{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/r49g44kp8h/manifest","type":"Manifest","label":{"en":["Dr. Donald Fink"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Date"]},"value":{"en":["1992-04-26 (created)"]}},{"label":{"en":["Type"]},"value":{"en":["Interview"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. John Frey (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["Society of Teachers of Family Medicine","Dr. Donald Fink","family medicine","family physician"]}},{"label":{"en":["Subject"]},"value":{"en":["Dr. Donald Fink (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}},{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. 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No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/150636/file/277815","type":"Canvas","label":{"en":["Media File 1 of 2 - Fink_Don_1992.04.26_-_Side_1.mp3"]},"duration":1906.06288,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/150636/file/277815/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/150636/file/277815/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/277/815/original/Fink_Don_1992.04.26_-_Side_1.mp3?1750275691","type":"Audio","format":"audio/mpeg","duration":1906.06288,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/150636/file/277815","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/150636/file/277815/transcript/81406","type":"AnnotationPage","label":{"en":["Dr. Donald Fink interview transcript  [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3629/collection_resources/150636/file/277815/transcript/81406/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Interview by John Frey of Don Fink\n\nApril 26, 1992\n\nSt. Louis, MO\n\nQ. - John Frey\n\nA. - Don Fink\n\n___________________________\n\nQ.  --26th of April, 1992, in St. Louis.  Basically, what I'm interested in is, tell me your story.  Tell me how you got involved with family medicine.  You stood up this morning when they identified people who were at the first STFM meeting.\n\nA.  Yes, right.\n\nQ.  But you were involved before that, so can you tell me a bit about how that happened?\n\nA.  Yeah, I should go way back, enough to tell you that my father was in general practice in one neighborhood of the city of Chicago for 57 years.  So I lived with a model of general/family practice, literally lived with it, because he actually had his office for much of our life, at least the first 10 years, his office was in part of where we lived, and we lived in the other part of the building in the city.  And I saw, literally saw his role as a practitioner.  And I was born in '32, so remember when I was growing up this was through the '30s.  So it was that model of general practice, he was on call 7 days a week, 24 hours a day, had evening office hours four nights a week and Saturdays, and we ate our dinner at 5 o'clock, which I had to come in and--I couldn't play like the other kids 'cause I had to come in and have dinner at 5 because my father had to go back to the office.  So I had a model of how doctors were supposed to be that I just lived with, I mean I just grew up with it, that was how it was.  And when I went to medical school, I went to the University of Chicago, and needless to say general practice was not in high regard.  I entered in '52, came out in '56, I think two of my classmates went into quote general practice end quote, and as you know there weren't even 20 programs then, they were mainly 2-year internships, and apart from--I'd done well in school and I never got talked out of going into general practice, it never came up.  So what I did is I chose pediatrics as the closest field in which I, that was a generalist field that had health and illness in it, and that dealt with family.  'Cause somehow that seemed to me a much more enriching kind of medical practice.  So at some level that's, had been my model genetically or culturally passed on down, and I chose pediatrics 'cause it was a generalist field in a limited age group, whereas internal medicine, which was the other thing I looked at, was a very different, even then a very different kind of role and there weren't the kind of level of subspecializations that we have now.  In fact, when I was a medical student there weren't even intensive care units or coronary care units.  It was, you know, there were some specialists, particularly at the University of Chicago, and they were strong, but most, many of the people were generalists, and actually my pediatric residency, I had the good fortune, which I did at the University of Chicago, and the guy who was chairman of the department, F. Howell Wright, was an absolute raging generalist.  He insisted that all of the faculty, which were all full-time, which was unusual then, had a well baby clinic and a follow-up clinic.  And the only one--\n\nQ.  Even the specialists?\n\nA.  Even the subspecialists.  That was his requirement.  He had it himself.  And we had, believe it or not, a continuity clinic in our senior year, and we had a well baby clinic of our own, we had a continuity clinic of our own, and we consulted with the medical students and took their patients into our continuity practice.  