{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/q52f76853r/manifest","type":"Manifest","label":{"en":["Dr. Norman Kahn"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Description"]},"value":{"en":["\u003cp\u003e“I’m a change agent,” explains Norman Kahn, Jr., MD. And, since 2007, he has been instrumental in making changes as the Executive Vice President and Chief Executive Officer of the Council of Medical Specialty Societies. He leads the 38-member association as it considers professional self-regulations, transparency and keeping the patients’ needs first.  Prior to this position, Dr. Kahn spent 16 years at the American Academy of Family Physicians (AAFP). When he was hired in 1991, the organization was seeking a “tricultural person” who had practiced as a family physician, served in a community hospital family medicine residency and was in an academic health center. At AAFP, he was the Director of Education, Vice President for Science and Education and served on numerous committees and commissions. He is especially proud of working on the Future of Family Medicine Project.  \u003cbr\u003eDr. Kahn spent five years as director of UC Davis (University of California) network of affiliated residency programs in northern California. He was also the assistant dean for AHEC (Area Health Education Center) as well as director of the residency program at Sacramento. During those years, he served on the steering committee that created the AFMRD. In addition, he was a member of the Academic Council that created the National Institute for Program Director Development.  \u003cbr\u003eHis initiation as a residency program director and faculty was in Modesto, California, during the nine years he practiced as a family physician in rural Hughson. He was prepared for this challenge through his own family practice residency at the San Francisco General Hospital, a large county facility designed to produce physicians who would serve the urban Bay area.  He says, “This was a politically active residency. It was new. It was closest to the people. … It was here that I learned how to be a servant leader in family medicine.”    \u003c/p\u003e (summary)"]}},{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}},{"label":{"en":["Date"]},"value":{"en":["2012-04-13 (created)"]}},{"label":{"en":["Type"]},"value":{"en":["Oral History"]}},{"label":{"en":["Agent"]},"value":{"en":["Michael Devitt (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["family medicine","family physician","American Academy of Family Physicians"]}},{"label":{"en":["Subject"]},"value":{"en":["Norman Kahn, MD (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}}],"summary":{"en":["\u003cp\u003e\u0026ldquo;I\u0026rsquo;m a change agent,\u0026rdquo; explains Norman Kahn, Jr., MD. And, since 2007, he has been instrumental in making changes as the Executive Vice President and Chief Executive Officer of the Council of Medical Specialty Societies. He leads the 38-member association as it considers professional self-regulations, transparency and keeping the patients\u0026rsquo; needs first. \u0026nbsp;Prior to this position, Dr. Kahn spent 16 years at the American Academy of Family Physicians (AAFP). When he was hired in 1991, the organization was seeking a \u0026ldquo;tricultural person\u0026rdquo; who had practiced as a family physician, served in a community hospital family medicine residency and was in an academic health center. At AAFP, he was the Director of Education, Vice President for Science and Education and served on numerous committees and commissions. He is especially proud of working on the Future of Family Medicine Project. \u0026nbsp;\u003cbr /\u003eDr. Kahn spent five years as director of UC Davis (University of California) network of affiliated residency programs in northern California. He was also the assistant dean for AHEC (Area Health Education Center) as well as director of the residency program at Sacramento. During those years, he served on the steering committee that created the AFMRD. In addition, he was a member of the Academic Council that created the National Institute for Program Director Development. \u0026nbsp;\u003cbr /\u003eHis initiation as a residency program director and faculty was in Modesto, California, during the nine years he practiced as a family physician in rural Hughson. He was prepared for this challenge through his own family practice residency at the San Francisco General Hospital, a large county facility designed to produce physicians who would serve the urban Bay area. \u0026nbsp;He says, \u0026ldquo;This was a politically active residency. It was new. It was closest to the people. \u0026hellip; It was here that I learned how to be a servant leader in family medicine.\u0026rdquo; \u0026nbsp; \u0026nbsp;\u003c/p\u003e"]},"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153057/file/281705","type":"Canvas","label":{"en":["Media File 1 of 4 - 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That’s where we met. \n\nHow long ago did you meet?\n\n1974.\n\nDo you have any children? \n\nWe have four. \n\nWhat are their names?\n\nFred, Brian, Max and Abby.   \n\nHow old are they?\n\nThis is part of the interesting history. Diana had Fred and Brian when we met. They were born in ’71 and ’72. And then Max was born in ’78 and Abby was born in ’82. Fred and Brian were born in Baltimore which is where my wife is from. Max and Abby were born in Modesto when I was there as a residency director.\n\nAnd what do they do?\n\nThe older two, Fred and Brian, are construction plumbers. They don’t do house repairs; they build things, plumbing construction. And Max is in the middle of changing careers. He has a Master’s in Business Administration. He was in the food industry, worked for Whole Foods, and now he’s going to nursing school. And Abby just finished her Master’s degrees in Public Health and Public Policy at Berkeley and just got a job as the Policy Analyst for the National Association of Medicaid Directors in Washington, DC. \n\nCongratulations.\n\nIt took her two and a half months to find a job, but she got the right one. \n\nYou must be proud of them.\n\nWell, of course. If you were my kid, I would be proud of you too. \n\nTell us a little bit about yourself. When and where were you born?\n\nI was born in Kansas City, Missouri, 1947. I grew up on the Kansas side though in a little town called Fairway which is now just part of the Shawnee Mission metropolis.   \n\nWhat was it like growing up in Fairway at that time?\n\nThat was the ‘50s. That was the idyllic period when TV was just coming in. Those were the good old days, as they say. Prosperity was building after the wars, the Korean War and so on. So it was a typical urban/suburban environment. The truth is, everybody talks about walking to school, but I don’t remember it being a problem. I won’t complain about it being uphill both ways. It was uphill one way, but not the other way.   \n\nTell us a little bit about your parents.\n\nMy father just died this past year at almost 93. He was in the steel business for his whole life. My mother is still alive. She lives here in Kansas City. And she’s been very active in the arts community. She’s had a gallery. She has a collection. And she’s involved in a lot of civic projects. She’s always been active. Actually both of them have always been active in the community. My father was a docent at the Nelson-Atkins Museum. He was very proud of that as a businessman. \n\nSo they both had some sort of ties to local culture and the arts?\n\nA lot, yes. \n\nWhat kind of effect did that have on you as a child?\n\nWell, it had effect in a number of ways. I was very conscious of the fact, as I was growing up, that my father’s father was an immigrant and my mother’s father was an immigrant. So they were first generation Americans. And they were really trying to build a life and a family in America the way they defined it. But I was also conscious of the fact that education was extremely important to them. My mother had a master’s degree. But my father and no male in my family had ever graduated from college. So I was going to be the first one. And that was something I was aware of even when I was young. \n\nDid you feel a lot of pressure?\n\nNo, I felt like it was very exciting. It was a given. I mean I knew I was going to graduate from college. There was no pressure. It was just that’s something that’s unique, that’s cool.   \n\nBeing the first male in your family?\n\nYes.\n\nWhen you were growing up, you talked about your father being in the steel industry. Were they your role models? Or did you have any other role models, people you looked up to when you were younger?\n\nNo, I think they were pretty much my role models at that point in time. Later I had role models. But when I was growing up, it was my parents. \n\nDid you have any brothers and sisters?\n\nI have a younger sister and two younger brothers. My sister is a physician and my brothers are in my father’s steel business. \n\nAnd what are their names?\n\nMy sister is Barbara Kahn, she’s not married. And then my brothers are Fred and Ted. \n\nDo they live in the area as well?\n\nFred does. Fred lives out south in Bucyrus, Kansas. Barbara is a professor at Harvard. And Ted lives in Steamboat Springs, Colorado.   \n\nSo they’re just spread out all over the place?\n\nYes.\n\nDo you keep in touch with them still?\n\nI’m very close with all of them. They were just in town last weekend. \n\nHere in Kansas City?\n\nYes.\n\nAny special occasion?\n\nYes, Passover. Everybody gets together including extended family. So we have a lot of people that were in town. Plus, it was the unveiling of my father’s headstone, so we had a few more people than usual. \n\nSo there were a lot of different events going on?\n\nYes, a busy weekend. \n\nTell us a little bit more about your childhood. When you were growing up, did you have any sort of dreams or goals, things that you wanted to achieve?\n\nYeah, I wanted to graduate from college. But I was not one of those people who knew he was going to be a physician when he was young. Think about it – my grandfather ran a dry goods store. He emigrated from Lithuania in 1905 and he came and the first job he had was rolling cigars in a factory in Aurora, Illinois. And gradually he ended up having a grocery store and then a store that sold everything that the men who worked on the streetcars in Chicago needed. And so they moved to Kansas City during the Depression, in the early 1930s. And my father grew up and served in the Army Air Corps during WWII and came back and got a job as a male secretary in the steel business. Scrap business actually. And then worked his way up to salesman and eventually bought part of a steel company himself. So that was the history. It was a very recent history. There wasn’t a long history. There weren’t a lot of role models in my family to model after. So I knew I was going to graduate from college. And I knew that when I was in college I’d figure out what I wanted to do – and that’s exactly what happened. \n\nWhen you think about it though, in just over a century, that’s pretty impressive. Just the progression in your family from your grandfather being an immigrant to here you are now.\n\nI think that’s a reasonably common immigrant story. I don’t want to be too stereotyped. There are all sorts of immigrant stories. I guess we could have been a mob family too, but we weren’t. I mean it doesn’t surprise me, coming here and each generation wants to succeed. I think my immigrant grandfather very much wanted his children to be successful in America. And they pretty much got that message and they were. And that allowed me the freedom to decide what I wanted to do. There was no pressure to go into my father’s business, for example. \n\nAside from going to college, graduating, they didn’t push you in any certain direction?\n\nNo. They didn’t even actually push me in that direction. That’s something I just recognized one day and found to be an exciting goal. \n\nHow important was education in the household?\n\nExtremely.  \n\nCan you give some examples of what a typical view?\n\nI’m the oldest. And when I got to be a freshman in high school my parents were not so sure that the public high school…at that time, middle school was [grades] seven, eight, and nine and high school was ten, eleven, and twelve. And they weren’t quite comfortable with the public high school, so they offered me an opportunity to go to private school. And I said sure, why not. I started at Pem-Day, now the Pembroke Hill School, in the tenth grade. There were a lot of people that started a lot earlier than tenth grade and yet I didn’t feel any difficulty fitting in. It was a small class and it was very academically challenging and socially supportive environment for me. And then my sister, who is three and a half years younger than me, did the same thing. She switched from public school to private school. And then my brother said my older siblings are doing that, I’ll do it too. And then my youngest brother said if everybody else is doing it, I’ll do it too. But he didn’t like it, so he went back to public school and finished. But the family ethos was you want to get a really good education. \n\nSo education was looked at as sort of a way to advance yourself or to get that career you wanted?\n\nI think education was looked at in my family as a basic foundation. You will do what you will do, but you will get a good education.   \n\nAnd if you had that foundation then you can just sort of build onto that?\n\nRight. And of course my sister and I went way beyond college. \n\nDo you have any stories or other memories from your childhood that you’d like to share?\n\nI’ll tell you one. We had a family doctor who was a pediatrician. And my experience of a physician in the 1950s was an older gentleman with a big black bag and lots of needles in it who would come to your house. I didn’t like getting sick because I had to miss school and other stuff. But it also meant the doctor, who was a wonderful doctor, I mean we loved him, but he would always give me a shot. I think it was really just to show my mother that he was doing something. But that was my experience. I don’t ever remember going to the doctor’s office.   \n\nThe doctors always made house calls?\n\nYeah. I mean I’m sure I did but I just don’t remember it. What I remember is the house calls.\n\nDo you remember the doctor’s name?\n\nSidney Pakula. \n\nAnd this was still all in Fairway?\n\nI don’t know where his office was. But it didn’t matter, he came to my house.  \n\nAnd he did the same thing for your sister and brothers? Did he take care of the whole family basically?\n\nNo, just the kids. \n\nLike you said, this was the ‘50s. And that’s just something that physicians did back then, they made house calls, basically from cradle to cradle.\n\nOf course when I went into practice in rural California, in a little town, I ended up making house calls because that was part of what you did when you were the only physician in town and the only doctor’s office in town. Only I didn’t generally do it on kids. I was making house calls on frail elderly. \n\nSo you saw the whole spectrum then?\n\nOh, yes. \n\nWe’ll get to that. And actually I have been to Modesto a couple of times myself.\n\nGood for you. \n\nI spent 22 years in Long Beach in Orange County.\n\nSouthern California is a different state. \n\nYes. I’ve been up to Modesto and San Francisco a few times. Nice country. It’s a little on the pricey side now.\n\nOh, during the house recession in ’90, the prices in Modesto and Stockton fell terribly. You could get a real bargain. \n\nYeah, I’ve seen stories. I still have friends who live out there and will tell me what a house used to go for and what it’s going for now. If I still lived out there, I might look into it. Like you said, we’ll get to that.  \n\nSo we’ve kind of touched on your childhood. You said you went to the Pembroke School. And you didn’t really have a problem going to a private school compared to the public school. You said you seemed to blend in.\n\nI offered my kids the same options. For example, my son Max went to Pembroke Hill and my daughter went to Shawnee Mission East. And I think they both got excellent educations. Although for their personalities, I think they should have been reversed. I think Abby would have done better at a small school like Pembroke Hill and I think Max would have done better at Shawnee Mission East. It’s just a matter of what your personality is like. I thrived in that small environment.   \n\nWhat was it about Pembroke? Were there any [favorite] teachers? Or the nature of the school itself was small class sizes?\n\nAll of the above. First of all, you’re dealing with a population, all of whom choose to be there. So there isn’t a single person there who doesn’t want to be in that environment, and that’s important. And their families are all very supportive. The teachers are just terrific. When you’re at a private school, they can get anybody they want to teach. They actually have a lot more flexibility. You don’t have to have the same credentials when you’re in private school. Now I never knew what credentials my teachers had. I just knew they were outstanding. And they cared a lot about the students and they all wanted you to get into a good college. So that was a good environment. Plus, you have the opportunity, when you’re in a small environment, to do things like sports that you might not qualify for. Like I wrestled my three years in high school. I’m not sure I was really good enough to wrestle at Shawnee Mission, but I could wrestle at Pembroke. \n\nSo it’s more of…cozy’s not the right word, but congenial maybe?\n\nI’m not sure those are the right words either. I’m not sure I can figure out an adjective to describe it other than it’s intellectually challenging and committed. It’s socially very supportive. It provides opportunities, because of the small environment, that sometimes you don’t get in a larger environment. No one is a number. Everyone is well-known in a small environment. It’s a little bit like going to a rural school where everyone is known. \n\nEveryone knows everybody. Nurturing is the word that came to mind.\n\nYeah, nurturing. That’s a good word. \n\nI’m not familiar with the area still per se. So where is Pembroke in relation to…\n\nShawnee Mission Parkway and State Line. There’s a lower school campus at 51st and Wornall. Those are the campuses. But when I was there, it was just one campus.   \n\nAnd the school there now, like you said there’s a lower school and then the high school itself?\n\nYeah, the middle school and high school are the Ward Parkway campus and the lower school is on the Wornall campus. They merged with a girl’s school, Sunset Hill. So now it’s co-ed. I had 54 boys in my graduating class, my son had 96 boys and girls in his graduating class.   \n\nSo that is a pretty small…\n\nWe still have class reunions too. \n\nWhen did you graduate from Pembroke Hill?\n\n’65. The end of the idyllic period in America.   \n\nYou mentioned the ‘50s. What was that like growing up in that era, the ‘50s? I mean you hear people who sort of are nostalgic for it.