW, now HS (?). And even had a short time of being deployed to the White House to work under Stuart Eizenstat who was the domestic policy advisor for Jimmy Carter. And so this was during the Carter administration. So I had this great chance as a kind of wet behind the ears young lawyer turned medical student to kind of experience the policy process and learn a bit about it and try to influence it some. But then I also had the chance to do some grant reviews. In those days medical schools used to get money from the federal government just for medical student education. Those -- days are long gone. But it gave me an opportunity to travel around the country a bit looking at sites that have received money, including family medicine training programs. So I got a sense of what was out there and as I began to do my own residency match process I decided to look at a number of those programs that I had been very excited about as a grant reviewer. So I ended up looking at a lot of the programs that were very prominent in the day – Rochester, New York, Charleston, South Carolina with --. And Rochester, New York, Gene Farley was there and Madison had John Weber. And then I also wanted a place … I knew I was going to have a National Service Corps commitment because we had been poor as church mice and GW’s tuition was tied with Georgetown for highest in the country at the time. And so I think the last three years, if I remember right, of medical school, I had National Service Corp’s fellowship assistance with the tuition. So I knew I had to go in an underserved area for a while, which was fine. It was something I actually looked forward to. But I also knew I wanted to have a very comprehensive practice with a lot of skills, so I was looking at places that had that tradition too. So I looked, for example, in California, the Santa Rosa program, the Ventura program in Santa Monica which were three programs that had been there or a long time and encouraged that. So I probably looked at, I don’t know, ten or twelve of the programs that I thought would be a good match for me. And when I went to interview at Santa Monica, Sandy Blume (?) was the residency director at the time and Sandy had gone to medical school in Wisconsin. I don’t think he had any other Wisconsin roots. So he ended up in California for practice where he started a medical group and was a very successful physician, then decided he wanted to go into education. And Sandy probably taught me as much or more about leadership than anyone I’ve ever met. We’d hear something in the works about the hospital wanting us to do some additional drudgery task as residents, because we saw ourselves as kind of the utility infielder for the hospital. Any job they couldn’t get some other practicing physician to do, they’d sort of dump on us. And Sandy would call a meeting and hear our concerns and why we shouldn’t do this and so on and so forth. And by the end of the meeting not only were we willing to do it, but we thought it was our idea in the first place. That was sort of Sandy’s diplomatic skill. And I really admired that man enormously. One of my more cherished moments was years later as I had finished my AAFP creditadency, you were able to confer a president’s award. And I picked a couple of people, I picked Linda Farley, Gene Farley’s wife who was my practice partner in a small practice that I’d been with the University of Wisconsin, as well as Cindy Hawk (?), another of my practice partners, who both had a huge influence on me. Some of the most service-oriented, committed and skilled clinicians I’ve ever met. But then I also picked Sandy Blume for the third one. And one of my more prized moments was … By this time in his life he was in his early eighties. He had had a couple of occipital strokes, as I understood it, and really couldn’t see anymore but his wife, Mary Jane, would still read him the medical journal articles when they arrived on their doorstep. So she would be reading the journals --. So I had a trip when I had to be in California and I made a special point of driving up to his place. He was living in Santa Barbara at the time and I was taking him this award and got a chance to thank him personally for what he meant to me and so many of the people who trained in Santa Monica. It was a great program in the day. And Sandy passed a few years later. Again, that time was just great. I still feel very good about that afternoon at Sandy’s house and watching this guy who stopped taking care of patients years before but still was passionate about keeping up with the ever-changing literature. Sandy was the kind of guy that you’d be sitting in grand rounds and you’d have all the specialists talking about this test and that test and Sandy would always bring us back to earth and say, well, what’s the patient’s major problem and we’d say pain. Well, let’s work on pain first. He had this wonderfully practical way of grounding us. So, again, those have been the sorts of experiences for me that have kind of, I think, helped me think about family doctoring in a very important way.\n\nDr. Ostergaard: Let’s go back, and for the record, I guess, I understood everything you said. But I’m not sure our transcriptionist will quite get it all. Begin the year you finished college in Madison and then the law schools years. Then on to GWU. Then I’m going to ask you a couple more philosophical questions. \n\nDr. Roberts: Sure, of course. I finished high school in 1971 and entered the University of Wisconsin. I would have normally, with the typical timeframe, graduated in 1975, but I essentially had completed my baccalaureate courses by 1974 – except for one course which I then took in the summer after my first year of law school, which I started law school in 1974. And then with the two years of law school, I got into medical school in 1976. Started then at GW in D.C. But had to come back for one more for law school because then you could only cram so many courses. So the summer between the first and second years of medical school, I went back to the University of Wisconsin to finish one course in law school. So the JD – was conferred in, I guess it was December of ’77. And that allowed my picture to be in the same picture case with my fellow law school classmates, which I also wanted. And I wasn’t worried about practicing law. In fact, when I applied to law school I said I don’t care about practicing law. I want to use my legal knowledge and the skills that were developed there to help try to make the health system better. In fact, one of the things that I’ll tell students today when I sometimes will teach a class of college students, medical students, law students, pharmacy, nursing, medical, whatever, is … I like to say that in 1976 I went to Washington, D.C. as a young lawyer turned medical student to complete my medical school training but also to fix the U.S. healthcare system - and forty years later it’s worse than ever and I’m sorry. But it’s been a succession of sort of getting onto the next thing very quickly and getting through that training process as quickly as I could. So what I did at MDC was I went through the more traditional four years of medical school in ’76, so graduation in ’80. And then at UCLA Santa Monica from ’80 to ’83. \n\nDr. Ostergaard: When you were at UCLA Santa Monica and Dr. Sanford Blume was the program director who you spoke so warmly. And parenthetically, by the way, at what city were you as outgoing president when you gave those awards to Cindy Hawke, Mrs. Farley and Sandy Blume, what city was it in?\n\nDr. Roberts: Sandy was not able to travel at that point. It was at that annual meeting that you gave your report. Gosh, I’m embarrassed to say that I don’t remember the city that the AAFP was meeting. I can tell you the year. It should have been 2001 because I was in office and fully involved in 911. And I’m trying to remember the city we were in. It might have been Chicago but don’t hold me to that. I won’t hold you to that. And it was just parenthetical.\n\nDr. Ostergaard: So after you finished your residency in Santa Monica and while you were there with the program director, Dr. Blume, Dr.Tom Stern was in L.A. at that time and he became the director of that residency later. Did you have any overlap with Tom Stern?\n\nDr. Roberts: Oh, yes. I think Tom actually preceded Sandy in that job and Sandy took Tom’s job when he came to the Academy. Exactly. So Tom left to join the Academy in Kansas City. So I met Tom a few times. He was a big muckety muck kind of guy at that point, so I was just a resident and told that this was an important guy in family medicine when I met him – and Sandy knew him. And I got to know Tom very much better in his latter years when he was with the Academy and the Foundation and very much enjoyed getting to know him and hearing his stories. One thing I should mention about Sandy, too – again, when you look at the things that have been a big, important part of my life in terms of leadership and involvement is Sandy was very committed to having people involved. People making the discipline of family medicine better. He, I think, served as the editor of “California Family Physician” for a number of years, if I remember correctly, so he was involved with the California Academy of Family Physicians board and he encouraged us to do that. And going to medical school at GW, I’d been involved with kind of more political organizations, AMSA and those. But there really wasn’t a family medicine interest group at the time and so I didn’t really know about the family medicine organizational structures until I went out to California and Sandy said to me, at the end of my first year, why you don’t to this meeting that they have in Kansas City? And it was then called NCFPR, National Conference of Family Practice Residents. And this would have been about 1981, I guess, August of ’81. And that had a whole big impact on me because here I suddenly was with several thousand like-minded young medical students and residents committed to family medicine and it was terrific. Not only that, but I had people coming up to me at the meeting. You know, leaders in the discipline, department chairs and the president of the Academy and people that actually were interested in what I had to say about things and what I thought about things and encouraging me to get involved. And that was really kind of a shocker for me because I had come from D.C. where people all spend their time trying to wiggle their way in and elbow their way to the mike. And here it was people very earnestly saying to you, you’ve got some important things to tell us, so tell us what you think about this or about that. And even the whole format of the meeting where the students and the residents had a chance to develop resolutions and those sorts of things. I just really got caught up in it and that’s what got me involved with the Academy, which I’ve continued to do for the last thirty-five years. And I got involved with the California Academy board. And in doing my last year or two of residency I came back to Wisconsin. As soon I was in practice, I was active with the Academy and organized medicine. So Sandy I really give a lot of the credit to for helping me see the value of connecting with fellow family physicians in an organizational way and trying to make the system better through that mechanism.\n\nDr. Ostergaard: So back to the chronology, when you finished residency at Santa Monica, you had a National Health Services commitment. And how did you fulfill that responsibility in juxtaposition to your beginning academic career? How did they relate?\n\nDr. Roberts: Well, there’s a bit of a story there. One of the things that I’d been involved with during my brief tenure in the federal government was helping to write some of the, not only the law but the regulations around the National Service Corps when I was a --. And the year that I was supposed to be matching my senior year residency to a National Service Corps site we were just beginning to have with the National Service Corps the option of either going with what was called private practice option or to be a federal employee. Usually civil service, so you could be uniform service. And I had decided that I would really probably prefer to go the private practice option because, to me, in many ways that evidenced a greater commitment to the community you were joining in. You weren’t there as kind of a federal employee with little at stake, you know, little to risk financially and things like that. And the two couples that we were closest to during our residency years, personal friends with, were Jim and Adele Conner, and Jim was two years ahead of me in our residency, also a George Washington Medical School Grad. And then another couple, Sue Farke (?). And what happened was, Sue and Jim were in an underserved area in Lake County, California, Clear Lake, and they really wanted me to come and join them. There had been a network, I think the guy’s name was John Irvin back then. And John had set up probably eight or ten kind of community health centers across central and northern California. And John was a family doc putting family doctors into these sites and that were National Health Service Corps private practice option sites. So I went up and looked at that site and I said, boy, this is great. We’re going to have you see patients three days a week, be the county health officer a day at week. Then I got to go down to the Santa Rosa residency a day a week and teach. It was like all the stuff that I loved. A perfect job, right? So that year, as I went through the National Service Corps placement process, you got a questionnaire that said, what region do you want to be working in? So Laura at some length. On one hand she really wanted to go back to Wisconsin. I used to tease her that when we moved from Wisconsin to D.C., it was an 800 mile long umbilical cord being stretched and that when we moved from D.C. to L.A. it was a 2300 mile long umbilical cord being stretched – which eventually snapped back and pulled us back to Wisconsin. But she felt like the position in northern California, especially with our close friends there, that would be good. And so she was willing to do that. So we put region nine, which was California, Arizona and Hawaii as sort of our region five. And region five, which was Wisconsin and some of the upper Midwest states. As our second choice I got matched to region nine. I got a letter back saying you’ve been matched to region nine. And then they asked in that letter to designate which state you wanted to be in. And so I put California, No. 1, obviously because of the Clear Lake opportunity. I put Nevada No. 2 because I had some residency program graduates who I knew who were up there practicing in Reno and Lake Tahoe and they were great folks, great docs and they had a great practice. So that was my sort of fallback. I picked Hawaii No. 3. I had a cousin that lived out there. I put Arizona No. 4 just because I’d never seen the state. I had driven through it once, I think, to get gas. And stopped there once to get gas when we were driving from D.C. to L.A. the first time, but I’d never been there other than that. So a few weeks later I get a letter back from Washington, D.C. saying, basically, because of my unique relationship with the state, I’d been matched to Arizona. And I thought, alright, I’ll try to work this one out. I’ll be the good soldier. And early in January that year, my senior year, the University of Arizona’s Office of -- Health had been kind of the contractor for the National Service Corps to help with these placements across Arizona and they had an orientation for all the people that had been assigned to Arizona. And there were people there that I got a chance to meet. Andy Nichols, Art Kaufman (?) and others. And it was great. The people were wonderful and the communities sent representatives to this meeting and we had little slide shows on their communities and people were really, really nice. But I was sitting at lunch with, there were tables of eight and the National Service Corps people and their -- were seated around the tables with us. And what happened at lunch that Saturday was there was a woman next to me, an African-American woman who had grown up in Watts, in L.A., and her mother was like the matriarch of Watts and her husband was in the P.A. program in Watts. And she wanted to go back to Watts, which was clearly an underserved area, and she got assigned to Arizona. And she was telling that story. And another person that was from Hawaii who was in the lineage of --, went to osteopathy school in Missouri because they didn’t have an osteopathic school in Hawaii and that’s why he was in the National Service Corps and he wanted to go back to Hawaii and they had a couple of spots there – and he got assigned to Arizona. I was listening to these stories and each time the National Service Corps regional administrative person said, gee, I’m so sorry that it didn’t work out like you wanted, but that’s just kind of how it goes. And finally I couldn’t take it anymore and I kind of threw my napkin down and said, pardon my saying, but this is bullshit. And I turned to the person from California and I said, here’s who you need to talk to in the Senator’s office in California. And turned to the guy from Hawaii and here’s who you’ve got to talk to in Skip Osanaga’s (?) office. He’s the Senator in Hawaii. Alan Cranston was the one in California. Because I knew these people. I had just been working in Washington, so I had all their legislative assistants’ names and numbers and so on. Because what had happened that year was there was no legislative or regulatory authority for the National Service Corps that required you to identify a state within the region. If your private practice option site met the medical need criteria, which my site did and all the other peoples’ sites around the table did, then you went wherever in that region that site was and they were, in effect, trying to do something that really wasn’t legally permissible, if somebody was going to challenge it. Why did they do this? Well, I think what it was, was that was the peak year of the National Service Corps and I don’t think it’s ever gotten that high as it was that year in terms of numbers of bodies they had to place. And they were overwhelmed, frankly, and there were bizarre situations of, you know, husband and wife … The husband was matched to Philadelphia, the wife to Alaska. That kind of stuff going on. And I was very committed to the National Service Corps, and still am, as a way to serve the people, to repay the federal government helping me. I was very committed to it. But I will say that that took a little bit of the luster off of my experience with it. And so what I had done during the Christmas holidays, when we went back to Wisconsin to be with family, like we always did,    and I had the presence of mind of always wanting a plan B, I visited about a half dozen sites in Wisconsin. So I put in, I don’t know, probably twelve weekends in a row in that beginning half of 1983, when I was looking at Arizona sites. And I would run out of clinic right after 5 PM, drive across the desert, look at sites in Arizona. In fact, I’ve been to every county multiple times. I could probably work for the Chamber of Commerce in Arizona now. And I really grew to love the state. The first time I was there, I thought, man, this is like a big gravel pit. But as the time went by and I was all over the state, I saw the wonderful topography, the diversity of the cultures. I really enjoyed it. So I thought, yeah, I could do this. And I saved what I thought were the best three sites for last. And Laura and, at that point, our infant son and I, the very last weekend went to visit the three top sites. One was in Williams. Another was in Shaklee up in the northeast in the White Pine forest, it was an Indian reservation practice. And then the final one, which I was especially interested in, was Patagonia, which was halfway between Tucson and Nogales and the Mexican border. And my particular interest there was I was going to be able to teach a day a week at the University of Arizona. But they had just lost their one and only doctor. And the woman that was the physician assistant, manager of the practice was the one that showed us around. So we saw Williams on Friday, Shaklee on Saturday. Now we’re in Patagonia on Sunday. We’re getting driven around and the lady is saying to us, you know, you’ve got to understand, half the winter nights you’re going to probably get stuck down in Nogales and have to spend the night at the hospital because the bridge washes out. And if you wanted to buy a house, forget it. It’s all either owned by the federal government of -- or the corporate ranchers. And she was kind going on, one thing passing after another. And President Regan has slashed our budget and so your salary is going to be less than what you earned as a senior resident. And I’m sitting in the front seat as this clinic manager is telling us all this stuff and looking in the rearview mirror and my wife, watching her eyes get wider and wider. And so at the end of the tour she pulled up to our car, which was parked kind of out in the middle of nowhere at a wait site. So Laura and the baby get out from the backseat, I get out from the front seat, go around to the driver’s side to talk to the manager. I’ll call you next week and we’ll follow up and so on and so forth. She pulls away and I go and get in my car and there’s no Laura and no baby. I thought where the heck did they go? So I get out and I look around and probably a quarter mile into a field there’s my wife standing. And she’s a little wildlife debloquet and I figure she probably just saw an animal skittering across the sand or something and wanted to go check it out. So I kind of jog to where she is and I’m standing there shoulder-to-shoulder with her and she’s -- with the kid. And without saying anything to her, she says to me, your son and I are going to be moving to Wisconsin. If you want to join us, that’s just fine, but that’s up to you. So when I got back to California that night, I set some wheels into motion, managed to get letters from fairly high ranking people, Bill Proxmire, Senator of Wisconsin, among others. And miraculously, with about a day left before I had to have a contract signed, I get this letter from Washington saying, well, we managed to find some guy that was assigned to inner-city Cleveland who wanted to go to region nine in the west coast, so you can go to Wisconsin. And that’s how I ended up in Darlington, Wisconsin where I was for almost four years in practice. So I think for me the moral of the story was this federal program, which I think has a wonderful objective or a wonderful goal, in the actual execution of the program, there were challenges that I don’t think necessarily the bureaucracy was up to. And, again, I still have a very warm place in my heart. I felt my experience in Darlington was wonderful. I don’t have regrets that way. But it’s made life pretty stressful for people who had a much tougher time with the --. But it was an interesting time in our lives, trying to decide where are we going to live. \n\nDr. Ostergaard: So you went to Darlington, Wisconsin and in the private practice option of the National Service Corps after residency. And the question then is, did you immediately engage with the university or did you do purely a private practice without the university for a while?