So through the senior year of the 3-year residency, we had a continuity practice.  And that was because of F. Howell Wright.  So, and I of course had this incredible learning experience.  So you need to--that's all, you know, elemental to my own development.  Go in the Navy, did pediatric practice, loved it, went into private practice--actually went back and did a year of fellowship in allergy and immunology, mainly 'cause I was taught that it was all baloney and bullshit, and I kept seeing all these kids coming in with allergies, and they were taking up all my time, and it didn't seem like anything I was doing was helping them, and I said, 'Well, if it's black magic, I want to learn how to do it,' so I took a fellowship mainly to learn how to take care of the 10 percent of my kids that were filling up 25 percent of my practice time with asthma and eczema and so on.  So--and then I went into private practice.  And I'd been doing some teaching part-time at the University in the allergy program, and I was offered the job of being the director of the pediatric clinics at the University of California, which is where I'd done the fellowship and actually had done a year of internship.\n\nQ.  So you went Chicago, Navy--\n\nA.  Well, yeah.  I went actually, from the University of Chicago I went out to the University of California to do a rotating internship.  Because I wanted to live in San Francisco, which is another story, but I wanted to have--I didn't feel complete as a doctor from medical school, so I took a rotating internship so I go to do 3 months--2 months of OB and deliver 300 babies and--I didn't feel finished as a doctor, so there was a part of me that wanted to be a family doc.  And I did 3 months of surgery and did a lot of surgery, and I did 3 months of medicine and 3 months of pediatrics.  And then I--I knew I was going to do a pediatric residency.  So I went back, but I had the contact at the University of California, then did my fellowship there, and then got invited to head this ambulatory care program.  And I felt very much like Grouch Marx, you know, I wouldn't--why should I go to any party that would invite someone as unqualified as me to take such a responsible job?  So I went in, and what I really started doing is, I'd had a good curriculum for practice relative for most residents at that time.  But there was much I didn't know which I learned from my 4 years of practice, 2 years in the Navy and 2 years in private practice.  So I set about to establish a curriculum that would fill in the things that I didn't know.  And it included seeing what normal kids were like, and taking residents and students out to see normal kids in normal settings, 'cause all they saw were these, you know, terrified little beasts in exam rooms, and working with the other people who were concerned with child health and the family, school people, social service people, and so on, and we ultimately set up a program where we had continuity relationships where our residents were assigned and I got a 6-month ambulatory care block in the peds curriculum so I could have some continuity experiences.  And assigned residents to a community center where they were the pediatrician, whether it was a school or day care center or adolescent program or whatever.  So I got more interested in the larger context.  And then two things happened: in '65 OEO came about and Head Start.  \n\nQ.  Health centers.\n\nA.  Well, health centers too, and I was very interested in health centers, though there weren't any in San Francisco.  And I was very interested in Head Start.  And I got involved, just for a fluke, as a consultant with Head Start.  Julius Richmond, the pediatrician, you may recall, was the first director of Head Start.  And that got me out into the community physically much more and working with community groups, and I started to visit communities as a consultant for Head Start and trying to get the pediatricians to be more involved and talking to community groups and parents' groups and school groups, and I said we got a, you know, we got a bigger problem here than I ever knew.  It totally changed my perspective.  So that--and I continued to do consulting for Head Start and OEO health centers later down the line.  So that was a community piece that came in, but it was--you can't deal with the examination room, which I already knew, you've got to deal with the larger context of child and family, and you've got to deal also with community context, or you're pissing in the wind, basically.  I became very convinced of that, though I had no idea what exactly to do or how to go about doing it.  \n\nQ.  Do you think that if you had not gone out into the Head Starts and the OEO kind of projects that you might have not had that kind of perception?  Was that particular experience--\n\nA.  Well, something else came up, yeah.  