\n\nOh, it’s very nostalgic. Everything changed when Kennedy was assassinated. That is the big defining change between the ‘50s. Of course, that was ’63. But the early ‘60s were the same environment. Kennedy’s assassination changed everything. And that started a new era. It wasn’t dramatic, overnight. It became dramatic in ’67 and ’68 with the Summer of Love and then in ’68 with the assassinations of Martin Luther King and Robert Kennedy. Then everything changed after that. But it really started with Kennedy’s assassination. Until then it was a very idyllic, nostalgic environment. \n\nWhat are your recollections of the first Kennedy assassination?\n\nEveryone remembers where they were on 9/11. Everybody my age remembers where they were when Kennedy was assassinated because it was that big a deal. I was up in the attic of the school working on the newspaper, I was a reporter for the high school newspaper. And somebody went around to every room in the school letting people know that there was an assembly. Then we were all dismissed to go home. It was an extremely traumatic experience. No one knew how to explain it or understand it. Even though this is not the first presidential assassination that’s ever happened in the United States, there have been several, but not in a long time. And we were very unprepared for it. \n\nThe first one was McKinley? \n\nI think so. \n\nThat was before WWI.\n\nRight. \n\nWhat were your parents’ or siblings’ reactions to all that?\n\nEverybody’s reaction was disbelief and horror and sadness and fear and now what? And what does this mean? And then it was okay, President Johnson took the oath of office on Air Force One and now we at least have a President, we’re relieved. He was a known quantity. He wasn’t an unknown like some Vice Presidents, so that was good. I participated as a volunteer in the 1964 Democratic National Convention in Atlantic City. I took a bus all the way across the country just hoping I could get a job there, and I did. But I’m not sure I would have done that if Kennedy hadn’t been assassinated.   \n\nSo that sort of galvanized you, in a way, to take more action?\n\nYes. Not just me. \n\nSo it had an effect on…\n\nOn the whole generation. \n\nInitially the assassinations of John F. Kennedy, Robert Kennedy and Martin Luther King, Malcolm X…\n\nThe Vietnam War…\n\nI mean all of those different events in a relatively short amount of time must have just…\n\nKing and Robert Kennedy were assassinated when I was in college. And college is always a transitional crucible for anyone who goes to college. And I probably was a little young and probably not even quite ready for college. But when those things happened, that was really galvanizing. And then there was a lot of protest against the Vietnam War when I was in college. Now you understand, this is an audiotape so that if anybody ever listened to this, they can’t tell that I’m actually dressed in a tie and a sport coat. This is the way I dressed in college. I went to the University of Pennsylvania and a lot of the time I spent in a sport coat and a tie until around the time when the assassinations took place and the sit-ins in Houston Hall and College Hall. And I remember vividly dressed like this, going up to the scruffy-looking crowd that was sitting in, in the President’s office. And I was pretty naïve and trying to figure out what the heck they wanted and how did they think they were going to get it. And much to my surprise, they got all their demands met. Well, that was an eye-opener about social action and about non-violent protest and civil disobedience. And I don’t recall wearing a tie much after that. But it also continued to galvanize me personally about what I was going to do with my life and how I was going to do it. That was a very seminal experience. \n\nThat’s funny because I’ve interviewed a couple of other people who were born around the same time as you and they both talked about how living and going to college and sort of growing up during that time, the effects that it had. And they also had mentioned sort of the social changes and the effect that had on them and the rest of the country as well.\n\nWhen I worked here at the Academy one of my staff took a sabbatical. She did interviews of men in a veteran’s home and asked them questions about what was the most important thing in your life. This was an older generation. The people she interviewed were my parent’s generation. And one of the things that I found so fascinating about that, the generation ahead of me, my parent’s generation, was that they all talked about World War II. That was the seminal experience of their lives. Even more than the Depression, it was World War II. And when you asked them who the most important people in their lives were, other than their family, it was always Franklin Roosevelt and Adolf Hitler. Those were the people who changed the world in my parent’s generation. \n\nMost people from that era, Roosevelt was the only president that they knew. And Hitler was and still is a symbol of evil, tyranny, oppression, you name it.  \n\nYou mentioned that you went to the University of Pennsylvania. What made you choose Penn?\n\nBecause I went to a private boy’s school and the expectation was that you get into a “good” college. Now that doesn’t mean everybody went to an Ivy League school, but there was some pressure to do that. And so my parents thought that would be a good idea. I don’t think they realized how much it would cost. But I had no objection. You have to understand, I didn’t really have a lot of experience or knowledge or wisdom at that time. And a lot of the Pembroke Hill graduates had gone to Penn and other schools as well. So they had a recruiter who came to town and talked to me and I thought it sounded good. I went to visit and it looked good, so I said fine. I was fortunate enough to get in. \n\nDid you look at any other schools besides Penn?\n\nI did look at some other schools. Most of them were back east. I remember looking at Amherst, at Princeton, and so on. But I ended up going to Penn. \n\nWhat made you choose that school? Just the other people from Pembroke who had gone?\n\nYeah, and the recruiter. \n\nWhat was your major?\n\nEnglish Literature. And I’ll never regret it. I’m so glad I majored in English Literature. It’s helped me understand society and culture and it’s helped me write. It was an excellent preparation for being a physician. Of course I had to take a lot of science courses. But when I went to college I wasn’t planning on being a physician. I still had no idea. There were no physician role models in my family. If you had asked me when I went to college, physician would never have been one of my choices. I was in my second year of college, and I think I mentioned that I consider myself a little too young to go to college and not really being ready and I think that showed the first year. So I left school and I went to work in New York City as a singer in singing group. And I did that for half a year. And then my father said come home, we need to talk. And what he wanted to do was have me go back to school. And I knew he was right, so I did. And then when I went back to school, I got sick. I had a really bad case of mononucleosis. Had mono hepatitis and all sorts of stuff and I was in the hospital for almost two weeks. There was a young African-American intern who would come into my room every day, draw my blood, ask me how I was. I spent most of the time sleeping. But I would see him twice a day and he became my new role model. And as I got better over the course of a ten- or twelve-day hospitalization I came to the realization that I was wasting my college experience and that I needed to have a goal. I was still pretty young and ignorant and inexperienced. So I thought my choices were I could go into my father’s business, I could go into medicine like this guy who came into my room every day or I could do something else. And I wasn’t sure what was in that category of something else. So I decided well, let me think about this for a minute. This young man is helping people. Every time he interacts with someone, he’s helping them. He’s never going to be out of a job. He’s going to be intellectually challenged for the whole rest of his life. I think I’ll do that. So when I left the hospital, one of the first things I did was went and found out who the pre-med advisor was. Now you understand, I had just come back to school after having left school, hadn’t done well my first year. Now I’d been sick and missed a lot of class. So that semester was pretty wasted. The only reason I graduated on time was I went every summer from that point on. But he looked in my file…I’ll never forget this, I’ve told this story before…and he opened my file and he started laughing.  \n\nAt your grades?\n\nYes. He said given your history, there’s no way you’re going to get in medical school. Think of something else. And I was really upset. I was very angry. So I said, I’ll show you. So I became motivated, went to summer school, etc., and ultimately went to medical school. But I have to thank him. He had a very strongly-motivating reaction to my career choice. \n\nHaving someone look at your file and laughing at you, that would be a motivating factor.\n\nRight. And he was right, of course. \n\nBut like you said, it was your first year and you were a little young. A lot of people go through that.\n\nI know that now but I didn’t know that at the time. \n\nHow old were you?\n\nI was seventeen. By that time I was probably nineteen, when that happened. \n\nStill, that’s pretty young. There are several questions that are arising based on what you just told me. Start with New York City first off. How did you end up in New York City as a singer?\n\nWhen I was in high school I joined the high school glee club. It had a very charismatic leader. It was a very good glee club. And they had plays that they did as well. It’s a small school, so you got to do a lot of things. So I joined the glee club. And in my three years of high school I went from a tenor to a bass. And the good thing about the director of the glee club was that he taught you a lot. And I had done piano when I was young, so I had a good grounding in music. But he really taught you a lot of music and I learned a great deal about music theory and music history and choral works and so on and I loved to sing. And it was fun because the glee club was large. Small school, large glee club. This was not some wimpy thing that people did. This was something that people from all over the school…football players did it, basketball players, everybody did it. So then I went to college and I had a very good preparation. So I tried out for the glee club at Penn. Now the glee club at Penn, I didn’t know, but it turns out to be one of the world class glee clubs. And I’ll never forget the audition. I mean I really aced the audition. A lot of it was sight reading and a lot of it was going things like singing the National Anthem with the syncopated rhythms by sight, which I could do. And so I got to be in the Penn glee club. I got to be in a small group called the Penn Pipers which was a traveling group. We traveled all over the East. Went to a lot of girls’ schools. And got to be in the Penn Players and the Mask and Wig Society and so on. So I had a lot of history with singing to begin with. So when I wasn’t doing well that first year in college…actually, this is a funny story…one of the other basses in the glee club was a real jerk, at least I thought he was a jerk. And actually I wasn’t the only one who thought he was a jerk. But he had a friend in New York City who was a producer. And the producer came to campus to recruit people to sing in New York City. Particularly guys who were graduated. So a friend of mine decided we’d go to the audition. He was a tenor and I was a bass. And we succeeded in the audition. \n\nHe signed you to a contract or something?\n\nYeah, we joined this group called the Lange Mano Singers. This was Art Lange who came. And Jack Mano was the other guy. Then we went off in the spring of that year to New York City and he got us a job. Our basic job was to sing in the stage show at Radio City Music Hall in between the movies. We had five shows a day. And then in between there would be movies. And during that time you’d go off and get your laundry done. You could only watch the movie once or twice. It was a great movie, but you can’t watch it…and the irony was, this guy who was this other bass that I didn’t like, he didn’t get one of these jobs even though he brought the guy there. And then toward the end of the summer, this friend of mine and I, who had gotten this gig, because we had lots of other gigs in New York City…we sang in the Rainbow Room and some other places…we decided to audition for a Broadway musical because the other six people in this group of eight were professionals, and then my friend and I who were college students. They have to find their next job, so they’re always auditioning. So we went with one of them to audition for a Broadway musical and we got in. So I called my dad and said isn’t this exciting. And that’s when he said why don’t you come home and let’s talk about this. So I never got to do it. \n\nYou didn’t get to be in it?\n\nNo, in the Golden Rainbow, Steve [Lawrence] and Eydie Gorme. I don’t regret it, I went back to school. \n\nBut that could have been like a completely different career.\n\nIt could have, but it wasn’t going to be.   \n\nWhat was New York City like at that time for someone like you? You were eighteen, nineteen?\n\nI was nineteen. It was just a big city to me. The first place we lived was at a fraternity house on the Columbia [University] campus which happened to be in Harlem. We didn’t quite recognize that at the time. We didn’t stay there very long. We found a basement apartment in a walk-up that was cheap and rode the subway everywhere. But we were working. We worked five shows a day, seven days a week. So all the time you really have is in between shows. \n\nNot a lot of time off to really…\n\nNo, but late at night after the last show, we would go down to the Village, to Greenwich Village. And there were a lot of clubs down there. I saw a lot of good music down there.   \n\nDo any artists, performers stand out to you, that you got to see?\n\nNo, I don’t remember in particular. I’m sure there were named artists down there. I just don’t happen to remember. Probably the most interesting thing was when you work at Radio City Music Hall…the other group that works at Radio City Music Hall is the Rockettes. And so who would accompany us down to the Village but some of the Rockettes. So that was a lot of fun. \n\nYeah, that’s not bad for a guy eighteen, nineteen years old, professional dancers. I’m from New York originally, so I can imagine that experience. So you end up getting sick. Were you in New York when you got sick? How did that tie in?\n\nNo, it was after I got back, when I came back and my dad convinced me. It didn’t take much convincing to go back to school. And then I got sick. \n\nAnd this intern that took care of you, what was his name? Do you remember?\n\nI have no idea. \n\nDid you ever get to meet him or talk to him after your illness?\n\nNo.\n\nI was just wondering if…\n\nHe doesn’t have any idea, the impact he had on me.   \n\nI didn’t know if maybe you got a chance to talk to him about it.\n\nNo.\n\nSo you have mono, you get sick. This intern has this effect on you and you have this discussion with the pre-med advisor. Tell us about what you ended up doing. You ended up graduating on time. Where did you go to medical school?\n\nI came back home to the University of Kansas.   \n\nTell us a little bit about your experiences there, at that medical school.\n\nKU is a very good medical school. It was at the time and it is now. That was 1969 when I started medical school. The key to that era was, that was the Vietnam War era. And I had already been kind of activated at college by that experience with the people that were sitting in at College Hall. So when I came back to medical school I discovered that there were a lot of politically active people in the medical school and I fit in really well with them. There was a guy, Ed Martin…this is where I start to get role models beyond my parents, at this point. Ed Martin was the Executive Director of an organization called the Greater Kansas City Council of Student Professional Organizations. And he was several years older than me. He graduated. I think Ed is retired now. He worked for the federal government. But I took over that role. That was a grant-funded organization. And for a couple of years, as a full-time medical student I was the paid Executive Director of the Greater Kansas City Council of Student Professional Organizations. And we had students from medicine, nursing, social work, pharmacy, dentistry, just a whole bunch of different groups. Very socially active. We had a clinic in Kansas City, Kansas. We had a home health project. We worked the Greystone community. I’m not even sure Greystone is still there in Kansas City, Kansas. But it was a very socially active time and a very socially active group. I had the privilege of serving as medic in two marches on Washington. And serving as a medic was a very unique experience. First of all, almost all you deal with as a medic in a march on Washington at that time were two things: talking people down from LSD trips and dealing with tear gas. Almost nothing else happened in the hospital. We were in the basement of a church. And I remember vividly watching huge crowds that were protesting in Washington at the time. And any vehicle that would come into those crowds, police cards, fire trucks, whatever, they would all get tipped over. The crowd would just ascend on them like ants on a beetle or something and tip them over, except the ambulance. If a truck had a red cross on it, they’d get through to wherever they were going. They would pick up people, they’d bring them into our hospital. That was a very interesting experience, to watch that happen.   \n\nThis was 1969, 1970 or so?\n\nThis would have been ’70 and ‘71.\n\nHow did you get involved with being a medic? Was this part of the professional organization?  \n\nYes. And when you’re getting politically activated, you find all of the opportunities to do that. And you find the people who will support that, people like Ed Martin and Bob Graham who was the CEO of the Academy [1985-2000], who was three or four years ahead of me in medical school. You find people like that who are active and wise and can be role models for you and get you in touch with people and help you understand what you can do and should do and be mentors for you and so. So you find out those things. \n\nNowadays it’s easy to have that type of organization. You’ve got Facebook, all the social media and so on.  \n\nWe didn’t even have cell phones. \n\nRight, you didn’t even have cell phones. So how did you organize? How did you assemble as a group?\n\nLots of word of mouth. Lots of posters and fliers. You meet periodically. You have regular meetings. There was a Mennonite church on Rainbow Boulevard. It’s not there now. But we’d meet regularly at the Mennonite church. At certain times of the week you would know that’s where the people would be. And then there were fliers and posters that would get put up all over the school and all over that church and other places in the community. That’s how you found out about those things. \n\nSo let’s of legwork and lots of word of mouth. And this is still all while you were going to KU?\n\nYes.\n\nSo you were commuting back and forth from Lawrence to here?\n\nNo, med school is here in Kansas City, Kansas. \n\nIsn’t there a med school on the campus in Lawrence as well?