\n\nDr. Roberts: So the way that we did this, I joined a practice where there were four doctors. There was an older physician, Dr. Olson --, who was probably in his late fifties, early sixties when I got there. A physician who was two years out of residency before me, Robert Bernadoni (?). And then joining just a little bit after I did but graduated the same year I did was another physician, Dr. Laurie Newman. So we were basically the doctors for Lafayette County, Wisconsin. There was a solo or single-handed doctor, Dr. Fritz --, but he had a fairly kind of … I’m not quite sure the word to use. I wouldn’t say part time, but he didn’t have a real busy, busy practice like we did. So there were four of us essentially taking care of about 17,000 people. And we were busy. We were the emergency room doctor. We had a small hospital, -- Hospital. We were the obstetrician. I did C-sections, I did appendectomies, I did tubal sterilizations using a mini-lap (?) approach then later an obstetrician/gynecologist up the road taught some microscopic techniques. But what I also had was this desire to teach. And so the way the practice worked was that each of the physicians took off one-half of a day during the week to do basically whatever they wanted. And the other three partners either tended to their sheep farm or various hobbies they might have, hiking or whatever, which is what they did. But I would drive up to Madison to volunteer teach at one of the residency clinics. The Madison program at that time had three training sites and I was one of the volunteer clinical faculty that would preceptor staff one-half day a week, every Tuesday afternoon actually. \n\nDr. Ostergaard: How far away was Darlington from …\n\nDr. Roberts: It was probably about an hour’s drive. I mean it kind of depended obviously on snow and things. But probably about an hour. And one of the other things that happened, another example of the importance of connections with the Academy was, I had been, what in those days called a Meade Johnson (?) Scholar as a resident, which was some help and support, financial support, and also got me to the national meeting. But they had a program, also, at that time, called the Parke-Davis Teachers Award program that provided a very small amount of money. I don’t remember what it was now, but it was fairly modest, if you were going to be a teacher while you were in private practice. And I was selected for one of those, which was great. So what started off as purely a volunteer thing, I got a little bit of an award for I think one or two years. And that’s kind of what got me into the university system. And then while I was there, during those four years at Darlington, running up to the Madison program in --, the clinic in --, the people that were at that clinic, John Beasley, Bill Schibel, Jim Damos (?), all would kind of pester me, why don’t you try this fulltime? And I said, well, I really like my small town practice in Darlington. I get to do --. And I really feel like I’ve got a place in the community. And they said, well, we’ve got this other practice that we’re kind of starting up down in Belleville and it’s a small town and we’d really like to see it grow to the point where we could have residents there and make into their rural experience like the Madison program. And after about four years in Darlington, that’s what happened. I left with some considerable sadness because I’d had a number of friends and colleagues that I really didn’t want to leave. But I also realized that to be able to do the other kinds of things that I wanted to do in terms of teaching and trying to fix that system. And that was just going to be more possible in the context of a university job. So in January of 1987, having started in Darlington the summer of ’93 … Started at the University of Wisconsin. Half of my job when I started was being at Belleville. And that would also include being on our inpatient services, delivering babies, teaching residents. Well, the residents I was really teaching at -- because it took a while to build enough of a practice volume at Belleville to finally having residents. There were about a half dozen after I arrived. And then the other half of my job was in what we call the pre-doctoral or medical student division of our department. And John Beasley had started a twelve week -- elective, it was called, where we weren’t at the place where we had enough political clout in the medical school to require students to take an experience in family medicine but John put together this three month, which was a long time, program that basically students did in the senior year. And you really had to want to do it because it messed up people’s schedules to no end, to have that experience. But it was an amazing experience. We’d go out for three months a very busy, usually rural family doc. And they would come back from those experiences saying, man, I delivered more babies than I did when I was in OB and I participated in more surgeries than I did on surgery and set more fractures than I did in orthopedics. So they just had this amazing experience. Well, my job was to ride the circuit. And I would go around and sit in and watch the student with the patients, watch the student with the local faculty preceptors that they were working with for those three months.        \n\nAnd looking back now, it probably was what was set into motion, what became later one of the most valuable things I’ve done in my career. Which was with all the different leadership roles that I’ve held in the U.S. and internationally, I’ve always made it a point, when I’m traveling, to sit in and watch a doctor in his or her practice, wherever they are. You know, wherever I am visiting them. And that’s been an amazing experience to see now more than 5,000 consultations in more than fifty countries with more than 500 family docs, how family medicine gets practiced around the world and across the U.S. And as I think back on it, that’s probably where that interest first was sparked, was this chance to kind of circuit and watch students and faculty preceptors together with patients.\n\nDr. Ostergaard: I’ve had the privilege of seeing you, seeing those practicing doctors in many of those fifty countries. And I’ve always been impressed. And we will come back to one of them, as I alluded to earlier, that experience you had in Tajikistan. \n\n(Break.)\n\nDr. Ostergaard: Today is Monday, January 18, 2016 and this is Dan Ostergaard doing an oral history with Dr. Rich Roberts in Madison, Wisconsin. And this is the beginning of Side 2. We just completed an hour tape of Side 1 and now we’re doing Side 2 for a second hour of this time to visit together. So picking up where we left off, just another quick comment from you, please, about the National Service Corps. When you were in the NHSC private practice option in Darlington, were you a civil servant, a commissioned officer, or were you paid by Darlington? How did it work?\n\nDr. Roberts: Well, the private practice option, at least in those days, meant that you were, as the name implies, completely on your own. In fact, in some ways you were disadvantaged financially by virtue of the fact that you had to accept medical assistance, you had to accept Medicare patients, you had to write off bills that people couldn’t afford to pay. And that created a little bit of a concern among the partners that I were joining because they had a private practice and they had to pay the bills and cover the overhead. But we managed to work that out. There were some times when my check didn’t quite look like theirs did because they had to write off certain visits, costs and things for patients that weren’t in a position to pay. Whereas if I’d have been in the civil service, I would have gotten a paycheck regardless from the federal government. But part of my interest was I didn’t want to go into a community and potentially be a competitor to the other private docs in the community by having a federal paycheck. I wanted to be able to kind of stand on my own two feet, so-to-speak, in terms of practicing as just another member in the community, another member of the medical community. And I think for me that was a wise choice. I certainly didn’t think any less of people that decided to go civil service or the uniform service route. But they tended to practice more in National Service Corps inbound, in usually community health centers where it was, what we call it, FQHC, Federally Quality Health Centers. And Darlington not that. It was a very underserved community in the state, in a very rural area. But it wasn’t an FQHC at the time, so I wouldn’t have been able to go there as a civil servant. And what we liked about Darlington was I liked the community, I liked the people. It was a little more than an hour to our extended families, which made that nice. So that was all the things that went into my having them as plan B when the whole Arizona thing fell apart as we talked about on the previous tape. \n\nDr. Ostergaard: So when we left off Side 1 you were talking about the transition into the circuit riding you did between the Verona existing residency and the beginning one in Belleville. Just a little bit more, please, about that. And then when and how much did you start working actually on the campus. I know for many years you kept a rural element to your work but you did more teaching as time went on. Tell us about that.\n\nDr. Roberts: Well, I think most academic family physicians tend to lead pretty complicated lives in terms of where they’re physically located. And that was not unique to me. I mean it was crazy at times. So after about two years in the department … In fact, just, again, a couple of quick anecdotes about the making of a young academic family physician: So my department chair when I first joined the University of Wisconsin faculty full time was Gene Farley. And Gene was there from ’82 to ’92 as a department chair. And Gene, for me, was this kind of wonderful mentor about people. And his leadership style, I used to say he led by -- in motion. He would kind of recruit good people, then he’d just hook them onto each other and whatever happened, happened. I’m sure he probably had a method to his madness. It was never obvious to those of us that worked for him. But Gene had this uncanny ability to really nudge people in the right direction even though they didn’t know it at the time and to see potential in people. And the other thing I always appreciated about Gene is I would lead a meeting with him … You know, sometimes you’d get called into the chair’s office and I was a little nervous about that … But I would always leave those meetings feeling better about myself and feeling very upbeat and positive about me and about the department and about the world. Gene taught me some important lessons about leadership. So one of the first things he had me do … You know, I’m only in the job a month or so as a fulltime faculty. He says, I’d like you to spend this summer in Hamilton, Ontario. And I said, Where the hell is that? So he sent me to what was then maybe the first or second what was called Critical Appraisal Workshop which really in many ways became the genesis of the Evidence-Based Medicine Movement. Brian Haynes and Dave Sackett (?) were at McMaster in Hamilton, Ontario teaching this thing and it was a wonderful two months or so that we spent there. Very intellectually stimulating looking at the limits of evidence, the kinds of evidence. You know, how do you develop guidelines. On and on. Brian stayed at McMaster for many years. Dave Sackett went on to Oxford. And that really set me on a trajectory in terms of my own academic work around guidelines, then quality improvement, then practice redesign and patient safety. So many things came out of that summer. And another thing that John Beasley, who was the head of our pre-doc program, and Gene Farley had me do was go to the University of New Mexico for a while. I spent three or four weeks there. Because they had this thing called the Problem-Based Curriculum that they were really the first American medical school to take up. Which I think it started in the -- or --. Then it went to McMasters, then it came to the U.S. And so I spent a few weeks there watching what, for me, was this extraordinary learning environment where you’d have everything in small groups. And you’d have a primary care doc sitting with a basic scientist. They would with a case, a patient with this problem, and he’d work all the way through the neuroanatomy and the physiology and the pharmacology and everything kind of around one problem, one patient – which I thought was terribly exciting. And one of the deals that Gene had struck with the dean of the University of Mexico in exchange for having me come there was I was supposed to write up a little report about it and debrief the dean at New Mexico because this was kind of a brand new thing for them too. They were a fairly new medical school. And so I presented my findings to him, my reflections to him, and I said this is great. This is such a wonderful place and it’s so exciting to see what you guys are doing around a small group of problem-based learning. I said you should be doing this everywhere. And he said to me, Well, you’ve got to remember, even though we’ve got a new medical school and a new curriculum, it’s staffed by old faculty from the medical school and it’s been a real uphill climb and a challenge of really trying to transform medical education curriculum. But that was another, for me, formative experience because I was thinking about educational methods at the same time that I was learning to become a teacher, at the same time that I was continuing to be a busy clinician. In those years I was in Darlington, I was a busy doc. I was cranking 100 patient visits a week. It was long hours but I actually loved it. I loved doing the clinical stuff. And so I still kept very busy clinically. I never, ever, in the near thirty years, twenty-nine years, have left Belleville. I’ve been there all that time and that’s where my practice has been at as part of the university. And that, for me, has kind of been my centerboard, my keel. I always had the patients at Belleville that I took care of over those many years. And as that practice grew, then I was able, after a few years, to shift my staffing of precepting time from Verona, where I had been, to Belleville where we now have residents that were part of the Madison program. So that was part of that transition that you asked about Dan. Then the other thing that happened early on in my career, in some ways, looking back, probably earlier than I guess I wish it had. Not that I’m regretting it, but it probably happened earlier than I was really ready for. I started kind of getting into the leadership thing. I was the Belleville director of medicine. Then pretty soon we had four divisions – research, pre-doc, graduate, post-graduate, residency. And the other one was community outreach and development or COD, which I used to call the fish department, COD. And Gene asked me to be director of that. And one of the things that was interesting with that, which I had, I think, from about ’89 to ’92, was we started the National Center for Correctional Health Services. We had a very nationally known guy, Armand Stark (?). Armand was a pediatrician who had been medical director in --, Oklahoma for their statewide prison systems and came up to Wisconsin. Again, this was partly Gene’s very kind of creative expansive way of thinking about healthcare and recognizing that 90%, 95% of inmates get back into the community and they deserve good healthcare when they’re incarcerated. So Armand started this national center and we had a contract. He was the medical director of the Wisconsin State Prison System. But we also were trying to do academic stuff, research and things in that area and I learned a fair bit about correctional health. Armand was a curious guy because he had a tendency to get himself crosswise with the powers that be. So, for example, he was interviewed a couple of times on matters relating to people being incarcerated for drug offenses; you know, people had been in prison for possession of marijuana, cocaine, whatever it was. And he was basically saying, look, we have so many of these young men who are in jail for not violent crimes, because they have a medical problem, a drug addiction. And we shouldn’t be putting them here. It’s a waste of money. They’re going to be out in the street. They really need medical treatment. And our politicians of the day, including Tommy Thompson, our governor at the time, wasn’t very happy to hear that. So Armand essentially left. But it was, for me, a kind of interesting experience to learn a little more about that. (Inaudible.) And then from there I was becoming probably half-time seeing patients, staffing, supervising residents at Belleville, doing some medical school teaching. But then the other half time became department chair when Gene retired in ’92. Did that for a year as the interim. \n\nDr. Ostergaard: So when Gene Farley retired, you became interim chair, I remember, for how long?\n\nDr. Roberts: It was just about a year altogether, ’92 to ’93. \n\nDr. Ostergaard: You spent a lot of time up in Madison then?\n\nDr. Roberts: Yes, very much so. And I was beginning to kind of transition that way more and more because so much of the stuff I was doing as a division director before that had me in Madison. So I was probably two to three days a week at Belleville, on a typical week, seeing patients. And then maybe another half day or so supervising residents. And then I was two to three days a week up in Madison with the department either doing divisional directorship stuff or later chair stuff. The department chair position at the University of Wisconsin is a little different than some departments and that is it was a pretty far-flung department. We had what we called campuses in Milwaukee, Appleton, Eau Claire, Wausau, each with a residency and some of them with several training sites including ultimately rural training tracks like Augusta off of Eau Claire. And one of the things that I tried to do was ride the circuit. So I would go around regularly to each of the campuses and not only meet with the program director there and often the hospital leaders that they were interacting with but also the residents and certainly the faculty there. And I would try to supervise or staff a session with the residents. Often would try to take call. I would spend the night in the hospital just kind of shadowing the residents, watching them. I did that a number of times in different settings around the state, with the programs that we had around the state. If I remember right, I think we had back then around a $60 million or so budget with about 150 residents and fellows. Actually, about 150 faculty and fellows. About 150 residents, I guess, too. Roughly 500 employees, 600 to 1,000 patients or something like that. So it’s a pretty big operation. The Madison campus was probably half of that. So it was the first and it was also kind of the biggest in terms of numbers of people and budget. But the other thing that I should probably share to give you at least my perspective and a candid history on our departmental origins that, again, had an effect on me was the department really got started in about --. There was a pediatrician at the University of Wisconsin, Mark Hampton, --, who had been trained out of Harvard but he was from Wisconsin originally. Had been exposed to something called the Family Care Program that Harvard had. Believe it or not, Harvard had an early residency program in the sixties for what ultimately became family medicine. And Mark was impressed by that and wanted to start something like that in Wisconsin. And our folklore was that he went to the university hospital and to the dean and said I’d like to start a family medicine residency training here, because he was a tenured (?) member of the faculty in the department of pediatrics. And basically got laughed out of the place. So he went across town to St. Mary’s Hospital where Sister Rebecca was a very smart CEO and said, well, maybe if we train those young doctors here and treat them well, when they go to the surrounding communities they’ll be sending their patients later. And that’s exactly what happened, lo these forty years later. And so we started as a residency program, then shortly thereafter a department, who to some extent were kind of persona non grata in the university. And we had a department headquarters, and still do, that’s two miles away from the rest of the medical school and that’s continued to this day. In fact, interestingly, then assemblyman Tommy Thompson’s first successful legislative act was to create a funding slot, a dedicated line item in the state budget, to create the department of family medicine. It was called the Department of Family Medicine Practice then. And he later became Governor Thompson, then he later became Secretary of HSS Thompson in the first term of George W. Bush’s presidency. So the department, as I say, had this something complex history and that reverberated over time. So the first chair that Mark Hampton brought in was a guy named John Renner and John Renner was a character. John believed that the way you kept docs in small towns is you trained them up near where you wanted them to practice. And he was also a train enthusiastic, so he had this idea that he’d send (and all the states were, of course, connected by rail) … He’d send a different train each week to these small towns with the cuisine or the month or the cuisine of the week on the train. So this week it might be French cooking, that when they pulled in the restaurant car to your local town, or Chinese the next week or whatever it might be. Those were some of his ideas about making small town life attractive for young family doctors and their families. But John also had the habit of provoking the authorities. So with this philosophy that we needed to create more training programs across the state, he got one going in Milwaukee and pretty soon he wanted to get one going up in Wausau. And the story goes that he’d go to the dean and he’d say, hey, Dean, I need $1 bucks to start a residency in Wausau. And the dean would say, you know, go soak your head in Lake Wingerjon (?) which is right near where St. Mary’s Hospital was. And pretty soon, the next thing you know the dean is getting a phone call from the co-chair of the joint finance committee of the legislature who happened to be from Wausau saying, hey, dean, what about this $1 million we’re giving you guys to start a residency in Wausau? So Dr. Renner did this one too many time and got fired. And then a fellow named Bill Scheckler came in as interim for two years and then was sort of permanent for two more years. But Bill Scheckler, by training a general internist, used to call himself an incomplete trans-family physician, which I loved. And Bill did a good job and he was a very organization kind of guy about getting thing just right organizationally and I think was really helpful to the department at that stage and, also, I think helped mend some of our fences with the university, the medical school, which was good. Then Gene Farley came in and succeeded Bill. But just an examples of sort of this continued sort of back and forth. You know, Bill apparently one day wakes up to find that the dean of the University of Wisconsin has cut a deal with the dean of what was then Marquette Medical School which was intent on getting state funds so it could become the Medical College of Wisconsin. But had to have a family medicine presence to do that, so suddenly our Waukesha residency program that we helped to start wasn’t ours anymore. It was now belonging to Medical College of Wisconsin. And apparently the chair of the department of family medicine wasn’t even, as I understand it, consulted. Just sort of read this in the newspaper. That was the kind of stuff that’s gone on back and forth over the years. Now, again, this all may be a revision as history. I wasn’t a part of it. But that’s part of our kind of departmental folklore and helps to shape, a little bit, our perception of things, I think. \n\nDr. Ostergaard: I’d like to get into your leadership because you mentioned a few things all the way back that had an impact on your leadership. But at the university you started getting more into leadership and becoming chair of committees and then you were the interim chair. How did all that factor in to your ability to become a leader first at the commission and committee level and then at the board of directions and then finally president of the AAFP? I mean how did all that work?