Because I realized that if I really wanted to influence--if I wanted to positively and beneficially influence child health I was going to have to work with a larger context.  A minimum was family.  And certainly community in terms of the community of people who were involved with the children and their lives.  So I already knew that there was no point, there was nothing I was going to do as a medical doctor in the course of normal pediatric care that would really in a substantial long-term way influence child health by itself.  And that I would play a key part in it, but that unless I worked in this larger context, if my goal was improved child health, which somehow I got wired up to have, that was the only way I was going to be able to do it.\n\nQ.  You know, I remember reading, I don't remember exactly the book, it was--anyway there was a book saying that basically pediatrics was a--as a specialty was a social movement--\n\nA.  Oh, it was.\n\nQ.  --early in its history, and that it--was that a sense, when you were training in pediatrics that you were part of something that was socially connected--\n\nA.  Well, yeah.  Less so at the University of Chicago except from this couple of people on the faculty, one who ran the ambulatory care center like it was important in our continuity clinics and the chairman of the department, who said, 'This is important stuff.  And while we're interested in science and we're interested in subspecialty care, let's keep our eye on the whole child.'  Now--you know, then it got taken larger by people like Bob Hagerty and others who influenced me by making that very real.  And the other piece that happened is we--and the reason I know this was still early on in my thinking is, we were at--the Millis Report, you know, Cogashow(?) Report, Willard Report were all out, we were all very excited about stuff like this, and in the school I'd gotten involved with student affairs and curriculum development and just about that same time, '65, we started a curriculum revision.  And partly to my amazement and even more so in retrospect, in our curriculum revision at the University of California, which was not the tertiary coronary(?) care giant that it is today, there was a lot of interest in general patient care and we got a 12-week required ambulatory care clerkship.\n\nQ.  Is that right?\n\nA.  Now we'd already had--\n\nQ.  Is that clinics or--\n\nA.  It was clinics.  We already had a 4-week inpatient peds and a 4-week outpatient peds, first 5 weeks originally and then it got shortened to 4, which I ran, and ran the teaching program.  What this proposed to do was to take what--there was no outpatient internal medicine, it was all inpatient, you know, a few little trips to clinic, and outpatient peds, and bring it together with some other disciplines and develop a 12-week required clerkship.  And I was on the planning committee for that, and as part of that I proposed, and they accepted, that we develop a family clinic.  And that we would establish a clinic in--actually, physically in the pediatric clinic that would care for families and where medical and nursing students would work together in the care of families, and we would get them for 12-week rotations and the families would then be picked up by others.  And the consultants were pediatricians and quote general practitioners.  In fact, one of my first faculty members was Bob Massid(?), who I pulled in from practice.  And his wife, his then wife Susan, was working in the internal medicine clinic, she was an internist.  So we started this family clinic and it went--I mean we didn't know what we were doing, I hadn't heard of anything like family systems, but we asked the people to care for families, to diagram the family structures, and try to figure out what was going on with the family and how the family both influenced health but also was a vehicle for health.  And that's what we addressed them to look at.  And these, you know, bright students who'd come over from the free speech movement and everything else, took it, you know, all the way.  So we had these incredible case presentations, where people were talking contextual medicine.  They didn't know that, we didn't know that, but that's what was happening, and the faculty was learning as much as the students were, because we just knew this somehow was good, and we should be doing more of this.\n\nQ.  It must have been a wonderful time.\n\nA.  It was a very exciting time, 'cause it was a rich learning time.  We were coming with total ignorance, but with the belief that, you know, what we were doing was not enough, couldn't be enough, and we had to learn how to do it better and bigger in a bigger context, though the tasks might be much the same.  Or a lot of the tasks.  \n\nQ.  And it sounds like there weren't all of these boundaries and kind of domains that people now seem to be fighting over.  There was a much more collaborative--\n\nA.  