\n\nNo, med school is the Kansas City, Kansas campus. \n\nThe one on 39th Street?\n\nRight. And I also belonged to the American Medical Student Association. It was called the Student American Medical Association at the time. And I chaired their National Community Health Committee. So that gave me some additional contact. That’s where I met Dan Ostergaard, for example, who I’ve been friends with since then. Because he was also active in the Student American Medical Association. \n\nSo there were all sorts of connections between these different members of the Academy that you wouldn’t even think about I guess until you have an interview like this.\n\nWell, Dan and I know about it. We think about it a lot. But you wouldn’t know about it unless I was interviewed, that’s true. \n\nThat’s the whole reason we’re having the oral histories.\n\nExcept you’re the only one who is ever going to hear it – and my mother!\n\nYou never know.\n\nSo you’re at KU. Did you originally go into family medicine?\n\nThat’s a really good question. At the time, family medicine was a new specialty. Remember, family medicine became a specialty in 1969. That was the day I entered medical school. So it was just building. There were just a few family medicine residencies out of the GP era – 12 at the beginning. I graduated in ’74. So in ’73 when I was looking for residencies, by now I have all this political experience. I made a decision to do family medicine. It wasn’t easy because there weren’t a lot of family medicine choices. We fortunately did have a Department of Family Medicine at KU and that was critical. But I thought about internal medicine and I thought about psychiatry. But I ended up in family medicine mostly because it was new, it was political and it seemed like it was the one that was closest to the people. You know, this was a power to the people era. And this was the one that was really going to serve people. This is where I really learned how to be a servant leader in family medicine. This was not about going into medicine to make a lot of money. Those of us who went into family medicine at that time did it for political reasons. We wanted to be in there to serve the people and find a vehicle for doing that. And so after looking at internal medicine and looking at psychiatry, I chose family medicine. Then having done that, it was now where? Because there were a handful, and only a handful, of highly progressive, politically active family medicine residencies. Montefiore, which is where Ed Martin went, in pediatrics. Cook County in Chicago, L.A. County, San Francisco General Hospital. Those were the ones I knew about. Because this is ’73. This is only three years after the first residencies were started.   \n\nSo I decided I wanted to go to San Francisco mostly because I was out looking around and I didn’t want to go back east. I had no clue about Chicago. So I went west. My sister and brother were out west. I went to visit. I went looking at lots of different residencies and deduced San Francisco was perfect, and it was. So I applied and ranked a lot of them. And I was just so hopeful I would get into San Francisco, and I did. \n\nDescribe what your training was like.\n\nSan Francisco General Hospital. Oh my god, it’s really hard to describe this in a short period of time, but I’ll try. It was absolutely a crucible for training in medicine in any specialty. This is a big county hospital. Everything happens at a big county hospital. A very indigent population with one exception. San Francisco is divided diagonally by Market Street. There are two hospitals south of Market Street and about twenty north of Market Street. The two south of Market Street serve a very poor and indigent and mostly Latino, but not Mexican-American – all other Latino countries except Mexico. The Mexicans at the time were in the Central Valley. North of Market Street served middle class and upper middle class. So the exception was that we were the trauma center and we were the coronary care unit. So if you were the mayor or the governor on a visit or whatever and you were in a car accident or you had a heart attack, you came to us. And so our coronary care unit was state-of-the-art and it was gorgeous. This was also before resident duty hours. So the chief resident in cardiology and the coronary care unit lived in the coronary care unit for a month. No days off. I was a family medicine resident and we rotated on everybody else’s service. Got outstanding education. We were treated like everybody else. When we rotated on trauma surgery, it was every-other-night call, 24 [hours] on, 24 off. Our only complaint was that we were missing the stuff that happened on our 24 off. We were on call otherwise every third night for all of the other services. When I was on the internal medicine service as a senior resident, I supervised internal medicine interns and residents. Can’t do that anymore. Internal medicine won’t let any non-internists supervise them anymore. But at that time, as a family medicine resident I was treated like a senior resident on the service and I managed the service. Obstetrics, I remember nights wandering the hospital, looking out at the city from the sixth floor of the hospital which was where the obstetrics unit was thinking you’re out there, you’re coming to see me, come on. Because you get multiple deliveries every night. And if you had a few minutes to spare, you’d just look out and say somewhere out there you’re on your way to come see me.   \n\nSo there was a lot more, you were all sort of colleagues, you were sort of equal?\n\nYes. And then I was very active as a resident. This was a politically active residency. I ended up helping to found the housestaff association, the housestaff union. And my job as first co-president (there were two of us who were co-presidents), my responsibilities were to serve on the hospital’s executive committee. That was great. What an opportunity as a resident to get up and say things like you know, if you want to improve the quality of care and improve the patient outcomes and so on, you probably ought to hire professionals to do some of the scut work like drawing blood and wheeling people to X-Ray and not rely on your first-year residents to do this because they have more important things to do. I mean what an opportunity to say that to the leadership.  \n\n(Break.)\n\nTo get back real quick, you were talking about being on the executive committee and being a resident. What was it like having that ability to tell the committee what you thought should be done?\n\nIt felt powerful and powerless at the same time. This was unprecedented. There had never been a resident on the executive committee of the hospital, so it was a wonderful opportunity. I also looked at it as a learning experience because I really didn’t have a lot of expectations that they were going to make all the changes that we needed. But on the other hand, I thought eventually they would. And you’ve got to start somewhere and I had the opportunity to be there to tell them things that maybe they hadn’t heard before or hadn’t thought of before. And it was in an environment in which I have a full voice. I’m a voting member of the hospital executive committee. So it was just a tremendous learning experience. \n\nThe other people on the committee, were they also physicians or more like administrators?\n\nBoth, And some community people.   \n\nSo there were people that had experience and they could understand what you were…\n\nYes. That doesn’t mean they were supportive. Remember, that was the time when everybody needs to suffer like I suffered. You know, why should we make it easier for you? It was hard for me, it should be hard for you.  \n\nSo you’ve got to learn the ropes a little bit. You’ve got to go through fire.\n\nYeah, like dancing.   \n\nI understand that. You talked about the ‘70s and the Vietnam era and I just want to ask…Did you end up serving in the military at all?\n\nNo. Remember, that was the time of the lottery. And my lottery number was like 273 or something like that. Everybody is nervous when the lottery comes out. When I started medical school there were deferments. But then the deferments went away and everybody got a lottery number and it was just whatever your lottery number was.   \n\nDid you have any colleagues or coworkers who ended up getting drafted?\n\nYes.\n\nWhat was that experience like, either for them…Or did you end up treating veterans or seeing them at the hospital at all?\n\nThis is two different eras. The draft occurred when I was in medical school. So yes, there were a couple of classmates, fortunately not very many, who got drafted. And they just disappeared and went off into the military. And by the time they came back they were either in a different class or they didn’t come back or whatever. I don’t know other schools, but in medical school, for whatever reason, we had a tendency to be very close with the people in our class and not in the other classes. We were in class with one group, not another group. We were on rotations at a certain level and then you get to the next level with your peers. So once somebody dropped a class…this happened to me. I took a year off from medical school too but for a different reason, to teach as a teaching assistant. I needed to earn some money because I always had a job when I was in college and in medical school. So I took a year off as a teaching assistant, so I finished a year late. When I came back with a different class, it was like I hardly knew anybody.   \n\nHow did those other classmates treat you or approach you when you entered that? Was it sort of a fish out of water type thing?\n\nA little bit. Nobody was hostile or anything. It’s just we weren’t good friends. There were a couple of exceptions. There were a couple of people that I had been active with in politics and so on. And then I ended up sharing a house with one of the other students who was in a different class. It’s interesting how this happened, it’s a whole different story. One of the African-American students…and you can imagine at the time, there weren’t a lot of women in our classes and there weren’t a lot of African-Americans. But I ended up sharing a house with one of the African-American students, so I became friends with him and his friends. And his friends were in lots of different classes because there was only a handful of African-American students in this school. So I got to know those folks as well. And then just a couple of others. Like I got to know Larry Anderson. Larry is a physician in Wichita. He’s been active in the Academy. Served on lots of commissions of the Academy. Larry and I were classmates together. And he was a front row classmate because he had already been to vet[erinary] school and he was really motivated. I was a back row classmate. And yet somehow we became friends and knew one another. So you never know exactly how it’s going to work out. \n\nSo you’re in this residency. You’re working at San Francisco. Like you said, it’s a big county hospital. After you finished your residency, what did you end up doing?\n\nThe residency in San Francisco is designed to produce family physicians to serve the safety net population of the urban San Francisco Bay area. They are extremely successful in doing that. And I’m sure were it not for having met my wife, I would have done it too. But go back to that day when I met the woman who became my wife, who was a surgical intern in the emergency room, with two kids, she made a decision that as a single mom with two kids it wasn’t going to be realistic for her to do a full surgical residency. There were very few women in surgery. And to have two kids and try to do a surgical residency just wasn’t going to work. So she ended up finishing in family medicine. Well, the rules in family medicine are if you’re going to finish a family medicine residency, you have to do two consecutive years. So she became a year off kilter from me. I graduated a year before she did. And she went down to Modesto (this is where we come to Modesto) to do her residency. So I needed to find something to do in or around Modesto. So in the middle of my final year of residency, the family physician, the solo family doc in the little town of Hughson, population 2940, twenty miles southeast of Modesto, committed suicide and left the town without a physician. They hired a young Chicano physician named Gabe Martinez who was a GP, he finished an internship only. And I committed to joining that practice. I finished my residency on June 30 and I started my practice on July 1. The only vacation I got was a few days to take my board exam at the end of July. And that was just an outstanding experience. Gabe and I served that community for several years. We ended up recruiting a few more docs. All of us taught in the residency program in Modesto. Eventually I became the Director of the residency program in Modesto. But I practiced in that community for nine years. Just one of the most wonderful experiences ever. Gabe ultimately left and went back to New Mexico, which is where he was from. And I hired a guy from the San Francisco residency to come out to Modesto three years after me. Not somebody that I knew at all. He said I’ll try it, and he stayed sixteen years. It was a very good area to practice and it was a very good residency program. \n\nAbout the practice in Hughson, what types of challenges did you face there?\n\nBeing a family physician in a rural community and the only medical office in town. There was a dental office. My last six months of residency, I wasn’t sure what I was going to need to do. I had a bunch of elective time and I took an elective in dentistry. And I worked in the dental clinic for a month at San Francisco General Hospital. I learned to pull teeth and to administer dental anesthesia because I didn’t know what I was going to need. It turns out I went to a community that had a dentist. They also had a pharmacist and one doctor’s office. We ended up hiring a physician assistant. So there were two docs and a physician assistant. And eventually four docs and a physician assistant. But it was just you see everyone in the community. You’re twenty miles away from Modesto. Modesto had a population of 80,000 and it was a pretty well-served medical community. So there were people who would go to Modesto for their healthcare. I’ll never forget, one of them, the mayor of the town who was not my patient, he would drive to Modesto to get his healthcare. But the cardiologist wanted him to have cardiac bypass surgery. Now you need to understand, one of the finest cardiac surgery hospitals in California was in Modesto, of all places. And he came to me for a second opinion. I reviewed all his labs and talked to his docs and said yes, you need it. But 40% of our patient population was Spanish speaking. Lots of others were very interesting ethnic groups like Assyrians, Italian, a lot of Portuguese dairy farmers. A lot of folks go into practice in small communities, and some of my graduates did this, because I ended up not only running that residency but going to the University and directing the whole network of all the residencies in North California affiliated with UC Davis. Some of the graduates who went to rural communities would feel really taken advantage of when they’re the only physician in the community. People would be sitting on their steps when they came home at night, after hours. That never happened to me. I was never abused by my community. And when Gabe and I were the only docs there, Gabe didn’t do hospital work, he didn’t deliver babies and he didn’t take call. So I did all of it. And just absolutely fabulous learning experience. The fortunate thing was I had the residency program as my backup. So I did deliver babies but I didn’t do C-sections. So I could get somebody from the residency program, if I needed it. \n\nAnd they’d come out and assist or you could refer them to …\n\nI would assist. They would do the C-section.   \n\nYou mentioned all of the different ethnic groups. What types of barriers or obstacles did you come across when you were treating all these different patients?\n\nThere are language barriers and there are cultural barriers. I learned medical Spanish pretty well. The problem with learning medical Spanish is that if you start using it, the families think you can speak Spanish. And they start speaking personal and family things with you and I’m going wait, I’m not really fluent in Spanish. I got to the point where I could understand pretty well. I wasn’t so good in Italian and Portuguese and Assyrian. So there would be translators that would come. Family members – they would just bring their translators with them. And then you had to be culturally sensitive. But then we taught that in the residency. One of the strengths of my residency was its behavioral science. And we learned, especially in a place like San Francisco with all the different populations, about cultural sensitivity. \n\nSo you saw pretty much everything though when you were there?\n\nYes.\n\nWhat was a typical day like, a typical week?\n\nIt wasn’t long after I practice…in the third year I was already doing a lot of work on the residency. And then at the end of my third year, I became the residency director. This is very early in one’s career to be a residency director, three years out of your own residency. But it’s a small community and the residency director gave two weeks’ notice in June, when you get new residents in July. And so the hospital administrator, the medical director who also became one of my mentors, Phil Botte (?), came to me and said would you take over as residency director? And I said no, I’m too young, I’ve got a practice, etc. He left and came back a day or two later and said Norm, I can’t find anybody else. You’re residency trained. We need someone who knows what a residency is to run this residency. And I said alright. So that meant I couldn’t work full-time in my practice. So I was only out there three half-days a week in the beginning and only two half-days a week later on. That’s when I went to San Francisco and recruited Sandy Lawrence to come to Hughson and take over that practice. But I would go out there two or three times a week. Because I was the residency director in Modesto now and I would think my god, I’m trying to do a full-time job on 70% time and I’ve got to run a residency and recruit faculty and recruit residents and support them and teach them and negotiate with all the other specialists for their training. I don’t have time to go back out to Hughson and see patients. But I would do it. And then I would get out there and interact with the community and the patients one-on-one. And I would sit there at the end of a summer’s day with the screen door open behind my desk writing my charts and I would think why do I do anything else? This is what it’s all about, being a doc here in this rural community. Then of course I would have to go back to the rat race in Modesto. \n\nAnd how long did you end up doing this for?\n\nI arrived in Hughson in 1977 and I left in 1986. Nine years Went to the University of California.   \n\nTalk about the residency program in Modesto. This was at Scenic General Hospital?  \n\nRight.   \n\nHow similar was it? Or what were the differences say between the hospital in Modesto versus the hospital in San Francisco?