\n\nDr. Roberts: Well, I’m not sure. If you talk to my wife, probably not well because I’d always been a pretty energetic workaholic. I mean I went back to working two jobs while I was taking too many credits as a college undergraduate, trying to play intercollegiate football. I just kind of got on that treadmill with too high a speed and just kept running. But it didn’t feel bad to me. I mean I felt like I was doing this great stuff, that was really kind of wonderful stuff. So what happened back in my Darlington years was when I got there, within six months I became the president of our local chapter of the Wisconsin Academy of Family Physicians, of the local chapter of the Wisconsin Medical Society and the chief of staff of the hospital because nobody else in the community wanted those, so the new guy always got that, right? So I’d been in town basically six months and suddenly I’m leading everything. And they weren’t things that I was seeking out. They were mostly things that other people were looking to let go of. \n\nI’ve got a quick story about self-found practicality. So two of my partners were farmers. Both of them raised sheep, Drs. Linadoneon (?) and Bolson. So when we would have a partnership meeting, especially if it was the summertime, we’d meet like at 5:00 in the morning because that way they could still get out into the fields for a couple hours before they started seeing patients. And we’d meet and we would do the practice partnership meeting followed by the hospital medical staff meeting followed by the Wisconsin Academy Chapter meeting followed by the Wisconsin Medical Society Chapter meeting. And the whole thing would be done within twenty or thirty minutes. Talk about efficient – we really moved through stuff. And, again, I think some of these older, wiser family docs taught me something about kind of you’ve got to keep moving. The need is out there. The demand for what we do is such that you’ve just got to keep moving. You can’t get all caught up in the bureaucracy of it. Get the decisions made and move on. And we certainly did. And so I took some of those lessons with me at the leadership posts. So what happened was I was kind of living several parallel lives. I had my practice, my clinical home and centerboard. And then I had the stuff I was doing, the teaching, the administrative leadership things. But then I had a third life that was medical politics. And so I pretty quickly … What happens, you find as a physician lawyer, is you get dragged into all kinds of stuff. So one of the things I got dragged into was the district attorney for our area, the Dade County area, was very close to indicting several physicians for failure to report child abuse cases. You know, children that they had evaluated. And the law was still a little bit fuzzy on exactly what those responsibilities were. So this was a big deal political thing. And so the Medical Society could be the taskforce and I was asked, as sort of the young up and comer, to chair the taskforce. And that gave me a lot of experience around child abuse issues. And that then led me to move into Wisconsin Medical Society politics, eventually becoming president of the state Medical Society in 1994, ’95. And I also, a couple of years before that, had been president of Wisconsin Academy of Family Physicians. And I can remember the then executive director of the Wisconsin Academy of Physicians, a wonderful man named Bob Herzog, had sat me down right after I had gotten to Arlington and said, hey, you know, you should get active in the Wisconsin Academy. I said, oh, yeah, I’m going to do that. Sandy Blume told me to do that right away. He said, you know, you’re going to have to make a decision about whether you want to become president of the Wisconsin Academy of Family Physicians or president of the Wisconsin Medical Society because those are jobs that take a fair bit of time. And I said, okay, I’ll go the Academy route, which I did. But I went through that so quickly that a few years later I became president of the Wisconsin Medical Society after having been their speaker for a number of years, which I really enjoyed. So I had kind of that third life, Dan, that continued on. And then at the same time that I was completing my Wisconsin Medical Society activities as president and past president, that’s when I went on to the AAFP board at the national level as vice speaker. And had a wonderful almost ten years there as vice speaker, speaker, president-elect, president and board chair --. So it was almost my third life. But it always felt sort of interwoven with the other stuff I was doing. For instance, Jim Gables, one of my colleagues and partners at the University of Wisconsin, had this idea about the need to create sort of a standardized approach to obstetrical emergencies because his belief was that for many family physicians it was that rare but catastrophic, you know, post-partum hemorrhage or -- or whatever it was that was scaring family doctors away from delivering babies. I think he had a lot of small town practice experience to base that on. And so he and John Beasley primarily got started this thing called ALSO, the Advanced Life Support in Obstetrics program, which many of us in our department helped to put together. We all had several modules we put together. But we realized a couple years into this that this has potential to go beyond Wisconsin but we didn’t have the capability in terms of either resources or -- to make that happen. So I entered into negotiations with then Mike Miller who was the general counsel for the AAFP and eventually the ALSO program came under the Academy’s wings and it’s been there for the last twenty years and it’s been fabulously successful. And the way I like to say it is if Jim Damos was the mother and John Beasley was the father, I was the awkward chair that kind of helped kind of give birth to this idea of a standardized approach to obstetrical emergency. It had a very family medicine or tone to it. It was more than just getting the baby out. It was dealing with an unexpected fetal loss and dealing with the social and psychological issues as well as the medical issues. So I’m quite proud of my small, small role in that process of getting this thing from an idea that we had here in Wisconsin to the rest of the world. \n\nDr. Ostergaard: Rich, I was going to get into it also because I had the privilege of talking with John Beasley for a couple of years about that. And then Mike Miller and I flew up to Madison while you were interim chair and we, for 10,000 AAFP dollars, bought it from the University of Wisconsin. And you were interim chair at that time?\n\nDr. Roberts: Exactly. \n\nDr. Ostergaard: And what year was that?\n\nDr. Roberts: I think it was signed off on the Spring of ’93, if I recall correctly.\n\nDr. Ostergaard: That sounds pretty much right. You and Don and Jim Damos deserve a tremendous amount of credit because that has had, as you well know, such a worldwide impact on mothers and children and midwives and the -- professional nature of taking care of mothers and babies.\n\nLet’s talk just a little more about AMA because you said you were state Academy president first, then you moved to the Medical Society president. Give us a little bit about your leadership beyond Wisconsin, in the AMA, and then we’ll come back to AAFP when we have time – because you were president of AMA as well.\n\nDr. Roberts: So during my activities with the Wisconsin Medical Society … You know, you start attending AMA functions when you’re kind of coming up the leadership line, certainly as president-elect, president, even as speaker, I was going to AMA meetings. And there were a couple of things that I think for me that made that especially meaningful. One was when I became president of the Wisconsin Medical Society we had had, right around that time, in the mid-nineties, several highly publicized accidental shootings of children in our state. And we’re a state that has a lot of hunters. If I recall correctly, something like a third of the adult population, male and female, are out in the woods during deer hunting season, so it’s an important part of our culture and a lot of people, certainly in my practice, are used to having guns and shooting and things like that. But I was concerned that we had these terrible tragedies and couldn’t we do something about this, coming at it from a medical perspective. So one of the things that I did in my inaugural speech was talk about these shootings and proposed an initiative called Child Safe, a health initiative with local doctors for safety and firearm education. And what people remember Child Safe for is mainly the thousands and thousands of trigger locks that we gave away free at different events. You know, sometimes they were gun safety courses, sometimes they were local county fairs, things like that. And actually there was a lot more to it than that. We developed our resource library, we had a speakers bureau that we developed where physicians across the state would talk to school groups or youth groups or hunter safety groups on gun safety. And, again, there are always valuable lessons you learn as you go through life, but part of making the world change, it’s not only about the ideas we have, it’s about who we know, it’s about getting the resources to make it happen. And it just so happened that when I gave my speech the then CEO of the Blue Cross insurance company in Wisconsin, Tom Hepne (?) came up to me and said, boy, your speech really moved me, it really got to me. And he said just two weeks ago we had an employee shot and killed in our parking lot in a failed armed robbery attempt after hours. And basically he said, What can I do to help? Well, they put $100,000 to get the thing going. So Child Safe took off and went beyond my tenure as president and past president. I think -- for another half dozen years to try to deal with the issue of firearms safety. And that was a really enlightening experience for me because, you know, when you bump up against the politics of gun control and the politics of the NRA … And we were trying to be careful. The message we were trying to send wasn’t so much anti-gun, it was anti-killing people and trying to, in fact, preserve the right of people to hunt and the things that were very important in our state, but to do it in a way that was safe and meaningful and at the very least protect the children - but hopefully each other. And I actually met and made a lot of good friends on the NRA side of the fence because they, I think, felt I was sincere, and I was, about allowing them to continue to do what they wanted to do, but at the same time to try to make their hobby, their avocation, safer. So we got a little bit of flack through the media from people that would call in or people that would show up at an event. But for the most part even people that were gun owners were pretty supportive. And we partnered with them. NRA’s got a program called the Eddie Eagle program to teach gun safety and we were very supportive of that. So that was, for me, in terms of my political education, another kind of important experience. And through things like that and my growing interest in evidence-based medicine, I got involved with a number of American Medical Association committees. So I’m showing up at AMA meetings, both the annual and the mid-year meetings that we would have with the house of delegates. But I was also now starting to serve on a variety of AMA activities. They had a whole Guidelines Initiative, a Practice Parameters Partnership. You know, AMA has always got committee upon committee upon committee and I served on a bunch of them, but mainly in the quality, evidence-based medicine and practice improvement areas. And I enjoyed that. Again, a great thing for me with these experiences I’ve had is, you know, those of us in healthcare are all in this together. Sometimes I think as family doctors we can get a little isolationist, you now, what we do is so special – and it is. But we don’t do it in a vacuum, we do it in the context of a larger health system. And my years of active involvement with the AMA really helped me connect with a lot of wonderful doctors all across the country, of all specialties, and we shared a common commitment to serving the people better and providing better healthcare. And those things remind me of this greater mission and calling that we all have as physicians and that we cannot be too parochial (?) as family doctors, which sometimes I think it’s easy to be because you never feel sufficiently loved or recognized, I think, many times in primary care. But the AMA is a great way to learn those lessons and I still have a lot of very fond memories of the people. I was probably really active with them for about fifteen years. I stayed on the Wisconsin delegation to the AMA even after being on the AAFP board. Often times some of the senior leaders on the AAFP board become Academy delegates to the AMA. But I thought it was important. I didn’t want to give up a seat as a family doctor from Wisconsin because you might potentially lose another family doctor voice. I knew all the Academy delegates to the AMA were going to be family doctors but I couldn’t because sure of that from Wisconsin. Wisconsin was always very supportive of me, which I very much appreciated. Even when I was so involved with the Academy board, my schedule was kind of nuts sometimes trying to be part of the Wisconsin delegation. I was always running between meetings or missing a meeting or part of a meeting here or there. But people in all the groups I’ve been involved with have been very sort of kind of forgiving of that craziness of the schedule that I had.\n\nDr. Ostergaard: Having been part of the AAFP delegation to the AMA during that period, we very much appreciated your role at AMA as a Wisconsin delegate. That was very, very helpful for the reasons you just said as well as your own innate talent and ability to work with all the different specialties.\n\nLet’s talk about the Academy a little bit more, we’ve touched on it many times. But what compelled you, what drove you to be president of a national organization?\n\nDr. Roberts: I think what happened for me was I served on a commission at a pretty early stage in my career for the AAFP. I was on Legislation and Government Affairs as a second year resident. I’m not sure, Dan, if you were part of the selection process way back then in 1982 … Yes. But if you were, I suspect that part of what made me attractive as a resident candidate for that commission was just my law background, my interest in malpractice and my interest in legislation and those sorts of things back then. And, for me, getting on an Academy commission, I was like a kid in a candy shop. I mean this was hog heaven. It was working on issues from the perspective of a family doctor with fellow family physicians in the setting of a great organization like the Academy well I felt very proud of what we did and what we said and how we behaved and at the same time I was able to work on issues that I had great passion for in terms of legislation and things like that. So that, to me, was like heaven. And that was also part of what prompted me to engage the Wisconsin Academy as soon as I finished my residency training and got to Wisconsin. It wasn’t so much that I had set in my mind I’m going to be president of the AAFP someday. I actually never … It may be hard for people to believe, but I haven’t looked at things that way. I’ve never said, oh, I’m going to work towards this or I’ve got this goal in five years. Maybe it’s just dumb luck. Maybe I’m fooling myself, I don’t know. But I’ve always been able … There’s always been another thing to do that really looked fun. And sometimes I was asked or sometimes it just seemed like the right next step. And that’s kind of how it was for the Academy. So I had such a great time being the speaker of the Wisconsin Medical Society that I thought when the vice speaker position was going to become open in ’94 I thought that would be great fun, let’s go do that – and so I did. Truth told and if you talk to any past speaker for the AAFP, it’s the best job in the world. You feel like you’re a traffic cop at an Italian busy intersection, trying to keep all the cars from crashing into each other. And it’s the best seat in the house. It’s incredible fun. You get to know everybody. Also, I like to describe politics as my second favorite sport because in that role you really learn the art of politics because on the one hand the parliamentary process has a formality to it, a language to it that sometimes can be off-putting. To some people it feels a little artificial or contrived. But there’s a purpose to it actually. It helps with the orderly movement of the business. But most importantly it helps to preserve the rights of the minority while still allowing the rule of the majority to be manifest. And that takes an art to do that and to still keep everybody feeling good about being there. And for me it was a wonderful, wonderful chance to do that. And working with people like Neal Brooks and Michael Fleming. We were like the Three Stooges with our various times up there because it’s got to be partly entertainment and it’s also got to be obviously serious business. But you want to make it fun – and for me it was. It was just great. It was just fabulous. And, certainly, being president was a really life changing event for me. It took me to kind of a whole other level of engagement with health issues and people both in the U.S. and abroad. But what got me going onto that pathway was really the speakership – and, still, with that kind of a great fondness. That’s probably why they continue to ask me to come back as parliamentarian, which I consider a great privilege, just because it’s the best seat in the house. \n\nDr. Ostergaard: Yeah, you have been up there on that dais, I’m sure, longer than any living human with the possible exception of Doug. But I think you have him beat because how many years have you been parliamentarian now since you left official leadership?\n\nDr. Roberts: Well, pretty much all of them, so that’s about fourteen or fifteen years. I think I’ve been on the podium now, nonstop, for something like twenty-two years. They will either push me off the table eventually or the coroner will come to declare me, I don’t know - but it’s been great.   \n\nDr. Ostergaard: Let me go back to something you said. You said that, and correct me if I’m not interpreting this right … You said that really you didn’t have being the Academy president as the goal way back then. It was that you saw other things that needed to be done that looked contributory and fun and you just went after the next one as they became available. Is that a fair way to say it?\n\nDr. Roberts: I think that’s a pretty fair way to say it. Let me tell you a bit of an -- story to make the point. When I was Wisconsin Academy of Family Physician’s past president you also were the board chair and you were the chair of the nominating committee. And that year that I was in that role, which I think was about ’90 or ’91, the person that, if you had followed tradition would have logically been the new delegate from Wisconsin to the AAFP Congress of Delegates was a doctor from Platteville, Chuck Sidinger (?). Chuck was a wonderful guy. He’s passed away now. So we’re at this nominating committee meeting and several of us are on the nominating committee obviously. And Chuck, at one point, whispers something to one of the other people at the table and this guy says to me, Oh, Rich, could you excuse yourself for just a second? And I thought, well, that’s kind of weird, I’m chairing the committee as the board chair. What’s up? I said, okay, sure. I came back into the room and the group announced you’re our choice to be the new delegate to the AAFP Congress of Delegates. And I said, What are you talking about? And I said, Chuck’s, it’s his turn. He’s the alternate delegate, it’s really his turn now and he’s earned it. I mean he was our president, he’s been at this a long time. And Chuck said to me, No, I really want you to do this because you’re going to be able to carry the banner higher than any of us could. And it still kind of chokes me up to think about it. And I didn’t quite know what to say. I mean if you’re a politician, it’s unusual, in my experience, for one politician to say to another, you do this. Even though he’s earned it, he said, no, you do this. I want you there. And that’s how I got onto the national stage as quickly as I did as a delegate. It was totally unexpected. I was prepared to kind of put my time in, following the traditional ladder, you know, taking a while to get there. But it was Chuck’s really very gracious insistence that had me doing it before I ever imagined. To me, there’s always been a bit of a philosophy of the organization which is yeah, we’ve all got egos and all of us have leadership potential, but as you understand the family medicine movement, you understand that in part it’s about people putting aside their own ego, their own ambition, to advance the cause. And that’s what it felt like when Chuck was saying what he said that day. And as I said, it got to me then and it still does, thinking about it.\n\nDr. Ostergaard: That is an amazing story because in all politics, Academy and AMA medical politics, at least, the Academy and AMA, it’s always wait your turn. So to see a leader recognize talented leadership ability in somebody else and forego one’s opportunity is really, really special.\n\nDr. Roberts: Well, for me. And, again, it’s taught me some very important lessons about that. And they’re never easy lessons. When the speaker and vice speakership I had people come to me and say, boy, you really seem to handle the bait well from the floor. Are you interested in doing this? And I said, well, gee, I’m only a couple of years as a delegate, it’s not really my turn yet. And I don’t want to be sounding like the guy who’s always talking to each job because a lot of the jobs I was thinking, man, this would be great to do. But I was trying to be circumspect enough to say, well, it’s not really my turn yet, you need to follow tradition. Part of why that happens in medical politics, as I thought about this, Dan, at some length, is one of the things you have to be careful about in medical politics is that our jobs, our lives as physicians, they’re hard. It’s hard work and it’s stressful and it’s intense and not many people are able or willing to give the extra time to work in medical organizations, whether it’s AMA or medical societies or the Academy. And when people do, when they are willing to put in that time and to participate it’s really important. It’s important for the profession, it’s important for our discipline, it’s important for the people that we serve. And then when they go the extra step of putting themselves forward as a candidate, that becomes a big deal, that person saying to the group, I’m willing to give of myself, my time, my time away from my family to do this, it’s a sacrifice. And any politician, I don’t care what office you’re running for, you never feel more naked than when you run for office. So I think part of the reason for the tradition of kind of waiting your turn was that when you have things like contested elections and some of the hurly-burly of politics you can get into with campaigning, you’re going to have some people whose feelings get hurt or who get embittered. And not only do you lose them as a potential officer but you may lose them as an active participant in the process because they don’t want to come back again because they’ve got plenty going on in their lives, they don’t need to do this, you know. So I hope I was never perceived, at least I never saw myself as somebody that was sort of jumping in inappropriately and pushing somebody aside because it usually seemed to me that people were either inviting me or nudging me to try the next thing and that’s kind of how it played out. But once you get on the Academy board there’s just this sort of natural progression or flow from, you know, if you were a director in those days becoming board chair, becoming a candidate for president-elect or vice speaker to speaker to candidate for president-elect. So that’s just kind of how it played out. \n\nDr. Ostergaard: How many years were you vice-speaker and then speaker before you ran for president?\n\nDr. Roberts: I was vice-speaker, I should look at my CV. I’m embarrassed, I don’t remember the exact years. What I can tell you is I know that I was president from 2000-2001 which means I was president-elect from ’99 to 2,000, which means that I was speaker probably, I think, from ’97 to ’99 and probably vice-speaker from ’94 to ’97. Something like that. I learned a valuable lesson from one of my colleagues from Wisconsin, Richard, Dick Shopshier (?) – and, again, you learn politics, just like every other human endeavor, there’s a science to it and there’s an art to it. So one of the things I think that happened to Shrop (?), as he’s professionally known, was that he had been speaker for four years. And what can happen when you’re up there doing this kind of high wire performance art trying to keep everybody happy, trying to keep the debate flowing but at the same time not trying to duck hard issues because that’s ultimately where the voice of family medicine on hard issues gets spoken – you know, you can also make enemies as well as make some friends. And I think what I learned from what happened for Shrop (?) was that he may have just outstayed his welcome as speaker. So I was very sensitive that if I was going to run for president-elect, I didn’t want to be up there forever and potentially have folks that were saying, well, you’ve outstayed your welcome. So there are political lessons all along the way that I think I’ve learned from others’ experiences.\n\nDr. Ostergaard: What was your most important activity or accomplishment as president? You mentioned, on side 1 of this tape, your presidential awards, as to who you gave your awards. What did you consider to be a major accomplishment or plural of your presidency of the AAFP?\n\nDr. Roberts? This is going to sound perhaps a little too fuzzy, but I think what it was, was giving family doctors hope. And what I mean by that was our discipline has gone through ups and downs over it’s forty-some year history as a board specialty and at the time I came into the president role we were on the downhill side. So our match of first year residents peaked in ’95, when I was on the board. I think we had like 3,000-something that year – and it was sliding thereafter. And part of that was tied to the changing economics of the U.S. health system. So in the late eighties, early nineties managed care was all the rage. Everybody needed family doctors and primary care physicians. Our salaries were skyrocketing. Every student applying to medical school would always write down in their ambitions application, I want to be a primary care doctor because they were sure that was going to get them into medical school. And then there was a pushback against managed care and sort of dumb things done by managed care companies and primary care got painted with that brush and student interest began to plummet and we were on the downhill side of that. And I can remember in ’98, ’99 the leadership of our discipline saying, man, we’re really in a funk; maybe family medicine was a great idea but maybe now it’s become a quaint, an acronym and should just go away. And out of that came the Keystone meeting, Keystone III, which you and I participated in, and the Keystone III meeting, we didn’t come up with a lot of answers during that weekend in Colorado but we came up with I think a number of questions that were quite important about what the future might look like. And out of that came the Future of Family Medicine Project which I was very intensively involved in and we might want to keep to the next tape because I have mixed feelings about the effect of that over time as the family medicine initiatives and recommendations continue to play out. But all of that was swirling around us where we were asking questions like should family medicine go away or we’re really doing okay, all we need is some fine tuning or, no, we really need to be doing something new and dramatically different. Which I thought those are all really important questions to be asking. I think one of the realities for family doctors is that we’ve always been … We’ve got our ideals – for us it’s about social justice, it’s about equity, but it’s also about being practical and what works and what doesn’t work. And if Americans didn’t want us anymore, it would be dumb for us as a community to continue doing what we’re doing. So those are profound questions.