In our place there was, and part of that came from the leadership of a fellow named Bob Creday(?), who was an internist who had been one of the star students of the school, and for reasons I never did find out exactly how, got into weird things like psychosomatic medicine, which was not too popular in internal medicine those days, but was enough of a generalist and had been in the dean's office, so he had influence in the school structure, and he was interested in this clerkship, mainly because he wanted to take the inpatient diagnostic workup model and move it to the outpatient, which he knew most care took place.  So he had the Kerr-White(?) picture, but he wanted to take the, I think, the internist's model, the general internist's model of the inpatient, the workup and the management over time, and move it to outpatient.  Which is why he fought for it, we got 12 weeks.  It's been reduced since to 8 weeks, by the way.  But we were I think one of the first, if not the first, in the country to have a required ambulatory care clerkship.  And they already owned the medical clinic, and I quote owned the pediatric clinic.  So I was a representative from peds to this planning group.  Actually Mel Grumbach(?) was the chair at the time, who was a very tertiary care fellow, but he wanted a good department and he wanted good in that area too, so he gave me a lot of leeway.  Anyway, so that was the formal family medicine, we were starting this family medicine clinic.  In the meantime I had--\n\nQ.  Did you call it the family clinic?\n\nA.  Yeah, it was called the family clinic.  And we--at the beginning, every quarter we'd get new medical students and nursing students who'd be paired and assigned to one or two families to follow, and they had the option to continue to follow them.  These were mostly seniors.  We required the students, the medical students to have medicine and peds before the double clerkship because we didn't want to teach physical diagnosis, we wanted to teach ambulatory care management.  We had psychiatrists, there weren't many psychologists around then, Herb Van de Voor(?), whose name you may know from the history through Don Ransom, Herb was the psychiatrist in the department, Don Ransom joined us later in that same academic structure.  It was actually technically a division of medicine, but it operated like an autonomous department.  Dave Vortiger, who went on to be chairman of our department at one point was there as an internist.  But it drew the people interested in change, who were very unhappy how it had been, and said we've got to make it better and let's make it as we go, let's make it up as we go.  So all of us, you know, I was familiar with George Silver's stuff, and I was--the most important thing was the program that had been started by Bob Hagerty at Boston Children's, which was a family medicine fellowship, and having contact through the Ambulatory Pediatric Association with pediatricians who were strong on family, and that was a formal training program, and that's, you know, Lynn Carmichael, Lynn took his family medicine fellowship there.  And they had mostly pediatricians doing the fellowship, but they had a few other general practitioners.  And some of the people who went through that went on to be active in family medicine, like Dick Feinbloom(?) and others.  There were other folks I ran into, like Mark Hanson, Ken Reed, who were pediatricians then at Wisconsin but who were into medical education by design and who were into real-life experiences as experiential learning for students, so a group of that original membership I think had a bunch of common interests.  One was the domain of family, who came to that first organizational meeting.  In fact I--my recollection was half of them were pediatricians.  More than half.\n\nQ.  Actually I haven't looked at the list yet, but I can do that.\n\nA.  Yeah, and a lot of quote general practice folks--and Lynn I think through Bob Hagerty and Joel Alpert and others who were there with him at a similar time got the names of all the pediatricians.  And I think that's how--I'm trying to think if I had met Lynn before that time.  I don't know that I had.  But he got the names of the pediatricians who were strong and interested in family, obviously got the names of the general practitioners who wanted to see family, general practice supplanted by a true family practice that was not just nostalgia, and a few behavioral scientists, and I think there were even a sprinkling of internists who were the most unusual there.  But there were I think a number of people in there, I think Lynn could probably tell you, who were internists.  But there were a few.\n\nQ.  My experience has been anyway that there's some kind of level of compatibility between pediatricians and family docs that's quite different than--I mean I've talked to internists, I don't know if it's a way of thinking or what's considered data, or--\n\nA.  Oh, yeah.  It's what draws you, it's the scope.  I--very definitely.  There's much greater congruence.  You see it in the students even now.  The students who are deciding between family practice and internal medicine are very different than the students choosing between pediatrics and family medicine.  Very different.  