\n\nNight and day. The hospital in San Francisco was a big county hospital, urban environment, all the specialists in the world, academic docs. The hospital in Modesto, a community hospital, a county hospital, indigent population. One residency and only one. Family medicine was the only residency. We had a senior surgical resident from UC Davis who would come down and spend some time with us. No OR residents of any kind. A multi-specialty group with nine family docs and eight other specialists who ran the place. In 1981 we had a contract with the county of Stanislaus to do indigent care. It was an accountable care organization. 2012 that’s what we’re building. That’s what we were. We got a budget, said that’s all the money you’re getting for the year to take care of the indigent. You go take care of them. And if there’s something you can’t do like cardiovascular surgery, you’ve got to go negotiate prices. We negotiated with the hospital in the community. They wanted to charge us too much. We said we’re going to do our cardiac care in Stockton. And they said alright, we’ll meet Stockton’s price. And when you run out of money at the end of the year, the last three weeks of the year, you’re giving away care because there’s no more money. But you’re also doing the best you could at the time. The quality movement hadn’t even started yet. But you’re doing morbidity and mortality conferences and chart reviews and doing everything you can to improve the care because you want to teach your residents how to do quality care while you’re managing the entire of a population. And at the same time, you’re teaching residents and medical students and nurse practitioners and physician assistant students from UC Davis. It was a marvelous environment. Excellent residency. UC Davis had a very good reputation. The Modesto program had a good reputation. We had six positions a year to start. Eventually we increased to eight. And we would have over 400 applicants for six positions. I mean you couldn’t even interview that many. So we got the best residents available.   \n\nAnd these were people from across the country?\n\nAll over. The commitment was if we’re going to train you, we’re going to train you to practice in rural California, and most of them did.   \n\nBut you can take those skills and transfer them pretty much anywhere.\n\nYes. But people don’t want to come. If you’re going to practice in the big city, you’re going to go to an academic health center. If you want to practice in a rural community, you come to a residency like Modesto which is going to train you to deliver babies and assist in surgery and lots of burn care and stuff like that. \n\nBut for people who when they finish their residency want to go back and work in a small town, this sounds like the ideal program for them.\n\nYes. And there were others. That’s what UC Davis was all about. When I moved up to UC Davis and became the director of the network, all the programs in the network including the program in Sacramento itself had a goal of producing family physicians for rural northern California, That’s what UC Davis was created for, a new medical school. That was its purpose.   \n\nI do have some question on UC Davis. But just a couple more on Modesto real quick. You talk about it being an indigent care program. How was it financed? The money came from the state?\n\nThe county. We did fee-for-service too. We took care of Medicaid. It was called Medi-Cal. And Medicare. And a little private insurance. But we were funded by the county budget. And then eventually, because we did such a good job, we got the contract to take care of all the county employees and they weren’t indigent. So now you have that whole group to take care of as well. But again, you have a limited budget. The county of Stanislaus did not have deep pockets. You get this money and this is what you get. \n\nAnd so even if they increased the number of patients with these employees, they wouldn’t give you any additional money?\n\nYeah, they would if they increased the number of county employees. They didn’t have control over the number of indigents. We had to negotiate that on a year-to-year basis. But it was a friendly negotiation because it was like what else are they going to do? We’re going to take care of them and they’re going to pay whatever they can pay. And we’re going to train residents and we’re all in this together. They got money from Medicare like all training programs do. Graduate in Medical Education and Indirect Medical Education Subsidies. And that became very important. And when you’re a small county hospital like that, it can make all the difference in the world. You get it because you’re a training program. That’s still true today. \n\nSo that still applies now as well?\n\nYes.\n\nDirecting sort of a smaller program like this, when something would come up, who would you turn to? Who would you consult with for ideas on how to run the program or how to improve it?\n\nThere’s two answers. First, the hospital had a medical director who was outstanding, Bill Botte (?). And he was a gastroenterologist who did a lot of primary care as well. But we were affiliated with the University of California-Davis. We weren’t alone. And so every month I would meet with my other directors from the other seven University of California-Davis affiliated programs: Merced, Stockton, Sacramento, Martinez, Redding, etc. And there was a full-time faculty member at UC Davis who ran the network, Bob Davidson. And he became a strong mentor of mine. He eventually became chair and recruited me to come up to UC Davis. But there was a lot of support. And the Academy offered training. They offered national programs, so I would go to the Academy’s programs in Kansas City. And the Society of Teachers of Family Medicine offered national programs and I would go to their programs. And the state of California offered educational programs because they were training people all over the state. So we became part of that network too.   \n\nIs the program still in existence in Modesto?\n\nOh, yes. I think they’re up to ten residents a year.   \n\nDo you know who’s running it now?\n\nPeter Broderick. \n\nAre you still in touch with the people in Modesto?\n\nYes. Actually, I just went back to San Francisco for the fortieth anniversary of that program. Not the fortieth anniversary of my graduation but the fortieth anniversary of starting the program. 1972 was the first year of the San Francisco program. They just had a big program and I went back and was on the program for that. I went to one of the Modesto reunions a few years ago but I haven’t been to a lot. \n\nSo you’re in Modesto and in 1986 you said you ended up taking a position at UC Davis?\n\nThat was the most difficult transition I’ve ever made. Leaving my practice was much harder than I thought it would be. And making the transition from a small community hospital to a big academic medical center and all that politics, a very traumatic transition. But I did it. I commuted for ten months. It took me that long to sell my house in Hughson.   \n\nHow long of a commute are we talking about?\n\nAn hour and a half each way. I would stay with one of my chief residents that graduated and was in practice in Sacramento. I would stay at his house one night. And I was on call a couple of times a week, so I would stay in the call room. So I actually only had to make the drive a few times a week. I didn’t make the drive every day.   \n\nWhat made it so traumatic?\n\nAcademic health centers are a very different environment than community hospitals. Lots of politics. Lots of backstabbing. Different motivations. It’s very individualistic. You’ve got to get ahead, you’ve got to publish, you’ve got to get promoted. There was a lot of competition between the departments. I’m used to an environment in which there was only one residency and there’s no competition. Every single physician of every kind supported that residency. Now UC Davis, to their credit, there was a lot of support for family medicine there because that was their reason for being. Sometimes you have competition with other departments like pediatrics or obstetrics. I did not have that problem to a great degree at UC Davis. But I went up there to be the director of the network and to be the assistant dean for AHEC, Area Health Education Center. And I worked for the dean, Edward Williams (?), to run the California statewide AHEC program and the Network of Affiliated Residencies. And shortly after I got there, they made me director of the residency at Sacramento as well. And I turned to my chair, Bob Davidson, and I said this is a lot more than I bargained for. You want me to be a full-time residency director and director of your network of affiliated programs all over northern California and assistant dean for AHEC and do research and publish and see patients and take call every third night, which eventually we hired more faculty so it was every fifth night, and do obstetrics, which is what we wanted to do in that program. I said this is too much.   \n\nSo how did you resolve that?\n\nIt wasn’t resolved completely to my satisfaction or I think to Bob’s satisfaction. But I did get to work with several outstanding…Jeff Tangey (?) was my assistant residency director. And I basically said to him “Jeff, any time you want the title of residency director, you’ve got it.” He said ‘I don’t want it.” I said “Well, you’re going to be it.” And he essentially ran the Sacramento residency as the assistant director. And Tom Nesbitt who became my research mentor, I would research with him. And Jose Arevalo who we hired and participated in our teaching and Walt Morgan. We ended up having five full-time faculty who shared OB call. We never had OB call before in family medicine. So it was a very powerful experience. But that was not my favorite time.\n\nHow long were you at UC Davis?\n\nFive years. \n\nYou mentioned some of these people. What was your impression of your colleagues? What was it about them that you enjoyed working with them? Or were there any difficulties that you had?\n\nFor the most part, when you’re in family medicine you feel like you’ve got something to prove. At least you did then because it was so new. So we were all in it together. And I ended up hiring a lot of people. So when you hire somebody, they have a commitment to you. And the guys I didn’t hire I ended up working very well with. And when you’re doing something new like OB call and you’re all going to be in a rotation and you’re working on it together and it’s creating something new, you have a good bonding with them. So those people I just mentioned, Jeff and Tom and Jose and Walt and I, we bonded very well. And then of course you have residents. And they’re just the most wonderful people in the world and you bond really well with them. I’ve followed some of my residents. I just had a resident who was president of the American Geriatric Society and she represented her organization to my current organization. She was my chief resident. I got a call last night from one my chief residents in Virginia who wanted my advice on something. So those kinds of relationships are just tremendous. \n\nAnd those are people that you worked with twenty, twenty-five years ago but you’re still in touch with them?  \n\nYes.  \n\nThat’s got to be a pretty good feeling.  \n\nYes.\n\nWhat was it that you enjoyed the most about UC Davis and what was it that you enjoyed the least?\n\nThis is going to be a short conversation. I didn’t enjoy a lot about UC Davis. I enjoyed learning. I learned a lot of medical politics there. The AHEC was a very good experience. The Network of Affiliated Residencies was wonderful because that was where I had come from. We all had the same goal. We all wanted to produce family physicians for rural northern California. Now I was in a position to help the directors. When I had been a director and Bob had been in a position to help me. Now I was in that position myself. OB call, there is nothing more rewarding in the world than obstetrics, than delivering a baby. It’s a hassle to do it in the middle of the night. It’s a hassle to do it in the middle of your clinic. It’s never predictable. But other than that, it’s just incredibly rewarding. I ended up, my favorite OB story is the last baby I ever delivered when I was leaving UC Davis was my chief resident. She had one of our women faculty as her doc. But the woman faculty member was out of town at a Society of Teachers of Family Medicine meeting with everybody else. And I was the one that year who got to stay home and do OB call while everybody else was gone. So she goes into labor while I’m on call. She had a very complicated labor and I managed it. I remember giving her some medicine to help her speed up the labor. And then we did a fetal monitoring and the heart rate of the fetus didn’t look good. So I asked the nurse to stop that medicine which meant that her labor was going to take longer. Now this is my chief resident, you understand. She knows all the nurses. She’s delivered babies herself. When I walked out of the room, she turned to the nurse and she said “Don’t touch that medicine.” And she delivered about thirty minutes later a perfectly healthy baby.   \n\nSo she knew everything that was going on.\n\nShe knew everything that was going on. She wanted that baby out.   \n\nAnd that’s the last baby that you delivered?\n\nThat’s the last baby I delivered. \n\nThat’s a good way to go out, I guess.\n\nLike the patient I assisted on in surgery before I left Modesto. A young man with severe back pain and a herniated disk. And you know those surgeries don’t always work. And we assisted on his surgery and he had a miraculous recovery. And he just went back to work and he was in great shape and he was so thankful. And I thought aren’t you lucky. A nice way to finish, but not everybody has a good result. \n\nSo you had been at Davis for five years. And in 1991…\n\nDan Ostergaard calls me and he says I need someone who is tricultural. I said what? Understand, I’ve known Dan since medical school. We didn’t go to the same medical school, we were just active in the Student American Medical Association. He said yeah, Jane Murray is leaving to go be Chair of Family Medicine at Kansas and I need someone who has been in practice, who’s been in a community hospital family medicine residency setting and who’s been in an academic health center – and that’s you. And I said I’m busy. I’ve got all this work to do and stuff. I’m in California. I like California. He said yeah, I need you. So I came and I interviewed. We were in the building on Ward Parkway. I came in the winter and there was an ice storm. And it was one of those storms where you couldn’t get from your car to the door of the building without slipping on the ice. So I walked into the interview and I said you know if I hadn’t grown up here, this would really turn me off. But obviously I ended up taking the job. \n\n  \n\nThat was an easy transition. It was easy for my family. We drove across country. My two older boys were grown and out of the house by then. They said they were staying in California. My son was starting in eighth grade, my daughter in fourth grade. We drove across country listening to Garrison Keillor the whole way. We stopped in Winnemucca, Nevada and Cheyenne, Wyoming and all these wonderful places. Had a great trip. Two months later my older boy said we’re coming too. And they got in their car and they drove here and they’ve been here ever since.   \n\nInteresting story. So it was that simple, just a phone call from Dan Ostergaard and…\n\nWell, I had to come for a couple of interviews and I talked to Dan and to Bob Graham. And I went back and I talked to Bill Botte (?) and Bob Davidson who had been my mentors in Modesto and UC Davis. And Bill Botte said something to me I’ll never forget. He was very encouraging of my going. But he said Norm, I always knew this was going to happen to you. This is the time when you’re going to have to give up practice. Because I practiced at UC Davis. Not much but two or three days a week I practiced, plus the OB call and the teaching call. He just pointed that out – and of course he was right. And Bob Davidson was getting ready to turn the Chair role over to Klea Bertakis anyway, so he was very encouraging. And Dan was a good salesperson. And it was a great opportunity to work at the national level. I found it very humbling. And I had learned so much, I wanted the opportunity to give back. And it was my hometown and I had a support system here. So I said yes.   \n\nSo when you came back, it’s not like you were completely out of the loop? You knew people here, you knew the area?\n\nRight. \n\nBut still, that had to be difficult giving up the practice?\n\nNo, giving up the practice in Sacramento was not as hard as giving it up in Hughson. Because in Hughson they were my patients. That was my practice. That was my base. And they depended on me, it was the only office in town. In Sacramento, by that time I was practicing two days a week. We were on teams. There were other people that took care of the patients. A lot of them saw residents anyway. That was not so difficult. \n\nDo you ever think about going back into practice?\n\nSure. That’s my greatest fantasy. When things in administration get really difficult, I think I’m going to go out and do a geriatric fellowship. I’m boarded in geriatrics but I never did a fellowship. I’ll go out and do my re-entry by doing a one-year geriatric fellowship. Those positions don’t fill around the country. There are open positions. Then I’ll go out and take care of old people the way I want to be taken care of when I’m old. I may never do it, but that’s my fantasy.\n\n \n\nWe’ll get to that at the end of the interview. So tell me about these people. Dr. Ostergaard, you’ve mentioned him a few times. What was he like to work with here at the Academy?\n\nWell, great. You have to understand, I’ve known Dan for a long time and I have always had a lot of respect for him. We’ve had very similar backgrounds in some respects. I never had the missionary experience that he did, but I respected that in him. But he was a very good supervisor. And he hired me for a specific reason and he basically said do this and I’m going to supervise you and ask you if you’ve done this. And this is how you’re going to be measured. But I’m not going to tell you how to do it. But there are some things that I know better than you, like running the RAP program, the Residency Assistance Program, now Residency Solutions and so on. He was a terrific supervisor. One of the things that I’ve learned, and I’ve told other people this that I’ve hired, I tell them don’t expect to feel like you’re competent after the first year. It takes longer than that. I was in my third year at the Academy before I felt competent, before I knew what I was doing. I talk about political action, I had been very politically active but not in family medicine. I had never run for office in California. I’d been on lots of committees in California but not elected. I was asked by people to serve because of my expertise. So I had no idea. Mike, this is the truth – when I came to work at the Academy and the politics of the Academy opened up before me, the people that are out there serving on commissions and trying to become president and all that…I was going holy cow, I had no idea people cared that much and did that. I had to learn that because I’d staffed a couple of commission. I had to help those people and mentor them and guide them in how they did a good job and how they were eventually going to run for the Board and stuff like that. Man, that was an eye opener for me. I had no idea about that stuff. \n\nYeah, there’s a big difference between being appointed to a committee and trying to run for the presidency of it.