\n\n(Break in conversation.)\n\nDr. Ostergaard: So you were describing the difficulties we were in at the time you were president – and you gave the members hope.\n\nDr. Roberts: As I was saying, we had gone through this time of exhilaration in the early to mid-nineties, in the Clinton years, Health Security Act – you know, we’re going to get universal coverage. Managed increasing is increasing the demand for and the salaries of and the prestige of family doctors and primary care doctors. But the Health Security Act does not pass. There’s a pushback to managed care – you know, it kind of reverts back to fee for service medicine and specialization by the late nineties. Gordon Gekko and Wall Street and everybody’s getting money. The whole culture shifted in five years when I was on the board. So now I’m president, right? And I’m thinking to myself during the president-elect year, where you spend a fair bit of time, I think, kind of watching the president and traveling around and meeting people and attending some of these national level things, you spend a fair bit of time thinking about what are the challenges that I’m going to likely face and how can I be most helpful. And what I concluded was that family doctors needed to know it was going to be okay and that what they were doing was incredibly valuable to not only their individual patients but to the health system and to America and that we were going to be there for them. So one of the things that I did was an initiative to directly reach out to individual members. Every day during my year as president I would call a member of the Academy. And the staff used a random numbers generator off the Academy membership file, looking at their telephone numbers. And so I called one every day. Now, that was an interesting experience. Have you ever tried to get through to a busy family doctor? There are all kinds of clever ways. You’ve got to get around their receptionist, right? And I figured out ways to do that, which I’ll take to my grave. But I talked to a bunch of individual family doctors, all of whom were AAFP members. But most of them were what we call checkbook members. They weren’t active other than being dues paying members. And there were a range of responses that I got from calling them. It was like why are you bothering me, I’m too busy to talk to you, to, my God, the president of the AAFP is calling me? You know, kind of everything in between. And some wonderful conversations about where the health system is at. And the most meaningful for me was … You know, I would usually start off with tell me what your life is like. What’s your practice life like? What do you enjoy? And how does that work with your personal and family life? And tell me how this is for you. And this is another thing … Just to show you how long ago it seems, this was when we were just starting up things like list serves and people were beginning to communicate by email. And I would see on somebody’s list serve during my year as president-elect these incredibly sad stories of, you know, I was part of this group that got bought by a hospital, that got by a system that went broke, and now I’m thrown on my own. I’m thirty-eight years old. No. 1, I’m a single mother of three (this was a woman in Pennsylvania) and I’m starting a solo practice and I’m scared to death. And I managed to get her telephone number and I called her. And then to watch over these list serves, as the next year went by, about kind of the Phoenix lifting out of the ashes. And in this lady’s case, well, gee, I’ve got a really successful practice going now and I’ve never been happier. I’m able to take care of my patients like I want. It was profound from me, just watching this. And I don’t know if you remember this, Dan, but the system went through incredible chaos and tumult during the late nineties because you had hospitals buying up physician practices and then big groups buying up smaller groups and then it would all break apart. Kind of like what we’re going through right now again, like twenty years later. So as I came into that presidency year I thought, man, those poor folks out there, my colleagues in the trenches, they’re getting slammed. And they just need to know that what they do is important, that they’re valued, that we’re here for them. And so I called a member a day and it was a really good experience. If I have a regret, looking back (you know, you learn as you go along), I wish I would have figured out a better way to kind of memorialize those conversations. I should have probably even taped them or … I took some notes along the way which I actually tried to share with the Academy leadership. But I think it would have been a really useful thing, to have compiled all of those conversations into something more than what just went into my head. But I did learn, a few years later when I was doing similar conversations with individual family doctors around the world, with WANCA (?), I did try to memorialize a number of those experiences, which I know we will talk about later. So for me it was about getting family doctors … And I had one guy say to me one time, you know, you’re like the firehouse Dalmatian of family medicine. And I said, what do you mean by that? He said, any time the alarm rings you’re ready to run. And that was true because I remember I had one meeting of five unhappy family doctors in Alaska. I was on a plane to Alaska to go visit with these guys. I had one guy who was just angry, angry, angry. It was a guy down in Mississippi that was so angry with the Academy’s support of a universal coverage approach to the world that I went down and I met with him. I mean I was there in conjunction with other meetings, so I wasn’t unnecessarily spending Academy resources. But I felt it was important to let every single family doctor know, even if they disagreed with the Academy policies – hell, I didn’t agree with every Academy policy either. I mean that’s just the nature of politics. But even when they didn’t agree, to let them know that what they were doing was valuable, that I respected them, that I wanted to hear what they had to say and that I wanted to give them a sense of hope for the future because there is something so fundamental about what we do that is, in my view, essential to healing and to health that I think we too often take it for granted. I mean not us as family docs but society certainly does. And they needed to hear that that was a legacy that should not be lost.\n\nDr. Ostergaard: That’s very, very impressive. As you describe that, I do remember your phone calls and some of the trials you had with that daily phone call. But as I think back and listen to you, you did do that. I mean absolutely. You were telling people, what you do is worth it. Times may be tough but this is what society needs, this is what people need and what you do is worth it. \n\nEnd of Side 2.","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282876#t=0.0,3246.70474"}]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282876/transcript/81720","type":"AnnotationPage","label":{"en":["Dr. Richard Roberts interview transcript (2) [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282876/transcript/81720/annotation/2","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Side 1: Today is February 11, 2016, this is Dr. Dan Ostergaard, interviewing for an oral history from Dr Richard Roberts. At the moment, I am in my home in Olathe, Kansas and Rich is in Madison, Wisconsin. We are just recording via the telephone. This is in follow up to two hours of oral history that Dr. Roberts provided on January 18, 2016 and we are going to go from there. Before we start content, I would like to reconfirm with you, Rich, that you give permission for this recording to occur along the lines of the permission you signed with Don Ivey, of the Center for the History of Family Medicine. Okay?\n\nDr. Roberts: Okay.\n\nOkay Rich. We had a good visit last time and we focused a lot about your history and your pedigree and a little bit in leadership. I’d like to come back to spend a lot of time on your leadership, how you got into leadership, which you have a lot of testimony about last time. But let’s go back to AMA. We talked juts a little bit about AMA, in that you were President of the Wisconsin Medical Association. But tell us a few of the things that you did at AMA while you were a delegate from Wisconsin, working closely with those of us who were on the AAFP delegation.\n\nDr. Roberts: I was involved with American Medical Association, actually going back to as early as medical student years where there had been this separation between the previous medical student organization that kind of broke off and became the American Medical Student Association and then    you had the Student AMA or SAMA. I was interested in learning about all different -- but then during my residency years, my organizational focus was really more on the Academy. But as I get settled into practice in Wisconsin, in the practice that I was in, which was at a rural county of 17,000 people, there were basically 4 of us there, in the summertime we would start, we called it our meeting day, usually at 5 in the morning and that way we could do our partnership meeting, the medical staff meeting, the chapter of the Wisconsin Academy of Family Physicians, our county chapter meeting and then our county chapter meeting for the Wisconsin Medical Society and still be done by 5:30 so the people… a couple of my partners were farmers, could get back out in the field before they started clinic. That was to me, a real lesson in efficient meetings, running an efficient meeting. \n\nAs I got involved with the Wisconsin Medical Society, they were kind of pushing me forward to become also involved at the national level with the AMA, and I found it a very important perspective because I think sometimes what can happy to any of us if we’re spending all of our time just within our own discipline like family medicine, sometimes it’s easy to not appreciate as well as we might, the issues, the problems, the challenges that our colleagues and other specialties have. So for me, the AMA was very helpful there. I actually got first involved, back in 1990 with them, serving on something called the DATTA panel, which had to do with using data to help with technology. And then I pretty quickly moved into a whole variety of activities involving what the AMA calls practice parameters, most of us would now call them guidelines. And I did that for probably 10 years, Practice Parameters Partnership, Practice Parameters Forum and it was always an interesting collaboration because of on the one hand I was there, kind of wearing my state medical association hat but I was also a family doctor and very active with the AAFP at the national level, so often I’d be conferring with my colleagues at these AMA meetings, trying to help develop policies that make sense for family docs. I became a member of the Wisconsin delegation to the AMA in ’95 and did that for the next 15 years. And one of the things that was a little bit of a dilemma for me was, with the AAFP, the leadership of the board became almost defacto at that time, members of the AAFP delegation, the American Medical Association House of Delegates which meets twice a year and I kind of struggled with whether it would be better to do that as I was rising through Academy Officer positions, or whether it was better to keep my seat as a Wisconsin delegate and in the end I decided, frankly, to have another family physician voice and it was better for me to stay in Wisconsin because I knew all the people representing AAFP were going to be family doctors. In some ways that may have set me on a different course in regards to the AMA, in terms of whether I would have ever gone on to do kind of national office with them. But I very much enjoyed the time that I spent with the AMA. In addition to the practice parameters stuff, they had a very important project for a time, called the American Medical Accreditation program or AMAP and I was on that governing body for about 4 or 5 years. And that was almost like a precursor to similar to what we see with the NCQA and the accrediting the patient centered medical home, we were going to be doing this for all medical practice, creating the accreditation program and the policies for that work. Fascinating and challenging. But it was a good experience, I served on AMA reference committees at their annual meetings. Served on and chaired the House of Delegates Committee on Compensation of the Officers of the AMA, which was also a pretty fascinating look at the organization. So when I finally kind of retired out of that in 2009, all my AMA activities, it was really because in 2010 I moved onto become President Elect of the Rural Organization of Family Docs and I’ve always felt that when you take on these very specific leadership roles, you have to prioritize your energy, your time, to try to have maximum impact. So while those 15 years, well almost 20 actually, from 1990 to 2009, active AMA involvement, were very educational, very enjoyable, they can take up all of your time beyond patient care and all the other things I was doing, so as I moved on to the Rural Organization WONCA, it was time to step away from that. And I still miss it at time. But there were many hours that one could spend at AMA House of Delegates meetings that you wouldn’t necessarily miss because sometimes the debates got a little bit boring.\n\nThat’s an understatement. That certainly is an understatement. But I think that historically, our leaders, like you, had to make that decision about AMA heavy focus versus Academy heavy focus and you did a lot of both. My observation was, retaining your role in Wisconsin as you said, gave us an extra family medicine voice, so I think that was great. Thanks for that history about AMA. Let’s go back to your presidency of the American Academy of Family Physicians, before it we go to WONCA, which you just led into. But let’s go back to AAFP first, because we talked quite a bit about it and left that off about the time you said you were talking about, last time we talked, about the fact you called a member of the Academy every day. We don’t need to go over that but let’s talk a little bit about your leadership as president of the Academy and also, how it related to the birth then of the Future of Family Medicine project of all of the organizations of family medicine.\n\nDr. Roberts: Well, in the spirit of trying to make this as candid as I can, I’ll try to describe some of the good, bad and ugly that I experienced. To be on the AAFP board is really an extraordinary opportunity. I’ve often called it graduate school in health policy and in family medicine because you’re sitting down with all the political and really, influence leaders around health issues in the United States and that was really amazing and I was and am so thankful I had a chance to do that. One of the things that then came up as we were watching the cycle of interest in family medicine from a peak, I think of about 3,500 medical students choosing residencies of family medicine in 1995 to eventually a nadir of around 1,400 in about 2005. So when I came into office as President Elect in 1999 and then became installed in 2000, 2001 cycle, that was right as we were watching our discipline go from kind of the top of the mountain, down sliding toward the valley and there was a lot of concern in the discipline about what our future should look like and the scenarios that people were describing was everything from, maybe we were just a quaint anachronism, kind of Marcus Welby but there is no Marcus Welby anymore so maybe we should just go away. That was one scenario people seriously discussed. Another was to say, no, we’re doing pretty well, we still represent the mode of practice. More patients see more family doctors and primary care doctors than the other doctors but we just need some fine tuning. And the third was to say, no, we need to do some dramatic transformation, which is sort of where we ended up at the end of the Future Family Medicine Project.. What we did to try to address this growing disquiet and to some extent, discontent among American family doctors was to first convene a group called Keystone Treaty, Keystone One and Two had been held in the 1970s and the condominium of Gail Stevens, one of the pioneers and philosophers of family medicine and he brought a couple of other people around the table to, as I understand, I wasn’t there, but to talk about what the future of the discipline should look like, in particular, how are we going to train these future family doctors? So a lot of the curriculum and ideas about teaching family medicine really came out of that. So it seemed appropriate that we would revisit that kind of a process. It’s just that the Keystone Treaty was a heck of a lot larger, I think 150 all told or something. And out of that several day, weekend in Colorado, I think what they took away, at least what I took away was, not so many answers about what to do about the future but some really important questions that we needed to answer, like should we just go away? Do we just need fine tuning? Or do we need a dramatic transformation?  That led to the Future of Family Medicine Project, which was all seven of the family medicine organizations, the board, Society of the Future of Family Medicine, directors, association, arm chairs association, the AAFP and the AAFP Foundation, the NAPCRAG (?), which was the pharmacare research group, kind of bi-national research organization. All seven of us came together and said, no, we’ve really got to do something significant and substantial. So the Future of Family Medicine Project came out of that. It began with influence leader interviews, asking CEOs and politicians and other influence leaders what did they want, need and expect in healthcare, what role family doctors? That led to I think, about 18 focus groups all over the country. And those were playing out while I was president and one of the things that was really quite an experience was to be able to sit in on a number of those focus group. They’d have to coincide with what part of the country I was in and I could sit, they always had a one way window that you could sit with the researcher and look through and watch the dynamic of the group. And it was fascinating, it stratified rural, urban, African America, Asian America, Latino. It was really, for me, it was actually a heartening affirmation of the importance of family doctors in the lives of these people that were kind of enough to give some time to talk about these important issues. And then we took all that information and put we put that into the web base and I think some telephone surveys, several thousand people and pulled that altogether. For me, a real defining moment was, we were sitting around the board table in Rockefeller Center, board table of the company we hired to sort of help manage all of this process, -- Gail is her name. I remember them doing the presentation with all these focus groups and influence leader interviews and surveys and all of what that told us and what it basically boiled down to was what Americans said they wanted was a doctor whom they knew and trusted and who knew them. That was a really important conclusion and all these family doctors around the table, we all looked at each other and said, yeah, that’s us. So then as the conversation went on we said, well is that us? Is that us if we don’t deliver babies anymore? Is that us if we’re not in the hospital? Is that us if we really narrow our scope of practice and narrow our availability to patients? It was quite, I think a very informative meeting in that it made us think differently about how and what a family doctor is and does and the new model, we called it at the time, family medicine kind of came out of that, that was one of the six taskforces in the Future Family Medicine Project. One of the things that was really interesting for me, I served on one of the six taskforces, looking at the finances, how finances changed toward a patient centered medical home. I chaired the -- taskforce which had some real luminaries on it, people like Dave Satcher, the Surgeon General, Nancy Dickey, the first female president of our medical association, Errol Alden, former CEO of the American Family of Pediatrics, -- McDonald, CEO of American College of Physicians, there was a leader from the nursing group. I mean, people from a variety of disciplines, these task forces had folks of all different backgrounds, they weren’t just family doctors by any means. And our challenge, our task as a group was…\n\nWhat was the name of that task force, Rich? The one you chaired?