So--but there definitely was a group of pediatricians very strongly interested in family.  And there were also these--the people like Lynn and Leland Blanchard, who I didn't know before STFM, who wanted to rejuvenate and resurrect, you know, and I think my sense was construct a new family practice.  Not only that had status, but that was not general practice in the sense that it had been, as my father had been, you know, who was all OJT and he took a year of a half-baked internship and then you went out and practiced until you got it.  And depending on your levels of perception you got very good at it, like my father got very good at a lot of stuff.  Never got good in the psychosocial domain, but he got very good in the family dimension of illness care and of relationship care, and was absolutely an advocate of his patients.  He used to go in and either scrub or be there in surgery every time one of his patients went to surgery.  He was there--they saw him first preoperatively, they saw him first postoperatively.  \n\nQ.  Incredible.\n\nA.  That was his role.  He was the defender of and coordinator of his patient's care.  So he practiced the model though he had no training to do it.\n\nQ.  My sense is that there was a, at least as I understand the origins of thinking about families as important parts of doctoring, that this influence of the Harvard program and a few places that legitimized taking that theme and really developing it academically and developing it intellectually.  And that a lot was going on in pediatrics much more widely than it was in general practice.\n\nA.  Absolutely.\n\nQ.  How did those start to come together?\n\nA.  Well, I think they started to come together in STFM.  The sad part, and this is my disappointment, is when I came to the first charter meeting, not the planning meeting Lynn mentioned but the one in '67, I was thrilled.  I mean I thought, 'Fabulous.'  First place, family medicine is not just for general practitioners or family practitioners or pediatricians.  Family medicine is for every doc.  Anybody who wants to care for people should have a dimension of family medicine, had that vision and know how to work constructively and positively with the family structure.  And I didn't know--I knew many people would not have to, want to deal with community, 'cause I'd had enough OEO experience at that point to know it was scary to some people.  It was scary to me at first, too, but I came to enjoy it quite a bit.  But family I saw, and I saw our pediatric oncologists who were working with family, they had to work with family.  And were seriously interested, you know, here's a kid with a fatal disease, leukemia, which was 100 percent fatal at that time, acute lymphoblastic leukemia was 100 percent fatal in children.  It was a death sentence every time a kid was diagnosed.  And they had to work with families.  The chronic renal problems, the developmental disorders, this had tremendous impact on family, and most of the, many of the subspecialists I knew were aware of that.  They didn't know what to do with it and they'd toss them to the social workers, but they wanted to have a social worker around to handle this stuff.  So to me family medicine was and is something for all of medicine, not just for family practice.  So one of my greatest unhappinesses is when the Society of Teachers of Family Medicine became the academic organization for family practice residency, basically.  That I was disappointed in, though I totally understood why it needed to be and become what it needed to become.  And if I have any hope, at some point it will become so mature that it will once again open its doors in a sense as an organization and in terms of its message to say this is not just for us and some secret skill we're going to keep, you know, like the obstetrical force(?), we're not going to reveal to anybody, but hey, we want you, the subspecialty internist or pediatrician or transplant surgeon to be able to use some of these same skills in your care, because it's absolutely vital.  And I used to go around preaching that, you know, the contribution that family practice had to make to all of medicine was family and the way of looking at family, which I still think to some degree that's true.  There's other things it has to contribute in terms of doctor-patient relationship and so on, but hopefully that will at some nirvana state also become part of medicine.  But the dimension of family--and that's what pediatrics and family medicine share, of course, is the necessity to deal with family.  Because when you're doing pediatric care or obstetric care, you have to deal with family.  Now the OB guys manage to avoid it.  But I don't think any family physician or pediatrician doesn't consider it an option.\n\nQ.  Well, you know, I think that the irony, at least for me, is that that may happen.  