\n\nAnd I respect that. But it just wasn’t part of my life. I just never even saw it happening.   \n\nWere there any committees that you ran for, that you had to go through all of that?\n\nNever. We haven’t even gotten to AFMRD, the Association of Family Medicine Residency Directors. Maybe we’ll get to that. I’ll tell you how I got involved in that. It’s very similar. That was not something that I intended to do. That was not something I asked for. It wasn’t a goal of mine. It was an accident. \n\nActually there are questions about the AFMRD that I have on the list and we can get to those shortly. But if you want, we’ll focus on the AAFP now. Tell me, at the AAFP you were Director of Education and Vice President for Science and Education.\n\nEight years Director of Education, eight years Vice President for Science and Education, right. \n\nSo tell me a little about those responsibilities. \n\nYou know from my history I’ve been mostly in graduate medical education. But I was in an academic center, so I did undergraduate. I taught some CME courses but I didn’t know much about CME, continuing medical education. I get here, they’re all three of them under my responsibility. I feel pretty comfortable about graduate education. I had been a RAP consultant. Now I was running RAP. It was like I had been a program director. Now when I went to Davis, I was supervising other program directors. I had been a consultant, now I was supervising other consultants. No problem there. But continuing education – suddenly I realized that undergraduate education is only four years (five in my case). Graduate is only three years, four if you do a fellowship. Continuing education is the entire career. This is far more important, and I had no experience with it. So I really delved into continuing education. Now that doesn’t mean I ignored the others. I didn’t. We had some very strong successes in graduate medical education and undergraduate too. But it became clear to me that continuing education was the most important because that’s where you’re assuring the patient population of America. More people see family physicians than any other kind of doctor. As a matter of fact, more people see family physicians than pediatricians and obstetricians combined. Almost more than pediatricians and internists combined. So if you’re going to do continuing education, what you’re doing is you are enhancing the care that’s being provided out there in America to the bulk of America. This is a big deal. \n\nDid you have like an epiphany that this is something… \n\nI did.  \n\nCan you tell me about it?\n\nIt’s like you just said – it was sort of an epiphany. I mean I realized when I took the job that this was where I needed to devote my efforts. \n\nWho did you turn to for advice at that point?\n\nWell, Dan most because Dan had been ahead of me in all of these things. And then Bob Graham to some extent. And then I got to know people over time. I got to know Dennis Wentz at the American Medical Association. When I started, the American Medical Association was very nasty to family medicine and to our continuing education. By the time I finished, Dennis was singing our praises and he was talking about how family medicine started continuing education, which we did in 1948 and so on. But he was a very strong person and mentor. And eventually Murray Kopelow at the ACCME who is still there. So there are some pretty strong people in continuing education to learn from. \n\nJust to kind of touch on that comment you made real quick about Dennis Wentz…Why do you think the AMA would have had such a nasty reaction to continuing education?\n\nBecause we were outliers. We were not active in the AMA and continuing education. There were three groups that ran continuing education credit systems and still are: the AMA, which is the big one. But they didn’t start until 1968. We started in 1948. Our system, which is different than the AMA system. We don’t use the ACCME. We don’t accredit providers and then turn them loose. We accredit every single program. And then the osteopaths. And the osteopaths have always been outliers. We work very closely with them now. They’ve also kept themselves a little insulated. So when people would come to the AMA and complain about continuing education, if it was the AMA they were complaining about, they could take care of it. If it was the osteopaths or the family physicians, they would say they don’t know what they’re doing. Well, that’s because we weren’t there, neither the osteopaths nor the family physicians were there. So we integrated ourselves heavily into the AMA system. When I hired Nancy Davis, Nancy and I ended up serving on the two AMA task forces that created the two new forms of CME, Performance Improvement CME and Point of Care CME. And I ended up being appointed to the national task force. Took over for Dan, his position. But the AMA convened. So once we got well-integrated and they came to understand what we were doing and understand that we’ve been doing it longer than them and understand that we had already solved some of the problems by reviewing every program that they hadn’t solved by turning people loose, they began to have more respect for us. \n\nThat’s why there were some of those bad feelings, part of it I guess that you were outliers but that maybe you knew something they didn’t in a way?\n\nOh, I don’t think they thought that at the time. I think they were much more arrogant at the time. I don’t think they thought we knew something they didn’t. I thought they thought we didn’t know anything. \n\nAnd it turns out that…\n\nWe knew more than they did. \n\nSpeaking of continuing medical education and all of these other committees, you have been on probably three dozen or so different committees, commissions, you name it, while you were involved with the AAFP (I looked at your CV). What was it like being involved in all of those different committees?\n\nTwo things in all of them: One, it’s an opportunity to learn. Every one of those was a learning experience. I learn by being immersed in things. That’s just the way I learn. I don’t learn very well if you just talk to me. If you make me get involved in it, I learn better. So they were all learning experience. And you learn twice as well from bad experiences as you do from good ones. So when you have experience like that with the AMA, that will teach you a lot. And then the second is it’s the opportunity to give back. It’s the opportunity to make a change. I became activated in medical school and I committed myself to being a change agent. That’s why I wanted to go to a political residency, a socially-active residency. And everywhere I’ve gone, I’ve recognized that I have a lot to learn. And that when I learn and I’m on that Dreyfus scale from novice to beginner to advanced beginner to competent to expert to master; when I’m on that scale, however far along I am on that scale, I need to do something. I’m a Conservative Jew. And the motto of Conservative Judaism is Tikkun Olam, it’s a Hebrew phrase that means “Repair the world.” And that’s basically what I’m trying to do. It’s not all that different from what Dan does.\n\nRepair the world. That’s interesting – I kind of like that. Out of all of these different committees, all of the different projects you worked on with the Academy, what do you consider your greatest accomplishments or achievements while you were working there?  \n\nWell, Future of Family Medicine probably. You know, that was a big deal. I think the Future of Family Medicine Project was very important and very successful. And I think you can find ways in which it…let me give you just one example of many – the patient-centered medical home. We did not invent that term. We freely credit the pediatricians with inventing that. In 1968 the American Academy of Pediatrics created the patient-centered medical home to try to take care of children with special needs who were growing up. Never caught on until we put it in the Future of Family Medicine report with the permission of the pediatricians. And actually we had pediatricians involved in the project. I was privileged to serve on the committee that did the Future of Pediatrics and so I reciprocated and I invited Pediatrics to serve on the Future of Family Medicine. That patient-centered medical home is now the foundation of the system in the Accountable Care Organizations. There are all sorts of demonstration projects that are going on. That’s important. That’s going to improve care. That’s going to meet people’s needs. So the Future of Family Medicine Project was very important. And there were some little things. One of the things I liked about being at the national level is you get to do things and sometimes they work, a lot of times it’s frustrating. You try hard and they don’t. And Dan has said this, and others have said it too, but I learned it from Dan…he would always say it’s amazing how much you can accomplish if you don’t have to take the credit for it. That’s one of the reasons I didn’t like academic health centers because that’s not a motto of academic health centers. You have to personally take credit for things in academic health centers to get promoted. \n\nPeople want their name on it?\n\nRight. So there are whole lots of things that you don’t know about. Actually there’s some things Dan doesn’t know about. But there are a whole lot of things that you’ll never know about that we got to do just working here at the national level. Perhaps one of the most important at the time, and it’s still lasting, is this primary care exception to the Medicare payments. Medicare for teaching. Medicare passed an act, it was an administrative change fifteen years ago. They were just trying to save money. They weren’t going to pay supervising physicians who were supervising residents because they weren’t the one who actually saw the patient. And they weren’t going to pay the resident because the resident was already getting paid through this program as a salary. So they weren’t going to pay for that care unless the supervising physician did it themselves. And so we negotiated a little bit about what exactly what it is that supervising physicians had to do. I’ll never forget this: Charlie Huntington was the Director of the Washington Office at the time. And he and I and Hope Wittenberg went to meet with Medicare and convinced them that you cannot train primary care physicians, particularly family physicians, but general internists and general pediatricians, by having them watch someone else do something. They have to do it themselves under supervision. And if the service is provided, you need to pay for it. You can’t have a service provided and not pay for it. That’s fraud. And it worked. It’s called the “Primary Care Exception.” They accepted the primary care setting. So now a supervisor still has to go in and see the patient, but they just have to corroborate what the resident did in order to bill for that particular service. And that way the resident gets supervised, the patient gets cared for and the payment is made. \n\nAnd the resident gets the experience.\n\nAnd the resident gets the experience and they get trained and they can be a real doc. But when you work at the national level you have opportunities to do that, that nobody else gets and you have to take advantage of them. That’s why you’re there. \n\nYou mentioned the Future of Family Medicine Project as one thing you’re really proud of. Are there any projects or any goals that you had in mind or something that you wanted to achieve or wished you could have achieved but were unable to?\n\nI’m going to answer it in a funny way, but I’m going to tell you about two other successes, neither of which ended up being a success in and of itself but spawned something else. The first is called Quality Points. In 1997 we had this idea that continuing medical education needed to evolve beyond lectures. The message of continuing education was “Trust me, I’m keeping up.” But it was not measurable. And we said what we really need to do with continuing education is show that the quality of care is improving. Bruce Bagley was the President-Elect of the Academy at that time. He became President in 1998. And he took this on as his focus. And of course now he works full-time in it. But we created Quality Points as a way, a pilot. Well, Quality Points had a short life. But now we have Performance CME as of 2005. So it took from 1997 to 2005 and it’s called something different. But that’s what we were after. We were after Performance Improvement CME and it happened. But what we started didn’t. I don’t know what the other example was that I was going to give you. \n\nWhat did you enjoy most about working at the Academy or just being involved with the Academy on a professional level?\n\nOh, my gosh, it’s just marvelous. I mean who gets to work at the national level? That’s just special. That’s just a great opportunity. First of all, you get the opportunity to go so many places and learn so much. You get to work with the best. The people that work at the national level are the best. You have tremendous mentoring. San and Bob were just tremendous mentoring – and mentors in other fields, in other organizations. And you have this opportunity to make social change. There is nothing more rewarding than being a physician in a rural community. Taking care of individual patients and helping them, there’s nothing more rewarding than that. If you’re going to make the choice, in my career I got prepared to do something different. I learned a different set of skills and I kept getting called on to use those different set of skills. Well, if you’re going to do it, you want to be able to say that you’re having an impact. That you’re making a difference, you’re making change. The national level is just an incredible vehicle to do that. So I was very privileged. \n\nYeah, where else can you have that big of an impact but at the national level?\n\nRight.   \n\nWhat did you enjoy the least?\n\nI can’t really think of anything. I mean I loved it. So I don’t know that there was anything I really didn’t enjoy. I mean there were a lot of things I didn’t like about academics, about the university system. But working at the Academy, I can’t answer your question. \n\nYou were involved in the Academy for sixteen years. You’ve been a member for how many decades?\n\nSince I was a resident. \n\nHow have you seen the Academy itself grow and change over time? And what do you think about where it is now?\n\nObviously the Academy has grown. It hasn’t changed a whole lot in my lifetime. I know it changed from being a GP academy to an FP academy. That was a huge change. But that happened before my time. The Academy has been a leader.   \n\nI know the other thing I was going to tell you about – it was evidence-based CME. It’s happening now but in a different way than we started it. But I’ll take a pass on that one.   \n\nSo the Academy has changed but not a whole lot. I mean it’s still the organization of family physicians. It still represents family physicians. Individually it still represents the specialty of family medicine. Externally it’s still unique. There is no other organization of practicing generalists. I don’t think the Academy has filled its potential yet. And I don’t think it’s completely the Academy’s fault. I think it’s because in America we are the only developed nation that doesn’t enfranchise the whole population. So there is not a primary care-based delivery system in America where there are in other countries. If there were, we’d have a much more important role. \n\nSo like in the UK they have the National Health Service?\n\nIn every developed nation. Yes, the UK, Canada, you name it. The Netherlands, France, Switzerland, Germany. We don’t learn from other countries very well.   \n\nI’m taking a health administration class on health policy in the United States. And one of the discussions we’ve had is a comparison between the health care system in the US and the other…just the delivery method and the payment structure. Yeah, you can say we have a lot to learn.\n\nBefore I go to any other questions, I know we’re nearing the end of this tape, the second hour. So I’m going to ask you in advance if you want to stick around and we can cover questions about the AFMRD and the specialty societies?\n\nMight as well. If you have the time, I have the time. Because I don’t know when I’m going to have the time again. \n\nDr. Kahn, let’s talk for a moment here about the AFMRD. You were a member, as I understand it, of the steering committee that led to the creation of the association. \n\nRight. \n\nSo how did you become involved with that and what was your role in helping the AFMRD come into being?\n\nAt the time I was at UC Davis and I was coming to the Academy’s Program Directors Workshops. I had been for a while. And you remember, I was always a political activist, so I was serving on various committees and so on. And we had come to a recognition, and I don’t mind admitting that I helped foster this recognition, that the Residency Review Committee which is an arm of the Accreditation Council for Graduate Medical Education. There’s a residency review committee in every specialty, twenty-four. It didn’t have any program directors on it. And it had had program directors on it, but they were all from academic centers. Eighty percent of the residency training in family medicine is in community hospitals, 4% in military and 16% in academic health centers. One out of six. And yet that 80% had never been represented on the RRC. And so they were making rules for how to run residencies and they had no input from the folks in community hospitals. \n\nSo the vast majority of the programs weren’t having any say really?