\n\nDr. Roberts: The title of it was, To Determine Family Practice’s Leadership Role in Shaping the Future Healthcare Delivery System. And so no small task, right? How are you going to transform the US healthcare system to be restructured in a way that builds on family docs? Which we see in most other countries that do better than we do. So it was no small task and our taskforce 5, had these really smart people on it which had all kinds of political and other experience. And the way that we decided to do it and this was one of those ah-ha moments, was, we were talking about the need for a conceptual model and a conceptual term that people could get their arms around because one of the challenges we felt people had when you talked about family doctors or primary care was, it seems so big, so amorphous, so hard to define that you can’t really get your arms around it in the sense of, how do I support that thing? What is that thing and how can I support if I’m a policy maker or whatever? As we were discussing this, Errol Alden, the pediatrician, recounted to us the story of a couple of pediatricians in Honolulu who had children with special needs, cerebral palsy, muscular dystrophy, things like that. One of the problems they were having was that these children really needed a generalist physician to be coordinating and integrating their many, many, many other specialist services that these kids with special needs were getting and they were trying to negotiate this with Blue Cross Blue Shield and some of the other payers to recognize and pay for those services. They came up with the term Medical Home, that these children needed Medical Homes so nothing bounced around in the system. And that struck a cord with our taskforce. And I’ll share that story, we all kind of sat up straight in our chairs, we just sat there. And that’s where the term, Patient Centered Medical Home came from. What we wanted to do we didn’t want to make it about the doctors, per se, we wanted to make it about the patient, that’s why we called it Patient Centered. Now people have gotten all kind of bent out of shape all around the world as this term has rolled about because people say, it should be Person Centered, or Client Centered. Some people say it should be Health Home, not Medical Home, that’s too doctor. People now talk about their Patient Centered Medical Neighborhood so the specialists get involved. I remember the base of the AMA meeting during the managed care era when neurosurgeons would go to the microphone and say, I’m a primary care neurosurgeon because I’m the first one to see someone with a traumatic head injury. I went to the microphone right after that and said, well, I don’t argue that first contact is one of the key attributes of primary care but do you provide continuity after the head injury is resolved? Are you taking care of their toenail fungus and their chest pain as well? There are a lot of other attributes than simply first contact. But that was the beginning of that taskforce and where we coined that term, it was the beginning of a concept, a phrase, a framework that most people could embrace. And I think in many ways, from my humble way of looking at it, kind of the most important outcome of the project Because now you have something that members of the Congress, legislatures, accreditation bodies, insurance plans could sort of point to and say oh, that’s what those guys do and that’s how they’re going to do it, with this new model that they’re talking about, PCMH. And I think it was really a very important keystone or milestone in the future of family medicine and primary care in the United States. It’s even had traction in other countries. In Canada, they describe their teams as Family Health Teams but they quickly talk about that it’s their iteration or their version of the Patient Centered Medical Home. I think it was a very important moment for us in the early 2000’s to do this project and maybe we can talk later at the end, Dan, about how, while it was important and I think in many ways, very helpful pushing forward new policies, I think there are some parts of it that in retrospect, I think we should have done better on, or should have been more aware of, that are coming to light now, which I’ll be happy to elaborate on later, perhaps, for you. That made a very exciting time. \n\nOne of the things I share about being the AAFP president is you’re constantly traveling and meeting all these people, not only family docs but other physicians, meeting politicians, you’re meeting members of the public, you do a lot of public events, you do a lot of public speaking, a lot of media stuff. That was all great, I loved it, I really thrived on it. I had a crazy year, it was also the year of 9/11 and I remember that day, getting stranded. I was supposed to be meeting with president of Hopkins. I met with him as the towers were going down and we had to cut our meeting short because he had other things to do, like shut down the university. So I have this flood of memories about that very extraordinary time in our discipline and also in our country’s history and I’ll be forever grateful for the chance. \n\nBut one thing I should also share because these life lessons are not always easy, sometimes they’re painful, the Academy leadership ladder is structured, when you complete your presidency you become an immediate past president but also board chair. What happens when you’re president, you’re sort of out there running around, relating to the outside world but when you become board chair you’re really focused inward and you’re really trying to do the best to help the organization work as well as it can. And of course we’ve had terrific staff, we’ve had excellent leadership, Bob Graham and a whole succession of people that really put the Academy at the top, as far as I am concerned, in the top of physician organizations in the country, if not the world. But I also learned some important lessons. One of the things that came up by way of being painfully candid here was, at the time I was board chair, we had concerns about the board not always being able to say… or certain board members felt like they couldn’t say what they really needed or wanted to say at the board meetings because if they were disappointed in something that was happening in terms of the execution of a particular program that the board had adopted, if they were to criticize that or to be less than positive, that there would be hurt feelings with the staff. Because what the Academy does, which I think is a great thing, is they have the senior staff, the vice presidents are at board meetings, as well as the CEO. And that’s not true for all organizations. I’ve been involved in lots of different boards, national, international boards where if there’s staff there at all, they just come and go based on whether they’re needed for part of the meeting but they’re not in a sense, participants in the meeting as the culture -- . So I kind of struggled with that as board chair, trying to reconcile this concern expressed about the need to be candid and have time for directors and board members to be candid and yet I didn’t want to disrupt what I thought had been a really wonderful culture that we had, both the Academy staff and the volunteer leaders in working together in a mutual respectful, collaborative way, view each other as partners. The only thing I could come up with was to try to kind of bridge this was just to, at a board meeting, give an hour or so early in the morning, before the formal board meeting was to start so that the board members, on an informal basis, could come in and sit down and talk about what they wanted to talk about. The first time we met, it was, we need to be able to talk about things candidly and that was basically the crux of the conversation. The second time was not much interest and the third time, we basically didn’t do it. The mistake that I made, in looking back, I think it created a rift, it hurt the senior staff because they felt shut out of something and that wasn’t the way t do it. So I will forever regret having decided that way. I thought I was doing it in a way that was going to be least intrusive or less visible, perhaps but it just didn’t work very well. And I’m glad to see that harmony was pretty quickly restored, which I think is a testimony to the people in the organization. It was an important leadership lesson for me and in retrospect, what I think I probably should have done is, those that were concerned, I should have sat them down individually with perhaps a few staff members and with the CEO of the Academy and just try to work through that specific issue, rather than doing the more general thing. Or if we had to do it as a general thing, to be much more transparent about it. There are lots of board that I serve on where the staff are specifically asked to leave so that the board members can meet in camera or without staff there but that’s not been the culture of academy and in fact, I prefer the Academy’s culture. But it was a painful lesson to me and I just wanted to share that because sometimes people looking in from the outside think that everything always goes amazingly smooth and painless and slides right along because family doctors just love each other. We are, but we also are human and prone to make mistakes like I did or to have concerns that may not, in fact, be real concerns in the end. So that was just an important leadership lesson for me.\n\nThank you, very, very interesting. Those anecdotes like that really do amplify the value of this oral history. Having lived through that, I really appreciate that. Can I go back just a little bit to sort of the transition from Keystone Three to Future of Family Medicine Two. Keystone Three was just a meeting but the Family Practice Working Party and the seven organizations really, for the first time, got around to doing something. Just comment on how that worked as the Working Party kind of directing and then turning it all over to FFM but still having some oversight.\n\nDr. Roberts: Again, to me, it was one of my proudest moments. I do a lot of academic work in guidelines so I’ve had the chance, really the privilege of meeting with the board and the American -- Association and all these different other national and international physician associations. So I got some feel for how different disciplines are. The ability of seven different family medicine organizations to come together and to pull of something like the FFM was really quite extraordinary. I’m not aware of any other physician discipline that’s been able to do that. The working party as it was called, had been meeting about twice a year for almost the entire year since it was a discipline, 40 some years and as near as I can tell and you can speak to this better than me, Dan, for most of those years the meeting were polite but it was really mostly designed to catch up. What are you doing now? We’ve got this thing going on, we want you guys to know about it. So that at least the discipline had a place that people could come together and share mutual concerns, give each other a heads up and that kind of thing. And that served a valuable purpose, but for the first time, as far as I’m aware, the seven organizations felt compelled to come together and really put resources and effort into transforming the entire discipline. They had everybody put up money, sort of proportional to your membership of the respective organizations and the size of your budget. The Academy I think was the most substantial funder, by far but American Board put a large amount in, but all of them did to the extent they were able to and they dedicated staff time and it was really terrific. The Future of Family Medicine also had its first separate structure and budget and appropriately, some autonomy because you didn’t want the current family medicine political organizations dictating to this transformation project, exactly what the outcome was going to be. That defeats the whole purpose. If all you get is the status quo, what’s the point? And so the FFM task forces, which were not, as I said, all family docs, in fact, it was pretty evenly divided between family docs and other disciplines, other physician groups and nursing and public members. Those groups had a fair bit of autonomy to kind of go where they wanted to go but the Working Party representing certain organizations, were the ones responsible for the budget and trying to provide staff support and things like that. I thought it was just really an excellent partnership across these different groups, to make FFM happen and I don’t think it would have been successful without that kind of cooperation and collaboration.\n\nFor the record, say it again, the years that you were president and board chair. Board chair was during 9/11, right?\n\nDr Roberts: Correct. I was installed in the Fall of 2000 as President and then when I stepped down from that, I think was the first week of October in 2001, I became Board Chair on completing the presidency year, so 9/11, obviously happened about a month before I completed my years as President.\n\nSo you were President during 9/11 and I remember… please say what you did after you left John’s Hopkins that day and there was no way to get home so what did you do?\n\nDr. Roberts: Well, a couple things to share about that. I had been in DC lobbying on the Monday, 9/11, if I remember, was on a beautiful, sunny Tuesday and on that Monday I’d been in Washington DC, working the Hill and meeting members of Congress and things like that. And the hotel I was actually at was in DC and then I drove up to Baltimore early on Tuesday to speak to the Robert Wood Johnson Fellows group there. There was a young woman who was going to be kind of my tour chaperone and tour guide and driver and all like that. She was a young family doctor who happened to be a Robert Wood Johnson fellow. When she picked me up at the appointed place to kind of take me to the fellows seminar, which was early, like at 8:00 or something like that, she introduced herself and handed me her card. She had her name and underneath it, Department of Family Medicine, John’s Hopkins University School of Medicine. I looked at it and I said, there’s no Department of Family Medicine at John’s Hopkins, what are you talking about? She said, no, I’m the department, I’m it. She had an official Hopkins card. Somehow she was able to get this thing printed and that’s what she used. Esa Davis was her name, it’s Esa Davis-Washington now. Thirteen years later, as we’re doing this interview, Dan, Esa and I catch each other up every 9/11 by email. How’s your family? Things like that. She had a profound effect on me and that’s why I’m telling you this story. So after we finished our visit at Hopkins we went up to Franklin Square, one of the residencies I was scheduled to visit, family medicine residencies and she was staff there, precept residents in the afternoon, one afternoon a week while she was a fellow at Hopkins. We’re in this long line of cars waiting to make a left turn and the city is crazy. They shut down the interstate highways around DC and Baltimore, they let the schools out early, parents had to go get their kids. We couldn’t drive on the interstate highways so everything was on the surface streets, people were driving on the sidewalks. It was just craziness. This insanity that we’re finding ourselves in, Esa pulled up in this long line of cars about to turn left to go up to Franklin Square and she said to me, could you reach behind in the back seat and hand me that paper bag? I handed her the paper bag and there’s a homeless fellow that’s on the median strip there who walks up to her and she rolls down the window and hands him the bag and rolls back up the window and we make our left turn. No words spoken. A few blocks down the road I said, Esa, what was that all about? Well, she said, I come here every Tuesday and there’s always the same group of homeless guys here and I usually try to bring some clothes or food or something like that, that I just give to them each week when I come through and they always know me, they know my car, they know what time I come through and that’s what I did. It almost brought me to tears because here we’re in the middle of this awful day, thousands dying on the East Coast as a result of the terrorist attacks and then you have this sort of random act of kindness that this young woman had been doing, completely unheralded, it’s just something she just did because she felt like they needed help and they did. It really got me and still does. Again, I think one of the real joys of the different life experiences I’ve had and the leadership opportunities have really provided me, is a chance to meet so many extraordinary people that continually reinvigorate me, have restored my faith in humanity. I could go on and on like that, with just example after example and Esa was one of them. \n\nI had to drive back to DC late that night, long day, everybody’s exhausted and very eerie driving down the interstate toward DC where the traffic signs overhead said, “Washington DC Closed, Emergency”. That really got to me. I ended up being stuck there for three days because there were no flights and I finally negotiated with a rental car company, they were very kind about it, to be able to drive home at no extra charge. I will never forget as I was driving back to Wisconsin, going around the loop in Chicago, that was exactly at the time that they listed the flight moratorium and I began to see some jet contrails for the first time in 3 or 4 days. I guess I never realized that I would miss seeing jet streams in the air until my experience on jet streams in the air. That was another kind of powerful moment for me as I finally got back to my family in that very uncertain time.\n\nI remember a powerful moment that you told me about at that time is you also stopped at a church. You found a church to stop at somewhere along the way.\n\nDr. Roberts: Yes, it was at the time that they were doing a big memorial service and I just felt the need to pull in. It was in Pennsylvania. It was just this little bitty church by the side of the road and there were other people there just like me that had just come off the road and then we were sitting there with the town folk, sort of talked about all that. It was just very… again, it sort of helped me get through what was a very psychologically shocking time. You find some kind strangers along the way. That’s been another life lesson for me, these unexpected acts of kindness that really do kind of lift your spirits.\n\nYou’ve provided this oral history of several points in your presidency and the board chair as well, as immediate past president. Anything else you’d like to add about your time as AAFP president before we move on to your presidency of the AAFP Foundation?\n\nSide 2: Today is February 11, 2016. This is Side B, the second side of a recording with Dr. Richard Roberts, an oral history of Dr. Roberts. In Side 1 we had just finished by asking the question, Dr. Roberts, what would you like to add to what we’ve already talked about as high points of your presidency and your board chair year following the presidency when you were immediate past president? And after that, we’ll switch to the Foundation presidency you held.\n\nDr. Roberts: The high points were the chance to meet with some of these family doctors across the United States and to hear their concerns. Realized that a lot of what I was doing in day-to-day practice and struggles I was having at times, were shared by many others, and to also meet with many other people in the health system and members of Congress and governors and on and on. That was really a great experience. The downside to all of this that I don’t think people talk enough about is that it’s also a pretty tough time. It’s tough in terms of your hours, it’s never ending. When you’re trying to each or see patients, you get paged or called out of things. We try to prepare everybody, the best you can, but that was hard. I think it was very hard on the family. I had a young family at the time, my kids were still in elementary school and middle school and dad was on the road quite a bit, 200 plus days each of those yeas so that was tough. I also think from a career development standpoint, while it can open some doors you also lose things. It’s impossible, as an academic physician, it was impossible for me to tackle any serious research initiatives because I wasn’t around for several years. All the things you might do in terms of academic advancement, kind of get put on back burners. I’m sure it’s the same for people who were exclusively clinical, it kind of knocks the legs out from under your practice to be away so often. That’s a part of why I think people tend to be a little bit -- when they get to that post now, or they use it as a crucial time to make a change, they go onto something different than what they were doing before. But it isn’t all easy, you definitely pay a price for it. The Academy does its best to make it manageable and try to take some of the sting out of it but it’s not an easy time for people, in terms of their other career development and family and things like that.\n\nI’m glad you said that because that certainly is something that the average member of the AAFP doesn’t really realize the toll it takes on the president. You became president of the AAFP Foundation sometime after you were president of the AAFP and then you went back on the Family Medicine Working Party at that time. Just tell us briefly about the chronology of being the Academy president and then you became Foundation president and some of the high points of that responsibility.\n\nDr. Roberts: Well, the AAFP Board has two representatives on the Foundation Board and I served in that role and really came to better understand and enjoy and admire the Working Foundation. I’ve always been a contributor, I always made donations but I really didn’t understand as well as I perhaps, should have, the programs that they were involved with and the effect or reach that they could have. As I was finishing my duties with the AAFP Board, I just asked to consider whether I might be interested in gong on to the Foundation Board. Part of my interest in doing that was to try to have family medicine in the US gain more visibility and activity in the international, global --. While we’ve done some things, the Physicians With Heart Program being most prominent, I just felt there were lots of additional opportunities out there where American Family Physicians really had something to share with the rest of the world, with the rest of the family docs. The Foundation was a very good way to do that and so I spent about 7 years on the Foundation Board and on the various committees and was President for the last two years on the Board. The things that I really enjoyed greatly, were not only the people but the Board helped the Foundation, I think, to really begin to focus in a couple of key areas what we call signature programs. The first one we took on were humanitarian efforts and that played well, worked well with the Physicians With Heart Program wed been doing for a number of years at that point. We also started a project to help support clinics of need, clinics that really need medical services and that was part of the humanitarian effort as well, so not only international program but a domestic program. And then alongside that, the largest grant in the history of the Foundation as received during the time that I was on the Board and that was the Peers for Progress grant, which was an initiative to help patients with diabetes. This was a grant from the Lilly Foundation to help patients with diabetes be more effective in their own care and help by having peers, people that also have diabetes, helping each other and this became a global project, with research, very kind of primary care centered because a lot of these activities took place at the primary care level, so it involved diabetes specialists from different countries. We started that, we launched that project with a global conference on peer support programs with the sponsor, co-sponsorship of the World Health Organization -- and then over time there were a couple dozen various projects all around the world, looking at peer support for diabetes and also what docs could do to help advance that. Those kinds of initiatives take you all sorts of places that you might not ever expect. So for instance, we got very involved with the YMCA, which has a very active program now, not only exercise but diabetes control. So all these terrific partnerships arose out of some of these initiatives that the Foundation was during the time I was pretty much serving on the Board and was President. One of the other things that was great is you had the chance to be part of the Physicians With Heart delegation. The first two that I did, which were in Uzbekistan, during my time on the AAFP board and in fact, the Vietnam trip was really quite special because it was to help them launch, help the country of Vietnam launch their first three training programs in family medicine. A family doctor from Maine at the time, Ella Monahue, put a lot of work in sort of setting the stage for this and we went over as a delegation to do that. One of the things that were memorable for me was, the dean of the Hanoi Medical School, who was a heart surgeon, was very committed to getting healthcare into rural areas. He was real kind of firebrand, he was also part of the parliament, he was the Health Minister and when we had dinner with him one night, he and his wife, my wife and I were chatting with him. He was just asking what we thought of the country and so on. He said, what would you like to start by asking me? I said, well, Professor Bock, I’ve kind of done my homework, why would you want us to come here? We’ve looked at the data that you have, Vietnam is really doing a very, very good job in terms of good health outcomes, given the pretty limited amount of money you spend. Why would you want to change that by investing more funds in training family doctors when you’re getting good outcomes as it is? And he said, well, you have to understand it through our eyes. When we started, they called it the Assisted Physician Program, those are people with about two years of training beyond high school. He said, they did a great job, we put them in commune health centers in every village and they did a good job with water potability and immunizations but as time went by and the population is older and more chronic or complex conditions developed, we needed to have people with more training so we started to put young graduates right from medical school there, but even that wasn’t enough. I felt responsible for this large area, large region here. I had to decide how to help the villagers. He said, I could either have them all come into Hanoi to see a specialist when they needed but that’s not really feasible, traffic is always terrible and it wasn’t easy for villagers to take the time or spend the money to come to Hanoi. Or he said, we could do what we actually did, which was on Tuesdays, the adult specialists would go to the village but the children would show up and on Wednesday we’d send the pediatric specialists and the adults would show up. He said, Thursday I’d go out with the other surgeons and nobody would show up. He said, I had to find a better way to connect this very robust community health system we already have in place in each of the villages, with a more robust and sophisticated healthcare system. He said, I found that in family doctors. I tell that story because here a heart surgeon in Vietnam was teaching me what it meant to be a family doctor and he was absolutely right. He said, we are the bridge between individual health, personal health and community health. Professor Bock, I’ll be forever grateful for sharing that kind of insight with me. He died, sadly, a couple years later of a heart attack, he was in his late fifties, while touring one of the health centers in a -- part of Vietnam. He’ll be somebody that I remember with great fondness.