What you wanted to happen, you know, in the late 1960s may happen in another 10 years because if this whole system sorts itself out and general medical physicians or whatever we call ourselves--I kind of like what Lynn said about primary care, I'm not sure--but generalists of some sort have to start talking with each other, communicating, and that the economic and political issues which have governed medicine for all this time start to get changed a bit, then I think there will be a way that, say internists want to learn about families, they'll come to meetings like this, or some meetings like Amelia(?) or places like that, and it won't just be people in family practice talking to each other.\n\nA.  Well, that may happen.  I'm thinking it may happen less now, and the only reason why, John, is looking at the demography.  I think we're going to wind up with two generalist fields, the geriatric generalist and the family generalist.  And I think general peds and family practice will, 50 years from now, be merged, and there'll be a geriatric generalist and unless there's a major change in the way society's families live, that elderly, large elderly population may or may not be in contact with the rest of their family.  I mean I've watched them get more and more isolated geographically, socially, and otherwise, you know, with distinguished exceptions.  Certainly in some minority communities where they do stay together more.  But it's--so I thought that absolutely.  I'm not as certain now, given what's happened with the, and what's happening with the demography.  And my guess is that the internists will become geriatricians, generalist geriatricians, and they will become much more psychosocially involved.  I don't know that they will become more family-focused necessarily, because they won't be required to do it unless, except you know on these critical care life decisions where the family flies in to hover around the intensive care unit in the agonal event.  So they may or may not.  I mean I'd like to think they would, you know, I'd like to think we're going to have one family practice mode of care.  'Cause there's no question in my mind, and there wasn't from my early experience, that family practice is the preferred model of primary care, and that it could well absorb--in fact in my practice I had felt frustrated that I had no patient care relationship to the parents.  Now I did have, but it wasn't official.  It was psychosocial, I spent most of my pediatric practice life, I'd say, training parents.  That's what was the bulk of my, and probably the most valuable thing I did as a pediatrician.  And I also would, you know, occasionally treat them--strep throat in the family, we'd culture the family and I'd give them a prescription and not make them go hunt down their internist or G.P., they'd get a prescription and so on.  But, you know, I didn't take care of their urinary tract infection, I didn't deal with family planning.  What I did do is I pushed my adolescent practice as far as I could.  And at first I went into practice with an older guy who had a bunch of 25-to-30-year-old kids he'd been taking care of, so--but that's a sort of future thing.  So in terms of the history, I came in definitely from the point of view of pediatrics under this larger rubric, family medicine, but strongly believing that the family practice model should and must be developed.  And so it wasn't--but it wasn't until 1971, actually 1970, when I made the commmitment basically to leave pediatrics, when I applied for this job, which would be in our division at San Francisco General.  I don't know if you know this, but there were three jobs--one was to be director of the outpatient services and improve the primary care services, as they were coming to be called, develop primary care education at that hospital, and start a family practice residency program.  \n\nQ.  Well, separate jobs, was that with one job?\n\nA.  Yes--well, I didn't tell you the fourth job, which I didn't know about at the time I applied, but to develop the outpatient services we were (?) an OEO grant, and to develop satellite clinics and so I had another major job which involved me in the community heavily and deeply, which is where I got most of my grey hair, but it also gave me the resources to develop the family practice center and to make our satellite clinics mostly family practice interdisciplinary clinics where we also had our residents.  And so I had the opportunity, which I wouldn't have had without that to develop student and resident in community center education programs.\n\nQ.  Which as you said was from your kind of historical roots--\n\nA.  Exactly.\n\nQ.  --which was a very strong part of your own sense of where doctors ought to be.\n\nA.  Exactly, and here somebody said, here, here's--not a blank check, but--here's some money, you want to go do that?  Go ahead, do it.  And so we were very fortunate in that we didn't have the opposition of the community groups to having students or residents right from the beginning, which you know, a lot of places had to fight that, 'you doctors aren't going to experiment on us' (?)--\n\nQ.  I went through that all the time in Chicago, and Worcester was the same thing.  