\n\nRight. So we decided we wanted to change that, so we did a little work. And somebody got up to the microphone at the special meeting that we were holding. I wasn’t working at the Academy. I was at UC Davis. And said we need to form a committee to plan how we can be better organized. You understand, this was the Academy’s meeting. There was no AFRMD at the time. So they were saying we need to have political representation on the RRC. Maybe other places but certainly on the RRC. How are we going to get it? And so we said let’s form a committee to look into how we can do that. And they identified three community hospital program directors: Al Haley from Indiana, Chuck Payton from Southern California and Dick Layton from Washington state. And I’m in the audience and I’m thinking okay, this is going great. But then I had this realization that someday this is going to be more than just community hospital representation. This is going to be all programs. And so I got up to the microphone and I said I think this is great, this is just in the right direction. But I think on balance, now that we’ve selected three community hospital program directors for this planning committee, I think we probably ought to have a university hospital director on there too. And they said fine, will you do it? And I said alright sure, I’ll do it. And Jane Murray was the staff at the time. And so it was really the five of us who served on that group. And our goal was to get representation on the RRC. And the goal was to get community hospital representation on the RRC. So there were four or five options. But the two leading options were to become a subcommittee on the Commission on Education because then we could [have] all the Academy’s resources. We would be a subgroup of the Academy’s commission. Or we could form our own independent organization. But we’d never been an organization. We didn’t know how to do it, etc. We decided to do the former. So we went to meet with the Commission on Education Chair. I can see him, I can’t remember his name. And he was very wise and looked at us and said I understand what you want. You don’t want to be a subcommittee at the commission, you want to be an independent organization. And Jane will help you do it. And he was right. So we formed an independent organization. And the irony of course was that just because you built it doesn’t mean you’re going to get what you want. We didn’t report to the ACGME. But the ACGME, in their wisdom, said – because other programs did have a program director association. We just didn’t have one. Remember, we were a young specialty. And so the ACGME was used to dealing with program directors associations in other specialties. So it was easy for them to say okay, now that you exist you can be a nominating organization to the RRC independent of the Academy. It didn’t exactly totally work out that way. The RRCs are set up so that they have nominees from the AMA, they all do. From the certifying board, they all do. And from the specialty society, they almost all do. And RRC can solicit nominations beyond those three. But generally the nominees are going to come from those three. And so ironically as it turned out the AFMRD had to nominate to the Academy to get the nominations on the RRC. But the Academy was all in favor of this because Jane was the staff and we were coming to the Academy’s meeting to do this. And the Commission on Education Chair had given us guidance. So they were going to nominate whoever we nominated.  \n\nRight. They were just basically giving green lights.\n\nRight. And then of course it became independent and we hire our own staff and so on. And it had a lot of other things to do. But that was the reason that it was formed. \n\nYou were also on its first Board of Directors. What was the difference between being on the Board of Directors? Your organization is formed. It’s an independent agency. What was that like, getting that off the ground and then…\n\nI didn’t actually want to be on the Board of Directors. But Dick and Chuck and Al and I in forming AFMRD with Jane’s help, we set up a Board with a certain number of people and we said you know, it would probably be useful for continuity if we participated on the first Board. And so Dick Layton ran for President, Chuck ran for something else. Al Haley is the answer to a great trivia question: Who was the only leader in family medicine who was elected Immediate Past President of an organization? So we elected Al Haley, Immediate Past President. And I just took an At-Large position for a year. And actually I couldn’t even serve it out because I ended up coming to work for the Academy.   \n\nThat explains – Dr. Haley is one of the other people that we’re trying to get for an oral history. And in looking at the paperwork on him, the first thing you see is Immediate Past President of the AFMRD. So that’s not a typo?\n\nNo, it’s the real thing. He loved it, we all loved it. But again, he was there for a year, like I was, as member of the planning group for transition knowing that the only one who was going to stay on the Board was probably Dick because he was President. And he’d stay for another year as Past President. Chuck might have stayed two years too. \n\nSo it made sense to organize things that way?\n\nYes.\n\nSo in addition to AFMRD you were also a member of the Academic Council. And that created the National Institute for Program Director Development. How did that organization…\n\nRemember, what we’re trying to do here is we’re trying to enhance the ability of family medicine to serve the nation. And so if you’ve got program directors…the original group of program directors in the early 70s came out of general practice because there weren’t academic departments of family medicine either. So there were some really good people. But over a period of time in order to do a good job and to be competitive and so on, you have to prepare people. They have to be ready. And if they’re in community hospitals…think about it, who are you going to take? You’re going to go to a practicing family doc in town? Well, now – they’re not going to do it. They have a busy practice. Are you going to go to an academic faculty? Well, you’re not in an academic institution. So who are you going to get to be your director? Well, you’re going to name one of your faculty, Director. Fine, now he’s Director. Who’s going to mentor him? There are no other residencies in the community. So you take him to Kansas City once a year. Well, that’s not enough. But eventually you figure out to have the highest quality people you have to do continuing education that’s focused on them. And that’s why the National Institute for Program Director Development was formed. It was basically to take people who became residency directors and make sure they had the skills to do the job well. Because if they didn’t have the skills, they were going to get run over by their hospital administrators and run over by their academic department chairs and run over by the powerful departments in the hospital. \n\nSo in a way this institution has sort of helped protect family medicine?\n\nAbsolutely. It’s also helped prepare family medicine. But it has helped protect family medicine, sure. You know, when you’re a fellow you have to do a project. That project has to be real. Many projects were things like understand the hospital administration’s budget and where you fit. Well, that’s kind of important particularly when your hospital is getting money because they have a residency for you and they’re not telling you how much they’re getting and they’re not spending it on you. And if you do this project and you discover how much money they’re getting only because you exist, you have a lot more leverage. \n\nBut as a residency director you wouldn’t know how much money?\n\nNot only wouldn’t you know, you would never be told. Because information is power and the administration would keep that from the program directors.   \n\nWas that just for family medicine or would they do that for all residencies?\n\nNo, for everybody. But understand, 40% of family medicine programs, and there were 470 programs, so how many programs is that? That’s a lot of programs – were in community hospitals with no other residencies. There are no other program directors. It’s just you. And yet the hospital is getting millions of dollars a year because they exist. And then they’re telling you they can’t afford to build you a clinic and they can’t afford to do this. And if you don’t know how much money is coming in because of you, you have no leverage to negotiate.   \n\nBut once you find that out…\n\nOnce you do then you have leverage to negotiate. \n\nAnd the tables can turn.\n\nOr it might be educational programming. How do you develop a curriculum? If you’ve been a faculty in one area, how do you run a family medicine center? Let’s say they nominate you to be program director, you’ve been running the family medicine center but you haven’t been running the inpatient service. Well, you’ve got to know that. So there are lots of things that a director has to know. He or she is in charge of everything. \n\nBut there are things that you wouldn’t normally encounter in a normal residency program?\n\nRight. So our school became a model for others. And I ended up having the privilege of teaching in the OB/GYN program directors school which they started, modeled after ours.   \n\nModeled after family medicine?\n\nYes.  \n\nSo this specialty really has had an effect on the practice of medicine in general?\n\nSure.\n\nSo you talked about OB/Gyn. That’s another specialty. You left the Academy to join the Council of Medical Specialty Societies in 2008. What were your reasons for joining the Council?\n\nAt that time I had been at the Academy sixteen years. Eight years in one position and eight years in another. And go back and let’s take a look. I finished my residency and I go and practice in Hughson and I’m there for nine years. I’m residency director for six years in Modesto, five years in Sacramento. Then I come, eight years of this and eight years at that. There were cycles here. I’m getting toward the end of a cycle. I’ve never done anything for longer than nine years without reinventing myself. So it was the right time. And some people were very supportive. Doug was very supportive. I was working as one of the vice presidents at the time. And the Council of Medical Specialty Societies, it’s been around since 1965. Never had a full-time physician CEO. In the year 2000 they decided that they wanted one but they weren’t ready. And so they hired Walt McDonald, also who is now one of my mentors. I also talked to him yesterday too. Walt had been the CEO of [American College of Physicians-American Society of] Internal Medicine and he had retired. And he said “Oh god, I don’t want to be a full-time CEO again. I’ll do this half-time for a while just because I want to be helpful. But I’m an internist, not everybody is comfortable. Surgeons don’t always like internists. I want a deputy half-time who is a surgeon. And so we hired Bruce Spivey who is an ophthalmological surgeon.” And the two of them took the position and they stayed for seven years. Neither of them full-time. And they did a great job building it up. But it was a transition and the Council was ready to go to the next level. They wanted a full-time physician CEO. This happened in the summer of 2007. This was about the time when I was getting antsy and it was probably time for me to reinvent myself anyway. Doug was very supportive. Dan was very supportive. A couple of people out in the field strongly encouraged me to apply. I actually said no the first two times because I felt like I was married to family medicine. I felt like I was committed my whole career. I loved the Academy. But after the third person encouraged me and it was the right time, I said okay, I’ll take a look at it. And once I took a look at it, I realized that this was a good challenge and that this was actually a good job for a family physician. But I was prepared for a question that the search committee would ask, because the Board of Directors was the search committee. None of them were family physicians except Dan who was on the Board of CMSS. But of course he had to recuse himself because of our relationship. So he wasn’t part of the process. So I’m thinking to myself, I know the politics here. They’re going to look at me and say we just had the CEO of Internal Medicine, the largest organization in the world. We just had an ophthalmologic surgeon who’s known all over the world. You’re just a family doc. So I was prepared for this, why should we hire just a family physician? And doggone it, Mike, if I didn’t get that question. I was prepared for the answer and I said look, who better? When I was in practice in rural America, I have to use all of you to get the best care for my patients. When I was a residency director in academic setting, I had to go to all of you to get the best training for my residents to make sure they could provide the best care to their patients. I am used to dealing with all of you. And they said okay, fine.   \n\nYou were probably the only one in the room who could say that.\n\nRight. \n\nDo you remember offhand the specialty of the person who asked that question? Was it a surgeon?\n\nNo, I don’t remember. They all could have asked it, it doesn’t matter. Every one of them could have asked that. \n\nWhat was their reaction to your answer?\n\nThey were quite satisfied with the answer, obviously – they hired me.   \n\nSo how does your position now compare to what you were doing at the Academy?\n\nWhat I learned at the Academy prepared me very well for this position. And again, I have to thank Doug for all of the challenges that he gave me. And Dan and lots of other people as well. Being a vice president of the Academy is different in some ways from being an EVP. But you’re involved in all of the things that the EVP is involved in. So budgeting, the vice presidents deal with the budget very seriously. So even though I was never a CEO of a specialty society, I knew everything that they needed to do. I knew what was going on with them. So the first thing I did when I took over, even the month before I took over in December of 2007 is I started calling and I interviewed every one of the CEOs of my member organizations, one-on-one. And that’s now something I do every January. Started out with one-hour interviews. Now I do thirty-minute interviews. But I have a one-on-one with them every year because they’re my real constituency. They’re not my Board, they’re not my Council, but they’re the ones who pay the bills. They pay the dues. So this is the opportunity to help specialty societies succeed in some particular ways. We’re a very small organization. When you’re small you have to focus. We don’t have a lot of money. We don’t have a lot of staff. So we went through a strategic planning process. We had a consultant. We involved everybody who was active. All the CEOs, all the Council reps. Had a committee of sixteen, all the Board members. And we came up with a strategic plan, and we have two priorities. Really we have three. The first one is we’ll convene the member societies around things they want to be convened around. That’s fine. But the other two are the real meaty ones. And one of them says the Council of Medical Specialty Societies and its members: surgeons, the ophthalmologists, the internists, the pediatricians, the OBs, all of them – we will facilitate a culture of performance improvement in practice. And the second one is we will model professionalism as we define it. And we define professionalism as altruism, which is putting the needs of the patients first. We work very closely with the AMA. I like the AMA. For better or worse it has the reputation of putting doctors’ pocketbooks first. We’re going to be altruistic. We’re going to put patients’ needs first. Self-regulation which is part of the social contract of any profession, to self-regulate in society. And transparency, which is hard. Disclosure to peers, transparency to patients, transparency to the public. And we’ve been very successful on those two. It allows us to have the opportunity to get involved in medical education, continuing education, performance improvement, performance measure development, quality improvements, guidelines development. All of the things that are going to lead to performance improvement and better care. And it allows us to do something like we just did a year ago where we adopted a code to guide specialty societies’ behavior in relationship to industry. An ethical code for societies that have ethical relationships with industry. Because there’s so much pressure, so much money out there where people can get into some unethical things. So we give guidance to specialty societies. And this spring, I’m crossing my fingers and knocking on wood, we’ve got another code, another set of principles that’s going to come to a vote which is on how to develop efficient, effective and ethical clinical practice guidelines. And I have strong hopes that we’ll adopt that as well.   \n\nThese codes and the principles and guidelines that you’re talking about, how does that work in terms of the Council? Are these ideas presented by a specialty society and then they filter on up? Or is it the Council that comes up with these ideas and proposes it to the specialty societies?\n\nI’d like to say that we’re always proactive and we always operate under vision. But you know the two best ways to change are to have a common enemy or a common vision. A common vision is a lot harder than a common enemy. When you have a common enemy, bless it – and we did. We had a common enemy in Senator Grassley. He sent out a few years ago these things called “Grassley Grams.” And the Academy got one, the AMA got one basically saying “Show us how much money you got from industry. Where did that come from? What are you doing with it? What’s your relationship with industry?” The New York Times picked up on it. Front page in The New York Times, “Docs Take Millions from Industry.” You know, isn’t quality, whatever. Extremely embarrassing. So we reacted. Wasn’t all that proactive. And one of the CEOs got up in front of his peers (he happens to be a very proactive guy) and he said “We’ve got to take responsibility for this. There is no guidance for specialty societies. We need to create our own…this is professionalism.” Bless his heart. We tried it a year before and we came up with a little bit. It wasn’t good enough and Grassley wasn’t satisfied and The New York Times wasn’t satisfied, and he stood up. And we said “Fine, you’re the chair of the task force.” He said “Great, I’ll do it.” And we called up another organization, the Pharmaceutical Manufacturers and Research Organization, the organization of the industry, of the drug companies, and we said “You have a code. When your code was adopted nobody signed onto it. And then a few years later you revised it and everybody signed onto it. How did you do it?” And they said “First of all, we had to have a common enemy.” Got that. The second thing they said was “You’ve got to involve everybody. No small task force. No six-person task force.” And so we opened it up to all the organizations. We have thirty-eight organizations, we have thirty-six participants on the task force. All the general counsels got to vet it, all the lawyers. Tom Robinett worked on it for the Academy. And we ended up with a code and they adopted it. And then the issue was will the organizations individually sign on? To make a long story short, it’s hard for some organizations to sign on to somebody else’s ethical code. But we got thirty out of thirty-eight and that’s’ pretty good. Similarly, with the clinical guidelines I got invited to the Institute of Medicine, a prestigious group in Washington, to testify to their Committee on Clinical Guidelines. And the chair of the committee, in front of everyone, being recorded, he said “Norm, you represent the specialty societies. I have two challenges for you. You’ve got to harmonize these clinical guidelines. Patients can’t figure out if you have a guideline on atrial fibrillation from one group and a guideline on atrial fibrillation from another group and they say different things. And the second thing is you can’t even trust all these guidelines because there are no criteria out there for creating guidelines. I want you to do this.” I said thanks, I appreciate that. I took it home and I called up my organizations, and we did not have an organization of clinical guidelines. Internally we do have a lot. We have membership directors that all meet together. We have CME directors. WE have quality in performance. But the clinical guidelines folks didn’t. And I said we just got this public challenge from the Institute of Medicine. I think we need to respond. And to their credit, the societies nominated people. And that’s now our largest group out of ten. There are forty-eight members of that group. And they spent the last year plus, since January of 2010, working on a set of principles to make sure that when specialty societies develop guidelines, there are criteria and that everybody follows the same criteria and that they’re the highest standard criteria. And that’s going to come to a vote this May.  \n\nThat was going to lead into a question that kind of played off what you were saying. These guidelines, for instance…When a situation like that arises, how does the Council address it? \n\nIt seems like you just…\n\nYeah, like that. The Council has external representation and internal groups. The internal groups are great because they network and share best practices because they’re not competitors. There’s no other organization of family physicians. So if family medicine’s membership director goes and asks a question of internal medicine, they’re not competing for the same members, so they can network and share best practices. We have ten of those groups. They’re very valuable. But we’ve also tripled our external representation. So, for example, we are one of the professional self-regulatory groups. So all of the agencies that regulate medicine that medicine has set up, and some government agencies, we nominate to. So we have seats on the Board of the Accreditation Council for Graduate Medical Education. That group that has those RRCs that AFMRD was formed for, now we have four slots on the Board of the ACGME. We have sixty-two of those positions in various organizations. Some of them I serve in. But for most of them we ask our member organizations to nominate people. So, for example, the ACGME has a Committee on Institutional Accreditation. Every training institution in the country has to be accredited, and there’s a committee for that. Well, our nominee from the Council of Medical Specialty Societies is a family physician nominated by the Academy: Peter Nalin, Past President of AFMRD. So the Academy got that by nominating him to us and the Council nominated him to the ACGME and they selected him. \n\nI think I follow how that works. It sounds complicated but it also sounds like it’s having a…\n\nIf you want to have an impact and there’s an organization out there that governs graduate education. All the rules for graduate education are set by this organization for your specialty and every other specialty, you’re going to be governed by these rules. Wouldn’t you like to have some say in how they’re created? So you nominate to the group that does rules for your specialty. But then there’s larger things. There’s the whole institution. And then there’s overarching rule, like residency duty hours, that are for everybody. And they affect you and everybody. Wouldn’t you like to have some say on that level? So the Academy doesn’t have a say at that level but we do. And so we have sixty-two of those positions, and we simply open them up. Two of those ACGME director positions, two of our four are open coming at the end of this year. This is a very important position. Sometimes I have to go beat the bushes to get nominees for my member organizations. Not for this. We’re going to have far more nominees than we can deal with. And our nominating committee and our Board are going to have the best of the best to choose from. And we’re going to be able to nominate four people for two slots, and we’ll have far more than four nominees.   \n\nIt sounds like there are so many different layers. And it sounds very complicated, but it sounds like you’re just…\n\nThis is about professional self-regulation. Because it’s a profession, it’s not a trade and it’s not run by the government. So if you’re going to have the independence that a profession gets to have, in exchange for that, part of your social contract is you’re going to regulate yourself. So if you’re going to have graduate training programs, you have to have a regulatory mechanism in your profession of medicine, not family medicine, all of medicine, that society is satisfied with. And so we set up the ACGME. CMSS is one of the five members of the ACGME along with the American Hospital Association, the American Medical Association, the Association of American Medical Colleges, Council of Medical Specialty Societies and the American Board of Medical Specialties. So that’s how the profession gets together to regulate itself for graduate medical education. Well, we do the same thing for continuing medical education. We do the same thing for undergraduate medical education. We do the same thing now for quality improvement. We, at the CMSS level, have positions on those self-regulatory bodies that none of the specialty societies get individually without going through us. \n\nThat clarifies things. So you have a lot of influence, definitely, on the practice of medicine.\n\nWe try. As long as we really do, this will work. If we don’t have influence and we fail to succeed in our social contract, something nasty will happen. And that’s why we try so hard to make sure that we do a good job at this. \n\nSo you have to adhere to the professionalism. You have to keep putting the patients’ needs first. You have to self-regulate. And you have to be transparent.  \n\nWe think so.   \n\nWhat about the four other organizations that you mentioned? Do they have the same sort of structures in place?\n\nThere are actually a lot more than four. For the ACGME there’s only a total of five. For the ACCME there are seven. For the ABMS there are nine. But there’s a limited number. The ACCME has a similar structure. They have seven members. The ACGME has five members. We nominate two directors at the ACCME. So that’s very similar. The ABMS is a little different. We’re an associate member, not a full member of the ABMS. We don’t nominate directors but we do get to nominate people to their committees. So it’s a little different but it’s still part of professional self-regulation where the groups of the profession get together, create bodies to self-regulate in the areas that need to be done. Physicians Consortium for Performance Improvement, which is convened by the AMA but is not an AMA committee, has like 170 members. But they have an executive committee that’s smaller. I don’t actually know how many are on the executive committee. I’m going to guess there are a dozen, maybe fifteen. WE have one of the two veto-wielding positions on the executive committee, the AMA and the CMSS, because we represent the docs. So we have veto-wielding positions, the only two. That’s a very coveted position. I have one of my board members who has that position. So the answer to your question is those self-regulatory bodies in medicine are set up similarly but they’re not all identical. But the point is, there is input from the profession, from other organizations in some way to make sure that they have input into what the domain of that particular function is – quality improvement, continuing education, graduate education, undergraduate education, whatever it may be. This is my job. This is what I get to do. I have to know this stuff. If you want to come work for me, I’ll teach it all to you. \n\nI’m going to go to our final section here where I have questions about just sort of business philosophy, questions about the practice of family medicine itself.  \n\nHow has family medicine changed over the years, in your opinion?\n\nThe good news is it hasn’t changed a lot. The bad news is society needs to change to give family medicine its rightful role as the foundation of the health care delivery system, which it isn’t in the United States and it is virtually everywhere else. \n\nYou mentioned earlier, the other countries that have primary care…\n\nThe basic values of family medicine haven’t changed. It’s all about comprehensive care, continuity of care, patient relationships. And that’s because that’s a need that society has and that’s the need that family medicine fills. And to be honest with you, it fills it fare more than anybody else. That’s not a prideful competitive question; it’s just a definitional question. Even if you’re a general surgeon, that’s not really a generalist. That’s a surgeon. That’s a consultant. If you’re a general internist, yes. Or a general pediatrician, yes. But you’ve limited your patient population. And quite frankly, in the United States there aren’t that many general internists anymore. And while there are a lot of general pediatricians, the real challenge in pediatrics is subspecialty. They need more subspecialists. Everybody understands that. So family medicine needs to have that role and society hasn’t recognized that. \n\nWhere do you think family medicine is going as a profession or as it relates to society?\n\nWell the patient-centered medical home is where it needs to go. And people really need to…the real challenge for the Academy is to get family physicians of the present and future to fulfill the tenets of the patient-centered medical home. They need to do that. And that’s going to be a real challenge because family docs, like other docs, think that they can get out and practice and do whatever they want. And doing whatever you want is not part of the social contract. And most physicians of all specialties don’t really recognize, when they’re trying to make a living in practice, their role in the social contract. The leaders do but the individual docs don’t. And so that’s a real challenge for leadership. \n\nAnd that role would be?\n\nIn family medicine that role is to be the foundation of the health care delivery system. To function as a patient-centered medical home. To establish relationships that are ongoing. Not to abandon people throughout the system. To coordinate their care throughout the system. To either provide or make sure that their patients get everything that they need and stay with them throughout the process. To have electronic health records. To have same-day appointments that provide access to the patients. To be able to communicate with them asynchronously. All of those things that are part of the patient-centered medical home and more. To be able to measure their quality and show and document that they’re improving the quality of care measurably with data over time – that’s all part of being a patient-centered medical home. That’s a huge challenge and nobody else but family medicine can do it. Well, alright – general pediatricians can do it for pediatric population. General internists can do it for adult population. But for the population at large, that’s really the role that family medicine needs to play. \n\nAnd they’re really the only ones who can do that?\n\nThey’re really the ones, yes. \n\nWhat’s your opinion in general on the health care system in the U.S.?\n\nWhat system? That’s a rhetorical question. We have a terrible, we have a non-system in the United States. \n\nHow do you think it can be fixed? Or what do you think is possible?\n\nThe first thing we have to do is we have to enfranchise the entire population one way or the other. The Affordable Care Act is attempting to do that. It will either be upheld or struck down in June by the Supreme Court. If it’s upheld, fine – we need to implement it and we need to get everybody access to care. As soon as that happens, we’re going to recognize as a society what Massachusetts recognized, and other states that have done this, that oh my god, we don’t have enough people to provide the usual source of care, the relationship-centered primary care that we need. And they’re going to turn to family medicine, general internal medicine, general pediatrics. But in our country, we’re going to turn to others too. We’re going to turn to those 9% of cardiologists who do general internal medicine. We’re going to turn to nurse practitioners and physician assistants. It’s just the American way. But they really need to turn to family medicine. Family medicine needs to be prepared and not wait to be turned to. We need to be preparing to be the solution. If the Affordable Care Act is turned away then we face a real question in this society – and that is, does the majority of America feel that health care is a right or a privilege? And we behave like it’s a privilege. And if we continue to have like it’s a privilege then there will be nothing to replace the Affordable Care Act. If we behave like it’s a right then something else will have to happen. I don’t know what it would be. I know what every other country has done. You know what Winston Churchill used to say about America – we’ll always do the right thing after we’ve exhausted every other possibility. So we have to enfranchise the whole population. Of course, this is the guy who has committed to that since medical school talking to you. But that’s what the United States has to do. And then family medicine has to be prepared with quality and quantity. We have to be able to train enough people to do that and they have to all do it. We can’t risk training people who are going to go out into practice, and I’m going to show my generationality here…part of the generational issues is that because we don’t have a system and we don’t have strong expectations of what people do and people can do anything they want, there are just lots and lots of people who don’t want to take call. They don’t want to be available after hours. They don’t want to go to the hospital. They want a hospitalist to take care of the patients when they get admitted. They don’t want to deliver babies. It’s too inconvenient. If we’re going to provide a patient-centered medical home to the degree that we don’t do things ourselves, we have to be sure that our practice arranges for all of those things to be done in the maintenance of the continuity of relationship. So if I’m not going to go to the hospital and I’m going to use a hospitalist, I have to know that hospitalist really well and have really good communication. And I have to go to the hospital in person and make that transition so my patient sees it, so my patient will trust the hospitalist. And I have to trust the hospitalist. I can’t succeed by just saying that hospital has a hospitalist – I don’t know them, I don’t talk to them. That won’t work.  \n\nSo the family physician is going to have to fill in some gaps in the system. And if the family physician is unable or unwilling to fill in those gaps…\n\nYou asked how are we going to have a system in the United States. That’s the answer to how we’re going to have a system in the United States. We don’t have to do that. If we don’t do that, we won’t have a system in the United States. What happens if you don’t have a system?  \n\nYou have chaos.\n\nYeah. Unless you systematize things you can’t measure quality, you can’t have any expectations of improvement in quality, you can’t control costs. You have to have a system to be able to assure quality, to be able to control costs and so on. Sure, you can have chaos. I won’t even call it chaos. Just laissez faire, market economy, whatever you like to call it. But that’s what we have. We can’t control costs. We rank 37th in the world in quality.   \n\nWhat is your opinion on the Affordable Care Act? What do you think the Supreme Court is going to do?\n\nI don’t know. I would be flip if I said I don’t care. I personally care. But professionally I’m going to deal with whatever decision the Supreme Court makes and whatever the aftermath is. I’ve already hired a guy to come to my meeting in the fall after the election. The Supreme Court will have acted by then. But then there’s also the presidential election. And I’ve hired a guy to come, a professional consultant in Washington, actually from the firm that runs the Obama campaign, to talk about the implications of the election on health care. And he’ll deal with the Affordable Care Act as well. Because by then we’ll either be well into implementing it or we’ll be well into reacting to now what? And I’ll deal with it either way. But I’m not going to give up on my goal and I’m not going to give up on the answer to your question, which is the thing you have to start with first is enfranchising the entire population. You have to cover everybody. Access and coverage for everybody. \n\nNow I’m going off the questions here. But it just seems that the only way to do that…The other industrialized nations that you talk about, a lot of them seem to have increased taxes or there is some other mechanism for funding it. How is that going to be…Here they talk about it being a penalty.\n\nThis is the American way. We believe that taxes are evil. We believe that taxes are wrong. We believe that taxes are bad. We have a very low tax rate compared to other countries. We believe in individual success. Any time you talk about sharing your  money like that, they accuse you of being a socialist. Well, look at the western developed nations in Europe. They’re not socialist nations. If you go to a country like the Netherlands and you have a baby, they provide support for you in your home. If your mother needs to go to a nursing home, that doesn’t come out of your pocket. Well, their tax rate is much higher than ours in the United States. So what’s right? What’s your preference? Do you have a society in which people cannot afford to take care of their elderly parents and put them in skilled facilities or take care of them at home but you don’t pay a very high tax rate? I mean these are choices that you make as a society. They’re not right or wrong, they’re just choices. We happen to make a certain set of choices, and that’s what we get for it. \n\nIt’s a tradeoff. In the U.K. or Germany or Italy, people don’t to declare bankruptcy because of medical costs.\n\nRight. \n\nThey pay higher taxes but they also seem a lot more secure knowing that they don’t have that issue to deal with.\n\nAnd of course we could be like Greece where you have tax rates but nobody pays their taxes anyway. \n\nGet the best of both worlds.\n\nGet the best of both worlds, that’s right. \n\nGoing back to our questions here…What do you think are the qualities that make for a great family physician?  \n\nThere are a couple of qualities that are key. One is maturity. I’m on the clinical faculty of both KU and UMKC and I have served on the admissions committees and I’ve also served as a mentor for students at UMKC. And one of the concerns I’ve always had about the UMKC school, it’s pretty unique, it takes kids right out of high school. One of the reasons, in my opinion, that it has failed to meet its original goal which was to produce really good primary care clinicians is that the kids don’t have enough life experience. They don’t have enough maturity. It takes maturity to be a family physician. You have to have life experience. You have to really have empathy for your patients. You have to have been there, in their shoes. You have to really understand. You have to have failed at things. You have to have done other things. Then you have to have really good behavioral science training. That’s really one of the hallmarks of family medicine. Communication skills, both listening skills and speaking skills and communicating skills. Those are key. And then you have to have a commitment to your patients, their families, the communities that they come from. You have to recognize that there’s more than just the person who is in front of you. That even if you’re just seeing somebody, they have a family. And that whether you understand it or not, that’s part of whom you’re treating and that’s part of the care of the patient who is sitting in front of you. But when you’re a generalist and you’re a primary care provider, you are serving a community need. And to be a good family physician, you have to recognize the role you play in the community. Even if you’re in New York City, Boston, a big community, it’s not like being in a rural community where it’s clear when you’re the only medical office. You have to have a sense of the role that you play in the community and the importance of population health care.   \n\nBecause when you’re treating a patient, you’re not necessarily just treating that patient?\n\nNo. And you have to have a commitment to continuity. You can’t be a good family physicians and turn off your relationships with your patients at 5:00, turn off your relationships when you send them to a specialist, turn off your relationships when they go into labor, turn off your relationships when they go in the hospital. You have to have continuity with people. In the Future of Family Medicine Project, one of the things that we learned in interviewing people, patients all over the country, urban, rural, black, white, was the importance that they placed on having a relationship over time and throughout the system with their primary care provider, whoever it was. \n\nSo they’re not just a physician in some respects – they’re someone you can talk to. Like you said, you create that relationship. But it’s not something that exists in a vacuum.  \n\nYes.\n\nTell us about your leadership style. With all of the different committees that you’ve served on, all the different organizations you’ve worked with and for, your leadership style, your management style – how did you develop it? And how has it changed over the years?\n\nI think servant leadership is a term that’s kind of overused. Maybe it means different things to different people. But I’ve read some things about servant leadership. And when I read that, I say yeah, that’s what I do. That’s what Dan does. And that’s kind of what you expect a family physician to do. I have to operate with a clear goal and I have to recognize how everything I do leads to that goal, even if it’s going to be a long time and a lot of steps to get there. I get very impatient if I’m not working toward that goal. The two strategic priorities in my organization, they’re a pretty darn good fit for me: performance improvement and practice in professionalism, altruism, self-regulation, transparency. So I know when I’m not  working toward those and I get myself back on track. There are some things that I’ve done well over the years. I can run a meeting pretty well, so I get asked to do that a lot, which is fine. I can analyze a situation and give feedback to the group as to what just happened in situations, and so I do that a lot. And I find, for example, when I’m a conference call that’s scheduled for an hour, they usually don’t last an hour. Well, there are some exceptions. My Board always last an hour. But if I’m on a committee and I’m running the committee, I like to be efficient. I don’t like to waste anybody’s time. I really do believe in Dan’s advice about how much you can accomplish if you don’t need to take credit. And I’m going to go a step further and I’m going to say this is where it really shows: If I or anybody else was always taking credit for what I do, there are some natural consequences to that. First of all, people get tired of giving you credit. They get tired of personalizing your successes. And then you become a target and then they’re going to start looking for your failures and they’re going to try to bring you down. So I would just as soon… it’s much more satisfying for me to know that something happened that I wanted to happen and nobody knows the role that I played. Because it worked, it happened and nobody’s going to be defensive about it and nobody’s going to attack anybody about it. Nobody is sitting up there saying I did this and then they’re going to say oh, who do you think you are? It doesn’t happen. So that advice that Dan gave me is part of the best advice that I’ve ever had. And so there are lots of things that we work on that I know the impact that we had, but I am loath to share it unless I have to. Once in a while I have to tell my member organizations what we did so they’ll keep paying their dues. But I’m a little uncomfortable doing that because I would just as soon that they knew it happened and not know exactly how it happened.  \n\nOr who was responsible for it?\n\nOr who was responsible for it, yes.  \n\nThat style that you have, is that something that you’ve always had or does this sort of happen over time?\n\nNo, you learn. My best teachers are bad experiences. When I find myself being impatient with the way somebody else is running things, that teaches me a lot. When I find myself incredibly impatient in a meeting, that says to me Norman, if you ever get the chance, please be efficient with your meetings. When I find myself reacting to somebody else in a way, saying I don’t like that, what that says to me is learn to do it better. And once in a while I’ll see somebody who does something really well. And I’ll say do your best to emulate that. \n\nSo there’s a lot of just observation and learning from …\n\nOh, yes. All the time. Plenty of opportunities. \n\nOf all the different committees and positions that you’ve served on, what was the toughest decision that you had to make in your career, either as a family physician or as an executive or both?\n\nLeaving my practice in Hughson. That was the toughest decision I ever had to make. That was the hardest decision I ever made because I was a family physician. I had continuity of relationships for nine years. I came into a community that needed me. I took care of that whole community. I did my best. I had relationships. I lived there. That was very difficult. \n\nWould you go back if you had the opportunity?\n\nI would never go back. I’ve moved on. I’ll go forward wherever I’m going, but I’m not going back anywhere. \n\nGoes to the geriatric?\n\nI could do that, yes.   \n\nWhat has been your biggest satisfaction from working in family medicine?\n\nWell, there’s two answer to that Mike. The first one is the same as the answer I just gave you. There is no question that the most satisfying part of medicine is direct patient care, absolutely. We don’t have time, it’s another whole interview. But to sit around and tell stories about where you really had an impact with the individual patients. And there’s nothing more satisfying than that. But I don’t do that anymore, so I have to find my satisfaction in a world of management administration. And so when I know that we have had an impact – I’ll give you an example. There’s a 23-page section of the Affordable Care Act called The Physician Payments Sunshine Act. Nobody ever talks about it. It’s going to come home to roost though pretty soon. Maybe in about a year. And the pharmaceuticals are going to be required, they already know this, to post on their websites the names of the physicians with whom they have a relationship and how much they pay them and what they pay them for. We’re very supportive of that Act. It’s part of transparency. We negotiated the elements of that Act. Now most people don’t know this; everybody else was focused on the other 977 pages of the Act. But this was our role, to negotiate with the Senate Finance Committee staff on the wording. They had things in there that they just didn’t understand. And they got changed in that act so that they’re not onerous for a physician and so that they make sense and they fulfill our strategic plan priorities and they’re not foolish and stupid, which they were. Like they had a rule in the original Act that said if you’re a doc and you go to a meeting of the American Academy of Family Physicians for continuing education (they didn’t say Academy, but I’ll use that), and that meeting is supported by industry; they get a grant from Pfizer and a grant from Endo and a grant from whatever, those companies are going to put your name on their website because you attended that meeting and therefore they paid you. And we said A) That’s not true; and B) Nobody will ever go to a  meeting if their name is going to show up on a company website. And they said oh, we didn’t understand that – thanks. And then they said but the faculty do get paid. I said no, but the companies don’t pay the faculty. The Academy pays the faculty. The Academy gets the grant but it’s not direct. They said oh, I didn’t understand that, and they took it out. Because if it had gone through, no one would have ever taught at the meeting because they don’t want their name on Endo’s and Pfizer’s websites. They don’t have the relationship with them. They have the relationship with the Academy. Well, that’s going to affect every physician in the United States. So that’s one of the things where we actually had some impact. I don’t get to work with individual patients anymore but this is what we get to do at this level. And there are many, many other examples of that. And I’ll not tell you them because I told you I don’t like to take credit for these things because then it doesn’t work as well. \n\nMy last question had talked about your biggest satisfactions and this is sort of a variation on that. But what are some of your fondest memories and what are some not so fond memories, if you want to talk about that?\n\nWell, the not-so-fond memories I’ve already told you about. I didn’t particularly like one of my three cultures. I didn’t like academic medicine. I didn’t like the backstabbing. I didn’t like everybody trying to get ahead. But there isn’t a lot I don’t like. Fondest memories, I loved my residency. Very hard, but I didn’t care, I was ready for it. I was motivated. I loved OB. When I was in practice, it was the best thing I ever did, delivering babies. I love being a family doc. I love the full scope of family medicine. I didn’t do C-sections and I didn’t do major surgery but I love that continuity of care. I really enjoyed the time I worked at the Academy. I learned a great deal. I had an opportunity to have some impact. And to be honest with you, I don’t spend a lot of time thinking about those things. I’m usually pretty consumed with what I have to do now and where I’m going and what I have to accomplish. And when I think back, sometimes I think back to remind myself of what I learned. And sometimes I think back when I’m chatting with my wife about old times. But my wife, who is very supportive, also isn’t all that nostalgic. Neither of us is, so we don’t spend a lot of time thinking back about that day in the emergency room when we met. That’s just not us. \n\nYou mentioned talking about where you’re going and what to accomplish. Where are you going? And what do you still think you have to accomplish?\n\nPeople have often asked me that throughout my career. And there are people who know their next step and have goals. And I told you I have professional goals about what I need to be working on. But I don’t have personal goals. I never have. If you had asked me when I went to medical school if I was going to be the CEO of the Council of Medical Specialty Societies, first of all I wouldn’t have known what you were talking about. But if you described it, I would have said no, I’m going to medical school to be a doctor like Dr. Pakula. Then in residency I was going to be a family doctor. Once I knew I was going to practice in Hughson then I knew I was going to be a rural family physician. And then I got involved in teaching and somebody invited me to be a residency director. I didn’t go there to be a residency director. I wasn’t ready anyway. And then they invited me to come to the academic center, which I wish they hadn’t. But I’m glad they did because it made me tri-cultural and so Dan could invite me to come to the Academy. It’s like what I’ve come to recognize is that I have developed a certain set of skills. Those skills have use. I’m going to put those skills to use in a place that wants me to use those skills. And I’m going to keep doing that. I’m a change agent. I have a goal. I’m going to keep working at it as long as I’m effective and enjoying it. And when one of those two things stops, I’ll stop. \n\nAre you enjoying it?\n\nYes.\n\nIt seems like other things that you’ve learned just sort of ties in and helps prepare you.\n\nI hope so. What good would it do to learn it? \n\nGood point. You don’t have any plans on retiring any time soon, do you?\n\nI have never had plans on retiring. And people all around me are retiring. I am of an age where people retire and they keep looking at me like there’s something wrong with me. Now my dad worked full-time until he was 81. Then he went to the office every day, just didn’t get paid, until the day before he went to the hospital, when he died, when he was 92. Am I going to work that long? No Mike, I’m not. But am I going to keep working for a while? Yes. I don’t have any current plans to retire. \n\nIf you weren’t working for the Council, if you had that choice, if you were to say I’m retiring tomorrow, two weeks from now, what would you want to do? Anything outside the field of medicine or outside of…\n\nI have a very balanced life. There are things I do outside of medicine right now. I don’t wait for my retirement. I’m very active with the Boy Scouts. I serve the Boy Scouts at the local level, on the regional level and I’m on a national Boy Scout committee. And I play competitive bridge. I’m going to a big tournament in early June, trying to qualify for the national tournament. And I’m a student of comparative religion, particularly the Abrahamic faiths: Judaism, Christianity and Islam. And I spend a lot of time at that. So I don’t have to retire to do that. I once had a fantasy that I would get a Master in Divinity degree. I actually would kind of love to do that. But that’s not my skill set. I have skills that I’m supposed to use. I’ve been called to use these skills. Society has given me these skills and they want me to use them. So it would not be fair of me, I would consider it to be selfish to do that. \n\nWhat about English literature? You mentioned that’s what you got your bachelor’s degree in.\n\nThat was just a good preparation. It helps me read, it helps me write. \n\nDo you have any favorite authors, since we’re kind of talking about that?\n\nYes. I’ve read everything Tony Hillerman wrote. Nobody could read everything Isaac Asimov has written, but I’ve read a lot of Isaac Asimov. I like science fiction. I like mystery novels if they’ve got historical faces [facts?]. That’s why I like Tony Hillerman, because you learn a lot about the culture of the Navajo and the Southwest when you read him. It’s not just a mystery novel. But quite frankly, I read a lot of religion and I read a lot of history. I’m really interested in what happened in the First Century. I’m really interested in what happened around the time of Christ and the time of the destruction of the First Temple, the Second Temple, and even to some degree after that up to the time of Mohammed. Because I’m really interested in how religions came to be and the role that they play in society. So I’m always reading several books. And right now I’m reading a book that’s the best of the Hugo Awards. The Hugo Awards are the science fiction awards. I’m reading the Best of the Hugos. I’m reading a book called Kaddish, which is a journal that a man who was saying the “Mourner’s Prayer” for his father for the year. I’m in the middle of my year, saying it for my father. So I’m reading this journal that he wrote, which is historical. It’s about where did this prayer come from and what function does it play? It goes back thousands of years and so on. I’m reading a book by Amy-Jill Levine who is an orthodox Jew, professor of New Testament at Vanderbilt on…it’s got a very provocative title, it’s The Scandal of the Jewish Jesus. But it’s about viewing Jesus in his role as a Jew and as a rabbi. And I’m reading The Greatest Jews of the Century by one of our local rabbis who picked one Jewish leader in the last twenty centuries and has a chapter about them. That’s my current reading.   \n\nIn addition to all the work you’re still doing for the Council.\n\nYes. Huston Smith, who is a professor of comparative religion, he’s still alive, he’s over 100 years old. He had this great saying. When people asked him what religion was the best one, because he’d studied all of them, he said “If you’re searching for water it’s best to dig one deep well, not a lot of shallow wells.” This from a guy who has dug a lot of shallow wells. But basically what he’s saying is if you want a spiritual experience, whatever your roots are, that’s where you’re deepest – go there. Because all religions have the same function. They’re all about believing, behaving and belonging. And just go into your roots. So that’s what I’ve been doing for the last fourteen years. And now I participate pretty actively in some of my religious ritual. If you knew me fourteen years ago, you would say you’re not going to do that. You’re not going to participate in religious rituals. That’s not you. But I do it because it’s digging a well.   \n\nAnd it brings you comfort?\n\nA personal spirituality. A personal experience of God, whatever that means. It also brings me a lot of social value. I’m a chaplain at the Boy Scouts. And there’s only two other Jewish chaplains and all the other chaplains are of various Christian faiths. Well, we’ve gotten to be very close, this group of chaplains. I hosted a Passover Seder for my Christian chaplain friends last week. And we’ve done a number of things together. We did a Ten Commandments hike for the Boy Scouts where we went to five different houses of worship and learned about the different faiths and how they all perform their duty to God, which is part of scouting. And they’re all focused on reverence, which is the twelfth point of the Scout law. When I go down to camp to serve as a chaplain, I sometimes stay in the Catholic chaplain’s quarters. If I’m not doing my own service, I go to somebody else’s service.   \n\nAnd that’s got to be an interesting experience.\n\nFascinating.   \n\nYou mentioned science fiction. There’s a gentleman by the name of Harlan Ellison – you might want to look him up.  \n\nAny particular book? \n\nAngry Candy. He writes predominantly short stories. He was born in ’34, he’s still active.\n\nMy daughter, of all my kids, is the one who is closest, most like me. And she likes science fiction too. She’s the one who told me to read Ender’s Game. And I’d heard of it but I’d never read it. And I’m going, this is really good. \n\nHe’s good. He’s won more Hugos than any other living…\n\nHe might have a story in this book I’m reading, The Best of the Hugos.   \n\nYeah, he’s probably got to have one or two. Dan Simmons is good as well. There aren’t many people out here who like science fiction or are willing to admit it.\n\nDo you know Perry Pugno? He likes science fiction. Vice President for Education at the Academy.   \n\nDo you have any final thoughts that you’d like to add?\n\nI have no final thoughts. I’m not at a point in my life where I have final thoughts.   \n\nAnything else you would like to put on the record for posterity here?\n\nNo. Nobody is going to listen to this but my mother anyway. Hi, Mom. \n\nThank you very much.\n\nThank you Mike. I appreciate it. Thanks for taking your time. \n\n(End.)","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153057/file/281704#t=0.0,773.02849"}]}]}]}