\n\nAnother trip, later when I was on the Foundation leadership was to Tajikistan and that was also a trip to remember because it was the twentieth anniversary trip of Physicians With Heart and in our celebration that we had a big sendoff at Andrews Air Force Base, State Department, Mr. Robert -- was there to give speeches, the Ambassador from Tajikistan was there and we were all dressed in our best for that ceremony and then we get into this big C5 cargo plane which basically looks like a 747 that somebody stuck a steel box in the top of, which was called the passenger compartment. You’re sitting 3 and 3, facing backwards with all the windows blacked out. It was a military plane. Where your feet are it’s ice cold and where your head is, it’s boiling hot. The heat circulation. There was no running water on it and now you’re looking ahead to a 15 hour flight with a mid-air refueling somewhere over Scotland. We were flying along about two in the morning and what we’ve been eating was the stuff that these young Air Force airmen, who had packed for us, which is stuff you’d expect to see packed, a bunch of big club sandwiches and several bags of chips and a bunch of cookies and soda. There’s no movie of course, there’s no flight entertainment. We’re all chomping away on this stuff all night long because there’s not much else to do, you’re trying to sleep, trying to stay warm in one half and cooled off in the other half. When the started to do the refueling, it gets really choppy. I’ve been through some weather but this was really rock and roll. We had a young resident with us, we always try to bring a resident from that country that will study in the United States, so we had a fellow there. And another guy who was a man who had just been part of our delegations for a number of trips, Bob from San Francisco was there, he wasn’t a family doc, he just --, he’s a former football player, I think for the 49’ers but after about 15 minutes into this 20 or 30 minute refueling he reaches across the aisle, he was sitting in a seat on the aisle and he slaps me and he says, doc, I think Pengis (?) is dead. This was the young resident physician who was seated on the window seat in the aisle that Bob was sitting on. And I looked across and thought, my goodness, he does look dead. He was pale and he wasn’t moving and he was kind of slumped down with his feet stuck under the row in front of him. I went over and barely palpable pulse, what’s going on here? Does this guy have some heart trouble or what? And I said, let’s get his feet up, maybe with all this jostling around, maybe he’s just gotten -- or something like that. Bob and I struggled. He was a very powerful guy, we struggled and we finally kind of get his feet turned around sideways so he’s now laid out across the three seats. The minute we get his feet up to the level of his head, the color comes back into his cheeks and he sits straight up and in a scene out of the Exorcist, he proceeds to vomit all over me, head to toe. Bob seemed to sprint down to the other end of the airplane. I’ve never seen a big guy move so fast. By then he’s feeling fine. But there’s no water so I have to go begging for towelettes from all the different passengers to kind of clean myself up. And because of the… and I’ve got a sergeant yelling in my hear, “you’ve got to sit down doc, we’re still refueling”. I said, I’ve got to get cleaned off here a little bit. So I’m using towelettes to try to wipe this stuff, not everybody else is getting sick. It’s like the great barforama, everybody’s… So we finally get settled down, we go through the refueling. Another 6 or 7 hours later, I’m supposed to be the first one off the plan, these big cargo planes, the bottom of it drops out so they can roll off trucks and all the supplies and stuff. All of the luggage was down in the lower level where the cargo was. Any fresh that I would have had were down there. Thankfully I had my brown suit jacket in the overhead space so that wasn’t affected by the exploding barforama but my pants were pretty well shot. So I had a pair of black sweat pants that I pulled on that were quite a contrast to my brown suit jacket and my brown shoes. And had a fresh white shirt that I put on. Now I proceeded to lead out the delegation, having not slept for most of the night, having been on our feet for 24 some hours, to walk out onto this red carpet. And you had to climb down a latter to get to the cargo area, so there’s another airman there to help us down. I said to the Sergeant, please tell me that there’s just a couple people there waiting. Oh no, they’ve got a number of camera crews, it looks like the ambassador’s there, the health minister from Tajikistan, the US Ambassador, all these people, there’s like 50 people. I’ve got to walk up to the microphone and I have the health minister from Tajikistan on one side and the US Ambassador on the other side and I’m having to do this little speech, thank you very much for welcoming us here, blah, blah, blah and they’re translating all this stuff between Russian and English and Tajik. The whole time, the health minister was kind of sniffing the air. What is it with me? One of my more memorable experiences in diplomacy. We actually met once again later, he’s a pretty nice guy. Hasn’t mentioned anything more -- Tajikistan.\n\nI’ve got to add just one little visual image because I was on the ground as you came out of that airplane. But somebody also put a great big bouquet of roses in your arms, so you were doing that interview, at least part of it, looking like you did, smelling like you did, holding a great big bunch of flowers. Quite an image.\n\nDr. Roberts: Yes, it was an image to remember. Thankfully we’ve been able to find and burn all the photographs.\n\nNo, I have some\n\nDr. Roberts: I was afraid you were going to say that. But you know, every good family doctor, just like the Marines say, something is going to be always special, you just figure it out. One of the other things I remember about that trip that really was profound to me was, and a very special part of the Physician With Heart trip, was the chance to go visit family doctors in different parts of the country. Another American physician, Lisa Fleishman and I, who’s from Montana, went with a Swiss position because the Swiss Foundation is quite involved with Tajikistan as well, to try to help to advance primary care. The Swiss physician not only spoke good English and German but he also spoke Russian. We had a Tajik family doctor that was also a translator for us and spoke Russian and English as well as Tajik. And we ended up in this little village, going up the mountains toward the border with Uzbekistan. To get there, you went by the largest hydroelectric plant and aluminum plant in the region, which was owned by the President’s family. I mention that because we’ll come back later in terms of access to power. A major expert for Tajikistan is exporting power to neighboring countries, Pakistan Afghanistan because these people don’t have adequate electricity. So we go to this village and Dr. Koronoff (?) was his name, Dr. K., we called him. He was excited, he’d been there for 25 years, he had 7 kids, two of them were physicians. His daughter, he was hoping would join him. He lived in kind of a family compound, it was right across the street from his clinic. He was on call 24/7, never took vacations. He was very proud of a new stethoscope he had just gotten. What was so profound about meeting with him was you walked down the street and little kids would run up and grab his leg, hug him. The old men sitting under the tree drinking tea, would invite him over to talk. And this was a bustling community where most of the working age men went to Moscow to do construction and they’re gone 11 months of the year and yet they trusted Dr. K. to take care of their wives and to deliver their babies while they were gone. They always ended up having babies 9 months after t hey came home from their one month leave and so and a midwife he worked with, both stayed pretty busy with that. So he showed me very vividly, what it meant to be that kind of a resource in a very impoverished place. How they had immense trust in the man. One of the patients I remember, I’ve only seen two cases of actual polio and they were both in Tajikistan on this trip. One of the children who was about 9 months old and had on the left side, a --, Dr. K. was talking with the mother who had just taken the baby to Duchon (?) Bay, which was like two and a half days by bus. This mom, who actually lived closer to Uzbekistan, so Dr. K. would speak to her in Uzbek. He then turned and spoke in Tajik to the Tajik family doctor and would speak in Russian to the Swiss family doctor and then speak in English to the other American and me. A four language conversation going. One of the things that I was so impressed by watching him at work was, he had a great understanding of this woman, he’d been her doctor a long time and the community. He very gently said to her, I don’t think that you spent your time and money well going to see the pediatric neurologist in Duchon Bay, the capital, the university. The pediatric neurologist, all the kids, for almost any neurologic problem got the same three drugs, phenobartibol and I can’t remember what the other two were. But they all got the same thing and he knew that. The family couldn’t afford it, but for this kid who already his polio recently and was recovering from it, what he said to the mom and again, in such a compassion and practical way, he said, you know? The exercises that you’re doing with him, massage therapy, the high protein diet that you’re feeding him that I know comes with a sacrifice to the rest of your family, those are the best medicine of all. That’s the thing that’s going to make this baby better. Forget these medicines that you’ve been prescribed, they’re not going to help and he was absolutely right. I didn’t speak his language but just by his body language his tone of voice, he said it in a way that really had a powerful impact on her and on also the rest of us. And then after she was gone, I asked him, I said, don’t you immunize your kids against polio? Of course, he looked at me like I was an idiot. He said, of course we do but the problem is that we use the oral vaccine and t he government buys it and sometimes they buy it on the black market so we’re never sure if it’s actually good or not. The other problem is, you’ve got to keep it refrigerated, I only have electricity for a couple hours a day for 3 months out of the year and the rest of the year the stuff is -- because I don’t have electricity. So one of the things that we did out of that was, as we were getting ready to leave, we said, is there anything we can do to help you? He said, well, it would be nice if we had some chairs so that when the patients were waiting, they could sit. Most of the time they had to lean against a tree or sit in the courtyard, outside the clinic. That was basically all he said. So Lisa Fleishman was the one who did all of this, she really got it organized, worked with her hospital back in Montana, got a bunch of donations to help get them some chairs, but also a solar system to pump up fresh water so he had fresh water when he lost electricity. Just another example of those many unsung heroes, both Dr. K. as well as Dr. Fleishman, make the world a better place, make me proud to be a family doctor. So I took away much more than either were given -- international.\n\nRich, go back in your memory bank for a moment because I think the story about Andrews Air Force Base and-- and the way you looked when you landed on the C 5A was actually in Tashkent, Uzbekistan. The tragic story of the child with polio and all was certainly in Tajikistan but what do you think?\n\nDr. Roberts: You may be right on that.\n\nI’m pretty sure I am.\n\nDr. Roberts: It’s a memory I’ve tried to repress, I think.\n\nI know and I told you, I have pictures of it. For the record, the C5A incident and the roses and the interview was in the country of Uzbekistan and the capital. The Ambassador was there and the Minister was also there but they were Uzbeks. But the Tajik story that you just told with Dr. K. and all, was Tajikistan. They’re wonderful stories, Rich. I’ve heard you tell them in many places and you can just keep telling them because they captivate people have give everybody a sense of the humanity you saw and you exhibit. That was part of a… when you talked about one of your goals for being President of the AAFP Foundation, it was to promote the global health mission, which you did and these were elements of that. \n\nWe’re going to move onto the World Organization of Family Doctors pretty quickly. But any more on your global health work as part of AAFP or the Foundation or anything else about your Foundation presidency before we move on?\n\nDr. Roberts: The thing I would say about the Foundation is, in many ways, I think the Foundation has done very good work without getting the recognition that it should. It’s a key part of the discipline’s leadership development efforts. The support for example, that brings medical students and residents to the annual conference, national conference, usually in mid July, early August, in Kansas City, a lot of that is handled by the Foundation in terms of fundraising and making funds available to young people to do that, which is a great way to create cohesion across the discipline, to identify -- leader, get people excited about a career in family medicine. And I think even at a global level, not only through Peers for Progress program, but other projects. One other project that’s just been started recently is a mobile health workshop that Dan, your office in the Academy has taken on, is this mentor’s program too and the Foundation has had interest in trying to support that as well. I think the reverberations continue, that the Foundation has often been a focal point for a lot of international programming, not only for the Academy but for all American family docs. I just wanted to mention that because I don’t think it gets the credit or the visibility that it deserves many times.\n\nYou mentioned also, Rich, in that context, the fact that the Foundation raises money for students to go to the national conference and all but that brings a need for me to ask you to comment on something which I’ve admired about you forever, and that is, and it crosses all the different elements of your career that we’re talking about, and that is your commitment to student development. That commitment to student development in the United States and abroad. Just talk to the tape here a little bit about why you’re so focused and committed to working with students, meeting students and developing students.\n\nDr. Roberts: For me it’s been, I would say young people more generally, certainly students but also residents and doctors first entering into practice. I think the impetus really came out of my early experiences. I think I mentioned in our first interview, Dan, how delighted and surprised I was that when I went to my very first national conference as a starting second year resident, that I had all these leaders in the discipline that were happy… not only happy but eager to talk to me and share ideas and try to help me get involved. That just really had an effect on me, a theme that I kept experiencing, not only personally but there were many others as well having the same kind of experience of being… affirmatively reaching out to young people saying look, you’re our future, we need your input, we need your perspective, we need your leadership, we’re here to help you. And so I felt like I was just carrying on a tradition. For me it was like, now that I’ve reached those leadership positions myself, that’s part of the job description, that’s what you do, that’s important. And it’s a heck of a lot of fun, the enthusiasm, the fresh ideas, the optimism for the future. Those are the things that really make it worth the while. The other thing that played out for me was, and a lot of this I think is happenstance but at the time, I think I was the only academic physician on the board, at least for a chunk of time, and so I was often in a position to be asked to go to this medical school where they were having some issues or that one. I remember going to LSU when they were having a department down in their department there and Duke and all these different places. At the end of my term of the AAFP Board, I’d been to virtually nearly every medically school at one point or another, to a huge chunk of the 450 some residencies. I had a special interest in that and the Board would often say, why don’t you go to that thing? And I was delighted to do that. So that was a part of it as well, it gave me a chance to meet with many, many students and residents on their setting. At the international level then, again, just trying to carry on the tradition. It coincided with really a global movement of young doctors. This is something I always have to tweak my European colleagues. They, beginning about the year 2000 or so, formed a group called the Vasco Da Gama group, which was for young family doctors, people in their residency training years and up to their first five years of practice, which is great. But where I would tweak my European friends was, they thought they were the ones that kind of invented young doctor and resident student -- but I said, wait a minute, the AAFP has been doing this for 30 some years, I know Canadians have too, so people are way out ahead of you on this one. But that movement has been really quite extraordinary and young family doctors moving now, really have groups all over the seven WONCA regions of the world, there’s the 360 program to try to help promote exchanges where a resident and even a student in one part of the world can go experience the health system in another. That new ownership (?) has been really quite exciting to be involved with and to watch and in my own small way, try to help nurture it. For me, it meant a lot of wonderful friends all around the world now. If I could have as part of my legacy that I in some small way, helped to foster or promote that, that would be great by me because it’s doing really excellent things around the world.\n\nWell, that clearly is part of your legacy. I got an email the other day by some folks who said… from the various young doctor movements who said, Rich was our guru. \n\nNow you’ve started talking about the World Organization of Family Doctors, WONCA is the World Organization of Family Doctors. So in the time about the 20 or 15 minutes we have remaining, Rich, trace please, the trajectory of your involvement in the World Organization of Family Doctors and culminating in the presidency and just kind of talk us through it. I remember early on, you were involved in the quality part and I remember, in fact, you haven’t talked about being a Kellogg Fellow and some of those things. When you were a Kellogg Fellow, we were in Uruguay or Rio or Buenos Aires or someplace and you got involved with the Canadian Quality people. Was that kind of in the early stages?\n\nDr. Roberts: Yes, well what I found when I moved to private practice in a very underserved area, I’d been up there in -- for about three years and then -- University. When I got involved with the University, one of the things that you sort of get drawn into if you’re a lawyer and a physician, is malpractice stuff. So I did some stuff there, research, malpractice, family docs delivered babies and things of that sort. But for me, malpractice is almost a reactive activity. The bad thing has already happened. My interest was trying to move upstream and say, what can we do to prevent the bad thing from happening, whatever the    “it” was. So that took me into quality and I got very active in the quality movement. In fact, I think I may have mentioned in the first interview, I was part of one of the earliest workshops on critical cradle which Brian -- and -- put together, which some view as kind of the beginning of the modern evidence based medicine movement. And so I was becoming very involved with the Academy around the variety of guidelines that we were doing. I was often asked to be kind of a token many times, primary care family doctor representative of other specialty groups, guidelines committee, the -- Association, American College of Cardiology, but that, I think caused the people at the AAFP to tap me on the shoulder in the early 90’s and say hey, they’re interested at the world level in having a family doc who’s involved in quality for their quality committee. And so I said sure, that sounds interesting. There was a Dutch fellow named Richard Grol, who oddly enough was a lawyer, sociology professor. Guy was a researcher but he was really a very, very, very important kind of founder of the quality improvement movement in family medicine in Europe. So I learned a lot from Richard about quality and put on an annual summer institute in the Netherlands. Serving on what’s called the Quality of Family Medicine Working Party was a wonderful experience for me. It was kind of hard -- walk up. The Kellogg Fellowship that you mentioned, which I did from 1994 was a natural leadership development program, but some of my travels that I was doing for Kellogg, allowed me to go to meetings like -- and other people and talk about quality stuff. So that played out as kind of a whole separate pathway for me, where I was doing these international things around guidelines and quality improvement, doing talks and collaborating with other family doctors about quality through the Working Party. That ultimately led me as I was finishing out my activities with the AAFP Foundation, 15 years later, to be interested in serving on what’s called the Walk Executive, their board, so I was elected to that at large in 2004 in Orlando. I served two terms doing that, then I became president elect for WONCA and the president terms are three years each. That was a pretty long commitment. The president elect terms are not quite so intense time wise, nowhere near as intense as it is --. But the presidency of WONCA was pretty intense because there were just a lot of things flying around the world that you were constantly being asked, not only national college or society or academy type meetings, but WHO things. This was right at the onset of the whole NCD or… (Recording ends)\n\n\nSide 1\n\nThis is Dan Ostergaard, interviewing Richard Roberts, MD, JD in the third installment of the oral history of Dr. Roberts that we started on January 18, 2016 and then did the second installment February 11, 2016 and today is March 7, 2016. I am in Ft. Meyers, Florida at the moment and Don Ivey is recording this in the studio in Leawood and Dr. Roberts is in Madison, Wisconsin. What we’d like to do today is, Rich, talk a little bit about… actually quite a bit about how you made the decision to run for president of WONCA and WONCA, by the way, if the listener doesn’t understand it, is the World Organization of Family Doctors, which is the largest family doctor organization in the world. Rich, how did you decide to do that? What were your major takeaways? I remember you had many, many goals, you had many sort of commissions you established when you were president. Talk me through a lot of that.\n\nDr. Roberts: Thank you Dan. A good part of my interest in WONCA has been just an interest in learning more about the wider world. Going back to my earliest days as an academic doctor, I had exchange programs going on where we’d have students from West Africa come spend time with us and then we’d send our students over there and I did a Kellogg Fellowship that allowed me to travel around the world and meet with leaders, high level leaders as well as local leaders. I found that every time I went to other places, I always learned more than I taught, that’s for sure. But I always felt like I got more than I gave. You actually, coached me in the early 1990’s about serving on one of the WONCA Working Parties, Quality in Family Medicine and I served on that a good dozen or more years and it really gave me a chance to work quite closely with a number of colleagues interested in quality improvement and redesigning primary care from around the world, who are not only leaders in their respective parts of the world in family medicine, but also just became great friends. We taught a series of workshops in every region of the world we put together, so that really was my formal introduction to WONCA and that got me very interested in the organization as a way to support and advance family medicine. After 9/11 and the terrible tragedy that represented, certainly for us as Americans but I think in many ways, it was kind of a wake up call to the world about the meaning for social justice, the mean for better understanding. That’s what ultimately took me toward getting involved with WONCA in a more formal kind of political way by seeking office, which I did first, what they call a member at large, to serve on the executive, equivalent of a board of directors. From there on, to president elect and president. I think overarching of all of this, the primary motivation being to better understand, learn, connect with family doctors all over the globe. And that to me has been the one consistent gift that I’ve felt like I’ve had from international participation, is just a chance to get to know so many amazing people in all parts of the world.\n\nI think you’re being a little bit overly modest in that and I’m going to probe you just a little bit about some of the incredible things that you did. But before I ask you, I have to remember to ask you to please verbally confirm that you agree to be recorded on this tape.