You took 7 years of convincing that we were there to help.\n\nA.  Well, we were very fortunate, and right from the beginning we had that.  And so we basically built up the centers and also--but even the first year of our residency, obviously the first full year--we matched two, eight positions in the first year, but we had the second and third year positions to start, which I foolishly thought you had to have a full residency, you need senior people.  So I brought in one pediatrician, one internist, and one general practitioner, all of whom were willing to do an extra year of training just because they were very committed to family medicine, each from their own points of view, including the internist.  And then brought in a bunch of people who'd had second, who'd had a rotating internship or a year training who wanted to do a second year and were committed to family medicine.  So we had a dynamite group and Bob Massid we recruited to be the residency director.  As I did feel strongly that the residency director should be a family physician, 'cause I was a pediatrician with all these leanings and, you know, commitments, but I wasn't a family physician, and I was very conscious of the importance of having role model family physicians.  So we brought in, you know, some general practitioners, but we also brought in a pediatrician and an internist who were committed to family practice and who--\n\n[tape side ends]\n\nA.  --service, and was very committed to community-based care and the family model, and he was in the program also.\n\nQ.  It's interesting, every time--people talk about, I have done the same thing, when you talk about the first couple of groups of residents in a program, there's this relationship that all of us have with that group that's very different than you ever had with any other group.\n\nA.  Well, it's like you were--I mean you felt very much like an invading party, that we were moving into an established multiresidency hospital, and so we already were banded together to make things happen.  It was interesting, though, because of that linkage of our residency program and the other programs that became affiliated with our division were also in public hospitals.  So Santa Rosa Community Hospital, Fresno and Salinas, Natividad, was the last one to affiliate, then we had one military program.  But because of that there was a lot of linkage between care of underserved, care of--public health care in our program, and it gave us a natural linkage to programs around the country who had similar things, the social medicine program at Montefiore, for example, where Bob wound up ultimately, as you know, with social medicine and social peds, and they added family practice.  I don't know if you knew that.  \n\nQ.  Vaguely, but--\n\nA.  Yeah, it started as a social medicine program and then got added to, family practice got added much later.  The Worcester program was added later, Cook County was added later, Martin Luther King was added later, but our program began as deliberately as a program--and this put us somewhat at odds, I should say--is we said family practice has just as much place in the urban as in the rural area.  It's just as needed.  People have just as much uncoordinated and duplicative care.  And furthermore, the need to take care of low-income families was even greater.  So we--our program was conceived originally as a program to train family physicians for urban underserved areas.  And that's how we started.  So we always were a little deviant from the mainstream of the community hospital, train for the rural area, train for the suburban area, which captured much of the family practice direction.  The group looking to the low-income, serving low-income population was always a subset, a significant subset but always a subset.\n\nQ.  Even though a lot of programs used patients from low-income settings to teach on.\n\nA.  Absolutely.  But most of their graduates were looking to, you know, where the shortage areas and income-earning opportunities were.  One of the differences in pediatrics is the Ambulatory Pediatric Association, which I was very active in and was on the board and did a year as president and so on.  They had a lot of community health center folks in that.  And in fact, they even had some general practitioner workers from the community health centers 'cause there was no organization for them to go to until NACHC formed, the National Association for Community Health Centers.  So there were a lot of pediatricians who were working in children and youth projects, you remember those?  The CMY projects, working in the first Title V programs which started at the same time as OEO, and community health centers.  So I had some exposure to colleagues in other medical disciplines, even though it was under a pediatric rubric who had the point of view of the community health centers.  So you're right, I mean I've always--at some level then I've had a tangential or a subset interest in involvement.  The only place that wasn't true was in medical school education.  