\n\nDr. Roberts: Yes.\n\nThat was a yes. Rich, during your WONCA, 7 years, 3 years as president elect and 3 years as president and 1 year as past president, one of the things that I know, in my view stands out, that you’re nurturing the whole student movement. Earlier in these tapes you talked a little bit about students but I need to call that up again because your desire to help bring students together in all walks of your professional flight is significant. And you also created some, I forget now the acronym, but commissions that met the whole 3 years of your presidency to do a variety of things. Talk us through some of those things.\n\nDr. Roberts: Well, I think one of the challenges for WONCA is, it’s been around for actually quite a long time, since about 1970. It really, to a great extent, represented older established, often academic, family doctors because it takes you a long time to work your way up through your own national college until you’re in a sense, ready to sit at the World Organization table. But the problem I had with that is that it meant that there were many important ideas, fresh ideas, kind of being lost in all of this or at least not being heard and it partly had to do with age. Because for young family doctors either in training or recently out of training, their practice world in many ways could be quite different than what I’ve experienced. And the same was true for women, the same was true for people in developing countries. So one of the several goals I set for myself was to try to actively reach out to groups and to try to encourage everyone to feel like their voice was important, that they really needed to be heard. It wasn’t only that it was just the right thing to do but it was important for the survival of the discipline and for the advancement of the discipline. How are you going to make family medicine an attractive career for a young medical student unless you’re tuned into what their concerns and needs are? Because those change. So that to me was fundamental. And frankly, I had good teachers. A lot of my involvement with the American Academy of Family Physicians taught me how important that was. I’ve always been very much proud of the fact that the AAFP in my view has been an international leader in fostering the development of young family physicians, actively grooming them, not only again for practice and teaching and research and all things we do but as leaders. And it goes way back to the earliest days of the Academy where we had national conference for students and family medicine residents, we had a whole series of formal leadership development programs, students and representatives, young doctors represent ted on the board of directors and on and on and on. So in some ways it wasn’t all that hard to offer ideas as to how we might do these things of bringing in other folks because I had pretty good teachers as I’ve experienced first hand as a young family doc, what it meant to be heard and encouraged and supported. I won’t say that it’s been an easy path at either the national or the international level because it’s tangled up in tradition and in different cultural attitude and a whole series of things. With the young family physicians, one of their challenges is, they’re trying to balance young families and work and they’re trying to pay in resources so they can participate. People are often in a difficult financial situation in terms of being able to take time away from their fledgling careers, spend the money to go to meetings, things like that. And so you have to be kind of creative about figuring out how to move resources around to get people to where they need to be. At the world level, with running an organization that operates on a very modest budget, surprisingly small actually, we somehow manage to do, I think, a reasonable job. Never as good as you’d like but a reasonable job of helping to stimulate folks getting connected. Part of the excitement for me, especially with young physicians is, the taught us a lot about how to meet. You didn’t have to meet in the same room, you could be meeting virtually and how to leverage social media and a whole series of strategies t hat allowed, not only young physicians groups but a larger group, worldwide group to really extend its reach beyond what we perhaps even though possible. So I give a lot of credit to them for kind of teaching me about that. \n\nJust to share some of the bumps in the road, I think one of the areas that has been a struggle for many organizations has been gender equity and in most countries, in fact, the majority of practicing family doctors, not to mention even more so, students and residents, trainees, are going to be female and yet, historically the WONCA executive was male and so one of the things that we helped to kind of nurture through the counsel, which is kind of like the assembly or the parliament of WONCA, was a resolution that required us to have at least 25% of the members of the executive being of either gender. You had to have at least one out of four be male or one out of four be female. But that means that sometimes people who thought it was their turn because they’d waited in line quite some time and thought they’d earned their way to the table, were not going to be able to get there and that created some tension and frustration. I think we’re still working through that. I give the women family doctors who are very, very active in this, a lot of credit for continuing to push the organization, kind of hold our feet to the fire, as it were. That for me was kind of one overarching theme, was trying to reach out to all family doctors irrespective of their gender or regional location or economic situation or career experience. I’m happy… my pleasure or privilege to do that and I’m happy with the progress we’ve made but we still have a long way to go, I think, internationally, to get it where we wanted. But we’re getting there so it’s been a very worthwhile journey.\n\nRich, another semi related part of your time was the development of the South American region of WONCA, the Americana as it evolved from the Center for International Family Medicine or CIMF. I recall your tenacity in working with the folks in Argentina and the folks in Mexico, as well as other countries, to incorporate that part of this side of the world into a viable region, along with North America, South America is now viable. Talk a little bit about your commitment to that because you were instrumental in consummating that.\n\nDr. Roberts: There were many, many, many people who were extraordinary leaders in making it happen. Part of the history of Latin America was that again, going quite a ways back into the seventies, there was a group called, see if I can remember the name correctly, the International Center for Family Medicine, which is CIMF in Spanish. The US was one of the founding partners in that activity and I think over time… and for a lot of reasons, not the least of which was probably language, I think it seemed better to have the US kind of step back from that because there’s always a tendency, intentional or not, that the US can dominate a lot of these things because of their size and their resources and it was important for the region to really have a sense of identity and cultural coherence. And so we kind of backed away and I was not very involved in those early days, I think you were, Dan and perhaps you can speak to that as well. But it also became clear as the years went by that having Latin America off    to the side as it were, kind of with their own group, CIMF, was not good. It was not good for them, it was not good for the world. We were kind of missing out on each other’s great idea. There’s a lot that’s happened in Latin America that frankly, for those of us from North America, it kind of flies through our radar, some very exciting things around bridging between individual health and community health and things like that, where in many ways we do it better than we do. There were a series of people at the WONCA international level but certainly in North and South America, people like Javier Dominguez comes to mind from Mexico and Dolphy Rubenstein from Argentina, who realized how important it was for Latin America to kind of engage the world through WONCA. In the US it was people like you, it was people like Rich Perkins from Canada, Warren Hefrin from the University of Mexico who were really key players in pushing this forward. And as you look at individuals and how they make things work, some of it’s just the times but some of it, I think is maybe talent. For instance, Javier and Dolphy are both very fluent in English and they work a lot… Javier had worked with the United Nations and Dolphy has done a lot of research, had a lot of NIH funding. People like Rich Perkins had been on the international scene for many years but coming from Canada, was kind of used to working in two languages, French and English. Warren Heffer is fluent in Spanish, so it was a nice coming together of people with not only global commitment but also, unique personal skills that they were able to bring together. My job, when I came into this leadership role was not to screw that up, to make sure the momentum continued. We were able to make that happen in a formal way so we made a point to have executive meetings in the region, Latin American region. I made it a point to get there as often as I could. I traveled extensively across Latin America. I speak what I call kind of a fractured Spanish. I do my best with it. One of the things I’ve learned as you travel the world, even if you do it badly, making the effort to give a speech in a language that’s not your first language and to not have 19 people in a 20 person workshop, all have to speak English because you’re the only one that doesn’t speak Spanish. Those are the sorts of things that cause people in Latin America to understand, at least I was really eager to work with them and to help them feel comfortable coming into WONCA. So I feel very good about it. I have so many personal friends down there, I’m very excited about this next WONCA World Council and conference meeting coming up in Leo in October of 2016. It’s very good to see this come full circle, but we still have work to do. One of the challenges again, for WONCA, is, again, it’s very limited resources, really the inability financially to have simultaneous translation. In an ideal world, every person could speak on the floor of the council in their first language, their native language but this has not been possible. So we’re trying to figure out ways to do this a little more creatively. I think we’ll get there step by step, by step. But as I say, I’ve been very excited about the things that are coming out of Latin America, not only in terms of universal healthcare coverage where many, many countries have committed to that through constitutional amendments and WONCA has been a part of that. In Latin America, one of the things they do, which is really very extraordinary is they have what they call a cumbrey, which is like a summit. They’ve been doing it every other year for golly, probably 12 or 15 years and I’ve been to a number of them and what they’re able to do is bring very high level people together from the various health ministries around Latin America and they spend at least one day in a --, kind of showing them these health system leaders of what family medicine is up to in the various countries and wonderful projects they have going and initiatives and things like that. And it’s created, I think, a really important dialogue in those countries. I can remember one of them that was in Northern Brazil, the Brazilian Health Minister came up to me and said, I never knew we were doing all these good things here. Part of my job, any time I travel into a place is coming there with the title of President over an organization, it often gets you an audience with the president of the country, prime minister, the premiere, the health minister and one of the more important things you can do is point out to them the great people and work happening in their very own country because they often don’t know. Because the family docs don’t always have access to the highest levels of authority and power in their respective country, so that was something I took to avidly and tried to push that agenda.\n\nThere’s one other part of the world that I should make special mention of too, if I might, Dan, because it had kind of a similar history and that was South Asia. India for instance, was one of the founding members of WONCA and for a variety of reasons, some of them political, some of them personal. It kind of drifted away and Indian healthcare is very complex. It’s a mix of millions without access to much of anything, to some of the highest tech, best quality care you’ll find anywhere on the planet and everything in between and family medicine often under a shadow of the enthusiasm for high tech care and coming from the United States, I think I appreciated that tension, perhaps better than people from other countries where family medicine is the solid, recognized, revered base of their health systems, which is what you find in most of the western world that have universal coverage because you cannot do it without really strong primary care. But I think I was sensitive to what was happening in India, perhaps because of the American experience, which is so often special -- and fragmented and almost chaotic at times, it feels like and it’s kind of like that in India. So again, through a series of personal outreach efforts, going to meetings, visiting with people, just kind of keeping at it, creating linkages to people like -- Parak and others, wonderful, smart, energetic folks, I learned more about India and the South Asian region and did my best to help them again, feel like they really needed to be part of the World Family Doctor Community again because it was time to come back into the group. And so they did. They have been reengaged and have really been taking off, which has been rejuvenating for them, literally has been a wealth of very bright young Indian and Nepali and Pakistani and other family docs in the region. So that’s been another area where I feel very proud of the role that WONCA has been able to play in helping raise the visibility and stature of family medicine. In the remaining regions of the world, Europe is very well organized now. The formation of the European Union, the coming together of many countries and their health focus, in terms of actually providing financial support for primary care across Europe, with a series of European studies and projects, a whole series of things, where family medicine really solidified family medicine is not only a really important academic discipline in care delivery system but also as a political force. When you look at Asia Pacific, it’s kind of been dominated by a lot of the Anglophone countries, Australia, New Zealand, Hong Kong, Singapore but we’re seeing more and involvement and presence of family medicine in Japan, South Korea, Thailand, Philippines, have great things happening there. Africa, the middle east… the middle east is called Emerald East or Mediterranean Region where they’re kind of following the WHO regional system. But those two regions have had the furthest to go, I think, today. Part of that in Africa in particular, is the distances, infrastructure challenges that sometimes is cheaper to try from Nigeria to London, to South Africa than right from Nigeria to South Africa. Things like that, that really create challenges for them. But there have been so many things happening in that continent, really facilitated I think, by WONCA and by members of the World Family Medicine Community. In particular, thinking of East Africa where folks like Jan deMassanero (?) of Belgium has had a project called -- for Health, it’s linked now to about a dozen countries around family medicine training. So I think around the world, the thing that I really was so thrilled with was watching family medicine get traction at a global level in ways that I’d never seen before. I just happen to be the lucky guy in that seat at that time, kind of go along for the ride, but enjoying every minute of it. \n\nIn fact if I might, it reminds me of the very first meeting that I’d had with Director General Margaret Chan, who still is the DG of the World Health Organization. WONCA had been trying for years and years and years to get into meet with her, because for many countries, in fact most other countries, WHO has great importance. The policies it writes are often adopted just on block, by national health ministries. So here are the WHO the guidelines on HIV policies or whatever it might be and Cameroon would adopt that, just the whole thing, they’d put it right on the shelf, that’s our laws now. So it’s very important to many countries. WONCA has been trying to have an audience with the Director General and it just couldn’t happen, there were just too many roadblocks, it seems. A happy confluence of circumstances allowed us, oh gosh, probably around 2007 or 2008, I don’t remember the exact year, to meet with her for the very first time and the confluence involved the fact that Dr. Chan is a very shrewd, very smart kind of medical politician. She’s been the Chief Public Health Officer for Hong Kong. She was there partly because of the rise of China on the world stage. But she understood that you were never going to be able to tackle the problem of chronic diseases, what WHO called non communicable diseases of NCD’s, without having universal coverage. And to have universal coverage so everybody in the system has access to the system so you can prevent diabetes or detect it early or high blood pressure or whatever. To have universal coverage you had to high quality primary care. So you have WHO, in some ways, rethinking its traditional role, which was focusing on infectious disease and malnutrition. At the same time you had people like Donald Li, family doctor, very involved with WONCA for Hong Kong who happened to know Dr. Chan well and was able, along with this happy confluence of circumstances, to get a meeting set up. So at this meeting, which consisted of, I think 3 or 4 were from WONCA, the CEO of WONCA, me, the president at the time, who was Dr. Chris VanWiel from the Netherlands, Michael Kidd, who’s our WHO --, so like 4 of us on our side of the table and then Dr. Chan had about a dozen on her side of the table. Our president began by saying, thank you so much for taking the time to meet with us and it’s great that we’re finally sitting down together. Then Dr. Chan proceeded for about 15 minutes, telling us all the reasons that she didn’t think it was worth her time to meet with family doctors. It’s like she said, I’ve got a billion people in the world that I’m supposed to help out that have no access to any kind of formal healthcare and all you doctors want to do is take care of the people with money and on and on like that. After about a 15 minute harangue, it was time for us to respond and I think our president was a little taken aback because he kind of looked at me. So I said, well Dr. Chan, I’d like to echo my colleagues thanks for allowing us to meet with you but I’ve got to tell you, you’re wrong. If that’s what you believe about family doctors or WONCA then you don’t know us. I said, our commitment is that every person in this planet should have access to a well trained, high quality family doctor. It wasn’t about their income status or anything like that. And I said to her, and she talked about other models of delivering healthcare. I said, when people are thirsty for water, they’ll drink water no matter what the potability or quality of the water is but I think as a human race, if we’re going to commit to having universal coverage, if you think that’s a fundamental human right, then we share that goal and we understand primary care to be central to making that right real. Then I said, you don’t give people less than completely potable water, you give them the best quality of water you can and that is family doctors. The evidence is very clear on that. And it really, I think, in some ways kind of helped break the ice because having come to know Dr. Chan pretty well in the ensuring years, I think she was testing us a little bit, testing our resolve. And she’s the sort of person, she’s very insightful. As I said, I’ve really enjoyed getting to know her. If you fast forward about a half dozen years, this culminated at the Prague World Conference in 2013 and her being the featured speaker and WHO Director General gets a million invitations a week to go speak somewhere, so she doesn’t do that very often. And not only was she kind enough to accept our invitation to come speak at our world conference, but she described family doctors as the heroes of healthcare. Because I think in those intervening years she’d had a chance to get to understand our agenda, our ideals and to some extent, get to see what we were doing on the ground as she was in a different country. That was a wonderful kind of a blossoming of a relationship. But it was fascinating to be in the middle of it all because it also gave me insights into the complexity of healthcare. For instance, as this NCD initiative was being launched, the tension always between the United Nations and World Health Organization, which in theory is an agency of the United Nations and WHO was trying to do its thing but the United Nations had decided that they wanted to take on the issue of NCDs as well because they saw it as such a key part of global development. If you have millions dying of cancer of chronic obstructive lung disease or whatever it is, you’re going to affect greatly, the country’s economic prospects and so on. And so the series of resolutions at the UN and what was again, really extraordinary for me was the specialist community and the industries that work so closely together, many pharmaceutical manufacturers making products for cardiac disease and that kind of thing, came together and actually formed these NCD alliances, kind of lobby in the form of these resolutions that they wanted the UN to adopt. Basically targeted only four chronic conditions, cancer, cardiovascular disease, diabetes and chronic respiratory disease. Ignored completely the important role of mental health in chronic diseases and we all know the high probability that somebody struggling with chronic diseases is also struggling with a variety of mental health problems from depression, anxiety, chronic pain disorders. And as primary care physicians, we just looked at each other and we were kind of shocked. It was like wait a minute, you don’t generate billions and billions across the world to support these very disease-focused, kind of a silo mentality? We really tried to rise up against that and I think WHO understood that because they were so used to working in resource center settings that they were at least quietly supportive of us. It gave us a chance, I was able to give a speech at the UN headquarters on primary care’s role in NCDs and the importance of mental health and the importance of engaging patients to kind of help determine their own agenda, which was for me, really a highlight. Later when the UN delegates came together in September of that year, the testimony I gave was I think in June, they came together to kind of vote on this. Again, one of the challenges is, family medicine is often not as visible in America as you might like, so some of these other delegations around the world, might have a family doc as part of the delegation, often their health ministry represented in the delegation. But I made an invitation, asked for an invitation to do that, couldn’t get there. Regina Benjamin, a family doctor was the Surgeon General at the time, was actually having some difficulty getting there because the State Department has to accommodate appropriately, UN relationships and so we were trying to figure out how to have these very important concerns made visible when the UN delegates finally got down to voting on the specific wording of the resolutions that were proposed. And I happened to be sitting at dinner with a friend, Viviana Martinez-Bianci, from Duke at the national conference, students and residents, in Kansas City about two months before that. She’s asking me how things are going with WONCA and I was describing this whole non-communicable disease initiative and the UN resolutions and how it was kind of frustrating, weren’t able to get our foot in the door with that level with the formal delegates from the different countries. Viviana says, one of my good friends when I grew up in Argentina happens to be the lead guy from the Argentinean delegation to the UN. I said, really? She said, let me see if I can connect with him. So we actually had a site conference call and he was actually quite supportive of what we were trying to do. There was kind of a middle income group, I think it was 77 countries that were kind of one bloc at the UN and he was going to be leaving the riding team for that group. Long story short, what happened was, Viviana, who had dual citizenship, US and Argentina, was made an official member of the Argentinean delegation to the UN and our job at WONCA was to brief her, to give her all the background we could and support her in trying to put a face and a voice to family medicine, primary care at this very important UN meeting in New York. It was great fun. She had Twitter feeds all the time, they said this and what do you think about that? And going back and forth and back and forth. We actually ended up greatly modifying the resolution, thanks to Viviana’s political skill and leadership and her colleagues from Argentina to have, what in the end was much closer to what we had hoped for. Not perfect, you don’t get perfect in the political realm but much closer to what we had hoped for. And I learned a really important lesson. I think sometimes when you hold the highest office in your organization, whether it’s president of WONCA or whatever, you may not always be the right person or even the possible person to actually carry the flag or lead the troops at that particular moment in time. I think you’ve got to be smart enough to realize that and support the others who can. It was wonderful watching Viviana, who’s very skilled at that, much better than me, really carry the banner forward, coming in at the very last minute and she did it quite skillfully. So that for me was a wonderful example, which I think has been kind of emblematic of family medicine and family doctors of just trying to have the best person at the best moment be the one in the spotlight to say what needs to be said. So that was another for me, a very memorable experience. I’ve been bending your ear for a big, Dan.\n\nThat was a great story. I think the word networking probably does it a disservice because it was really… some happenstance but really careful nursing of Viviana Martinez-Bianci, is probably going to go forward in WONCA herself, even though she’s still a young family doctor too. Great story. We do need to move on. But I’d like to, for the record say, of the three… there have been three Americans who have been president of WONCA, that’s Dr. Art Kobleski, Maryland doctor, Robert Higgins of Uniform Services and you, Dr. Richard Roberts of Wisconsin and all three of you were Academy presidents. But I think you were the only one of the three who was also president of the Foundation and we can check that for the record\n\nI’d like to ask a couple of political questions and then move on to some of your overall reflections on your entire career. Things like what were the greatest -- challenges and remembrances? A couple of political questions. I recall that there was conversation maybe 20 years ago that Dr. Rich Roberts should consider running for governor of Wisconsin. Rich, did you ever consider running for governor of Wisconsin or did I dream that up or did I hear it from somebody else?\n\nDr. Roberts: I’m not sure about your dreams or hearing it from other people. I was asked several times to consider running for political office. Tommy Thompson was our governor for 14 years here in Wisconsin and he later became the Secretary of the Department of Health and Human Services under President Bush in 2001 to 2005. After I finished my term as President of the Wisconsin Medical Society, the governor actually called me in, he called me in three times to ask me if I’d be interested in taking over the state’s Department of Health, which is now Health and Family Services. The first time I was just sort of surprised, I thought he was kidding and I said, thanks but no thanks. The second time he called me back and said, gee, you’re really interested in this, let me think about it, talk with family and kind of look at what could happen. Part of what kept me from doing that position and part of what kept me from pursing politics at some other level, governor or whatever, there were a couple of things. One was that in the negotiations over this Secretary position, or dickering with that, I said to the governor, is there any way that I could still at least still spend a day a week in my practice and keep my clinical skills up? I wasn’t sure I was ready to be a career politician and then his staff, much to my internal gratitude said, we’ll look into it and they did and a quick answer about a week or so later, no, you can’t work, you can’t do that. Because I was employed by the university and typically that’s viewed as double dipping in our state. But that was one important factor that kind of kept me from that position and other political positions, which was I still liked being a family doctor too much, that’s kind of who I am. It’s very much my sense of identity. The second was young children. In the early 90’s I’d also gone through this 4 year Kellogg fellowship where I was interviewing, both in the US and around the world, leaders, presidents of countries, all the way to alliance, which are local leaders in the hills of Mali, Indonesia. And talking to them and their families about what it meant to be in politics. I learned some things about it and I wasn’t really prepared at that time to kind of subject my young children to that kind of a life to where dad really is never around. I was around too little anyway but when you get caught up in that kind of a world you’re never around and I didn’t want to do that and just the public scrutiny that goes with that. I was flattered to even be thought of in that way and thanked people when they would suggest it to me but it was never a serious interest or pursuit on my part. I used to tease, I aspired to high appointed office. But the reality is, I enjoyed too much and still do enjoy being a family doctor.\n\nLet me ask you a couple of other questions. Right now we are in the… I think that was a wise decision, by the way, knowing how busy you were in so many other areas of your personal and professional life. We’re in the political season here in the United States right now, it’s March, the presidential elections will be in November of 2016 and it’s probably the most acrimonious primary season I’ve ever seen. Sort of as a snapshot in time, spend just a very, very brief moment reflecting on any of the candidates on either party that you wish to and then if there’s any comments you wish for the time capsule of 30, 40 years from now that you wish to say, what are their views on healthcare and what would election of any of them might mean, what that might be for the direction in healthcare in family medicine. Now that’s a lot and they didn’t say much but give some thought for the time capsule for the future.\n\nDr. Roberts: Sure. I think what I’ve been most impressed by and surprised with has been how little discussion there’s been on healthcare, at least in the primary season. We’re speaking in March of 2016 so the respective party nominees have not yet been identified. The way I would boil it down is, you have the Republican side, they don’t like the Affordable Care Act, Obamacare but nobody’s offering an alternative. The thing that I think America for the moment has kind of put on the back burner and it’s going to come back and burn is later is that the fundamental problems of having everyone covered, which is essential to having, not only an equitable healthcare system but an efficient one to get away from all the cost shifting and the dollars that get diverted away from clinical care. That still has to be addressed and the only way to address it is with universal coverage of some sort of another. I’m not sure kind of where I come down, whether that’s done through Senator Bernie Sanders has been advocating a single payer system, which you see in a number of parts of the world, or whether it’s done through some more pluralistic health insurance system where you’ve got a number of different health insurance companies to do it, which you find in places like the Netherlands and Switzerland and Germany and places that have pretty good health systems, universal coverage. But the second part of that conversation that we never quite had as Americans is primary care. And the reason that that’s bad is and the analogy I’ll use is, you can give everybody a credit card to a healthcare system just like you can give everybody a credit card to groceries. But if the only thing they can find when they get in the grocery is either food that is acceptable rich and expensive and not healthy for you or empty shelves, you haven’t really given them much. And if all you have is a healthcare system that’s so focused on high tech, tertiary -- care or conversely, no access points through primary care, you haven’t done them any favors. And that conversation we’ve just not quite had. I’ve been to every state multiple times, I’ve sat down with literally more than 5,000 doctors around the world now, more than 50 countries, watching them with their patients. But I’ve done this in virtually every state in the US and when you talk to individual patients, they love their family docs and they realize how important they are in their lives. But at a political level, people don’t tend to think about that, they tend to think about heart transplants and stem cell research and things of that sort because that’s where a lot of the media attention and marketing hype really is. To me, those two key goals for healthcare system are not being addressed during this election cycle. Now that may change as we head to the general election phase later in the summer but at this point, I think the thing I’m struck by is what a difference a few years makes because in many ways that was the election conversation back in 2008 when President Obama was elected. At some political level, I think many people, including Republicans, were sort of thankful we at least got something done and that it has done some things. Some things well, some things not so well and maybe we don’t have to talk about it for right now. And understandably, there’s a lot of other things that people are concerned about. They’re concerned about their own job, they’re concerned about safety in terms of terrorism and those are very appropriate things for presidential candidates to be talking about. But healthcare doesn’t seem to be at the top of anybody’s agenda right now and again, maybe that will change as the general election moves forward later.\n\nOkay. Thank you for that little bit of insight. -- politically in the nation and I do wish they would have some discussion of healthcare, other than simply repeal Obamacare. Let’s take a break and come back for the last several minutes, kind of to wrap up, reflections, other things you would like to say for the record and your thoughts about the future. Take a break for now and we’ll be back in just a few minutes.\n\nDr. Roberts: I’ll just leave my speakerphone on, is that okay?\n\nYes. I’ll do the same.\n\nDr. Roberts: Okay great, thanks.\n\nSide 2\n\nThis is Dan Ostergaard, interview Rich Roberts. This is Side 2 of the tape we’re doing today, March 7th, 2016 and we’re going into the more reflective conclusion if you will, of the tape by asking Dr. Roberts such questions as what achievements are you most proud of? I know you’ve talked about several. I egg you on to be less modest and talk about… what are you most proud of in your time as leader in family medicine in your overall career? I have kind of a loaded question. What do you plan to do after you retire? Not that I’m suggesting you’re about to retire, you’re much too young, of course. But what are your thoughts for the future, your reflections on the past, thoughts to the future. The floor is yours.\n\nDr. Roberts: The question, what am I most proud of, I’ve thought of my professional life kind of running along several parallel tracks. Sometimes those tracks intersect, sometimes they don’t. One has been as a family doctor, practicing family doctor. I’m very proud of the fact that I’ve been in the same community, same practice, small town of 2,000 people for the last 30 years. I have two families where I take care of 5 generations, to the point where I’ve been delivering women whom I delivered. That’s been very special to me and I think in many ways, it’s not only a reflection of what’s most important to me professionally, but has shaped how I look at the world and maybe I’ll come back to that in a minute. A second kind of parallel track has been being an academic physician, so I’ve had a chance to do some research, do lots of teaching, be a department chair, things like that and that’s all been wonderful. I have great admiration for our discipline. I think we’ve been very farsighted in recognizing kind of what we need to do to get young people interested in careers as family doctors to help teach them, nurture them along the way, assist them in their own professional leadership development. Proud that I was able to participate in a small way, in that and be part of that conversation both nationally and internationally. And then the third track is kind of what I would call a medical politician, American Academy of Family Physicians, WONCA, the World Organization. Having the opportunity to communicate the ideals of family medicine on a larger stage, public stage, to sit down with leaders of the other health professions and medical specialties, as well as political leaders. Those create parallel tracks. Kept me very busy and I think I’ve done my best to try to speak out on those issues that I thought I was the one who could speak out at the time and to represent the discipline as effectively as I could. I once had someone say to me, he called me the firehouse Dalmatian of family medicine. What he said he meant by that was, whenever there’s a fire somewhere for family medicine or family doctors and the alarm goes off, you’re ready to run to go help. There’s some truth in that. It was something that I started doing way back at the state level when we had a hospital privilege call for a family doc in one part of the state or another, or a rural county was struggling to find a family doc. I was always happy, in fact, honored to be ask to help. That just has continued, whether it was meeting with four doctors up in Alaska or a single physician in remote Tajikistan or Uzbekistan or whatever I was asked to do that way, I always thought it was very fun, it was exciting, it was a chance to learn some more. So I’m actually kind of proud of that label because I think at the end of the day and sometimes I think we kind of overlook how humans work, is that it’s about individuals. It’s all about the person that you’re dealing with. I believe that fervently as a family doctor. You’ve got to take care of people, one person at a time and get to know them. And we can talk very offhandedly about population health and improving overall population metrics and doing our checklists and following our protocols but if in so doing, the patients have a sense that their agendas are not being addressed or that their needs are not being met, regardless of what we as system experts think they should be getting, they’ll not trust us and the system will collapse. And I’ve seen that in different countries. Dan, you and I have been to some of those countries. We look at what happened to Soviet medicine in a number of places where you have the front door patient and the back door patient. The back door patient always got in with an extra bottle of vodka and got sort of ahead of the line. The system was designed to crank numbers but not necessarily address individual needs and in many of those countries they suffered mightily for it. In fact, ironically, that’s been part of their interest in family medicine, trying to figure out how to address individual needs better than they have. I may have related in one of the earlier tapes, Professor Bock, the fellow in Vietnam that was so instrumental in helping cultivate family medicine there, who taught me what family doctors do is connect the individual to the community when it comes to healthcare and that is something I strongly believe in. If there’s a legacy for me, it’s perhaps to be seen as somebody that tried to say that and hopefully say it in a way that people viewed as persuasive and meaningful. \n\nIf there’s another moniker that people would attach to me that at least describes how I think of myself is, I really do think of myself as a simple country doctor. My many years in Belleville have been mentally, enormously satisfying but it’s an important sense of my identity, so my patients all get my cell phone number and my email address and my Skype address. Part of that was born of kind of necessity 20 years ago when I started running all around the world because I learned that it was much easier to try to stay in the flow of things than to come back after a week away and try to catch up with things. I’ve learned by making yourself more available to people, you might have literally a one or two minute phone conversation that takes care of the problem, even with one of your practice partners that might even know the patient well, it’s a 15, 20, 30 minute office visit and in the emergency room it’s a 4 hour ER visit. And I was able to, just because I knew the patient, manage the thing in a fairly brief period of time. And I’ve had other family doctors teach me this, I found that by opening yourself to people more, you actually are bothered less. We all worry about personal work/life balance but I think what we’ve got right now isn’t all that great. When I talk to young physicians who are so appropriately concerned about balancing their personal lives and family lives with their work lives, they aren’t all that happy being on duty once every seventh night where they’re up all night taking care of other people’s patients. It’s more work. And I think that’s one of the things we’re going to have to sort of rethink and get back to, is a sense of the primacy of the relationship. Barbara Starfield, who many of us believe was kind of the, really the fountainhead of the research that shows the value of primary care, taught me, what makes primary care valuable in my view, family medicine is the acme, the epitome, the archetype of primary care. What makes primary care valuable are two things, continuity of relationships and comprehensiveness of services. My worry, as I watch the system changes that are going on, is that for a variety of reasons, those things seem to be constantly chipped at and softened up and blurred. What kind of continuity do you have when you spend half your workdays handing off patients to other people who then hand them off to yet other people? What kind of continuity is that? We know that in the United States, medical errors are the third leading cause of death and more than half those medical errors are communication errors. You don’t fix that problem by adding more people to the chain of care. Secondly, it’s the comprehensiveness. As I watch family doctors, in my cases in my view, too eagerly, stepping away from the hospital and delivering babies and being active in all the settings that family doctors are active in. In a sense what we’ve done, we’ve lost, I think some confidence in ourselves, in our ability to do these things well because after all, the science is getting so consequential. Baloney, I did guidelines for 30 yeas and the science really is not that great. It’s all about the relationships. -- more important than knowing the disease is knowing the person with the disease and I think we’re to some extent, forgetting that in healthcare in the United States at this time and in other parts of the world. We’re going to pay dearly for that because it’s still about people and we have a long way to go until our science is so certain, so immunable, so enduring that we can say to a patient with 100% confidence, this is how it’s going to turn out for you, not just for the population but for you. We can’t say that very often, still. So that’s where they depend on family doctors to help them think it through, to help make sure their values are aligned with what the professionals are recommending to them. Those to me are really the challenges as I look forward. \n\nIf there’s a legacy that I hope others would think of me along those parallel tracks in professional work, it was that he walked the talk of spending a huge chunk of his professional life just taking care of folks, taking care of patients, trying to do a broad scope of family medicine and that secondly, he treated us, his colleagues as well as he treated his patients. He made himself available. When the alarm sounded he was ready to run to try to help them out. I think if there’s a message that I’ve gleaned or taken away from my international work in particular, is that it’s important to keep those alive. Even as I get discouraged by what I see swirling around primary care in the United States and some other countries, I also see even within those countries, other people, individual family docs or initiatives to kind of resurrect or reclaim comprehensivism and continuity. It’s really fun when you go to a country where family medicine was a completely alien concept and watch it take root and just run rampant across the landscape because people see it as a much better thing. That has helped keep my hope alive and as I say, if I could be remembered for anything, it was at least for the brief while that I was able to carry the torch, that I was able to keep hope alive.\n\nVery good. That’s a very good set of things, about which you shared and I’m sure will be remembered. Embedded in what you’ve just said are some pearls of advice for future generations. It comes down to the individual, you said several times and that goes back to William Oaksburg (?) but it seems to be waning in the current professional mood. And to make yourself available. Those are good advices that you have offered for future generations.\n\nBefore we conclude, anything that you’d like to add that we should have asked you or that has popped into your mind? Knowing what things pop into your mind -- I don’t that we should go too far there. That was a joke. Anything else that you’d like to say?\n\nDr. Roberts: I know myself well enough that I started to laugh when you started to say that. \n\nI know you well enough to know you’d laugh.\n\nDr. Roberts: I think a good way to finish this off, you were asking kind of what’s next for me. I’ve never been one to actually plan the what next very well because there was always something that came up that seemed to be exciting and interesting and I thought I could make a contribution. I am reading a time in my life where it’s going to be time to step away from clinical care. I don’t know if I could ever do it in sort of a half hearted or part time way. I’ve worked emergency rooms, I’ve worked urgent care settings at various times in my life, usually helping out. Maybe I could do that some clinically, just to keep the clinical skills up but I’m concentrating more now on things like writing. I’ve got a lot of writing I’ve been trying to do and need to do. Part of it is just all these reflections of things. But also, I think if I’m able to, I’d like to communicate this to a public audience more than I have, whether it’s pep talks or New Yorker articles or whatever it may be, I think we haven’t really had the kind of conversations, certainly in the United States we need to about healthcare and I’m not certain that even if we did, people are prepared for what they need to hear, in my view. For instance, a lot of healthcare stuff is Dr. Oz and his ER shows and things like that. I’m as entertained as anyone by them but to me, they’re more entertainment than they are meaningful, thoughtful conversations about what we want healthcare to look like and what it needs to look like if it needs to do right by all of us. That may be kind of the next phase of my professional life and I’m actually looking forward to spending more time with my wife, Laura and my kids are kind of growing and moving into their lives, have more time for them. That for me would be a good way to finish it all out.\n\nThat’s I think really good advice that you’ve given yourself because if you do go into various public arenas and give pep talks and write for the New Yorker and whatever, I think that would be another contribution. This does conclude our interview, thanks very much, Dr. Richard Roberts. Today is March 7, 2016 and thank you Rich, for an excellent interview over three days.\n\nDr. Roberts: Thanks very much, Dan, for your expert interviewing skills.\n\n[END]","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282876#t=0.0,3246.70474"}]}]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282877","type":"Canvas","label":{"en":["Media File 2 of 6 - Roberts_Richard_Pt1_16_b.wav"]},"duration":3736.9724,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282877/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282877/content/2/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/282/877/original/Roberts_Richard_Pt1_16_b.wav?1752685497","type":"Audio","format":"audio/wav","duration":3736.9724,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282877","metadata":[]}]}],"annotations":[]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153757/file/282874","type":"Canvas","label":{"en":["Media File 3 of 6 - 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