And I was very active for many years in the medical school curriculum.  And the stuff I was interested in and involved in was the broader topics that interested family medicine, and trying to get some social medicine training, doctor-patient relationship training, family medicine concepts, to all medical students.  So that--and then we had our clerkship, and because we only had room for, we had so many students, only half the students could take the family clinic, the other half were in a home care program that Dave Whitaker developed.  So--but Dave had a similar social context, so we--it was through our medical education efforts I think that the--we had some common interests with the other primary care disciplines.  'Cause we shared those as important parts of the--the stuff that's in (?), you know, that wasn't really being addressed.  So we come together on stuff like that.\n\nQ.  Couple of questions.  One is, my sense is that you had some credibility as a trained pediatrician, you had some administrative responsibilities for the institution, you had a kind of--you had credentials that let you take family medicine in some way, and maybe take it farther than it might have gotten.  There were no people who had academic credentials of any type that were in family practice, who were actually general practitioners, well--\n\nA.  --(??)\n\nQ.  Well, most of the country.  These were folks, the group that came in from practice.  So that that, I mean in a sense you served as a kind of birther of the family practice program there because you had the ability to work with the people in the institution as well as these folks who were emerging in their own way.\n\nA.  Well, and in fact I joked with Bob Masid(?) more than once that it was the first time a general practitioner had been a member of the faculty as long back as anyone could remember.  I mean I'm sure there were, because there weren't---\n\nQ.  By accident--\n\nA.  --in the past, you know, way back in the history.  But we had to appoint them in pediatrics.  And yeah, there were three or four general practitioners that I did bring in, and I'm sure, you know, the experience very much influenced Bob's willingness to leave a comfortable and private practice setting and get involved with the nonsense of the university.\n\nQ.  But the other thing that strikes me, and it's the same kind of thing, is that when we first met I mean it was--Lynn had called, asked Bill Shorr and I if we would go and present this workshop, and I can't for the life of me remember what the workshop was about, something about working in--\n\nA.  At an STFM meeting?\n\nQ.  No, this is at the Ambulatory Pediatrics--\n\nA.  Oh, the Ambulatory Peds thing!\n\nQ.  --the first academic thing I ever went to was the Ambulatory Peds program.  And you had asked Lynn to come up and put on this workshop.  So that another function was to kind of introduce family doctors to the other people in academic--but it's a very important function.\n\nA.  I should, since we talked about Lee Blanchard, I should mention when I was starting the family practice residency.  I didn't know what was going on except I knew, I'd followed with great eagerness the development of the formal board's establishment, and then when the first RRCs(?) came out I thought, great, 'cause you know the first RRCs had three different models of family practice.  Has anyone talked about this?  \n\nQ.  Three models?\n\nA.  Yes, there were three models that were acceptable under the RRC.  Very important historical information.  Lynn has copies of it, I know 'cause he sent me one.  One was basically a GP model with the new elements added: continuity and behavioral science.  But it was a GP model, very rotational.  The second one was very much--though it wasn't labeled as such--it was very much an urban model, very downplay of OB, very heavy in pediatrics and medicine with even more behavioral.  But for the person who was not going to do surgery, there was--I don't even think, except for some outpatient surgery, anything was required in surgery.  I think--oh, some OB was required, but I'm trying to remember if no surgery was required or some token surgery.  But one was--the first model was for the rural GP who was going to be out there by himself and he better be able to handle everything.  The other one was in mind for the urban/suburban family physician, who wasn't likely to do any surgery--might assist--and probably, might or might not do OB.  But would be required to function in a setting where there were quite a few specialists.  And the third model was a very much community/public health, that was, would be absolutely perfect, didn't have an MPH hooked into it, but would be perfect for someone who wanted to go into public health or international health or work in broad kinds of programs.  And there were three very distinct curricula and programs that were acceptable, and they were encouraged.  Now I think, you know, (?) percent came in with Model 1, but were permitted to do this.\n\nQ.  That must have been, I don't know this, but that must have been behind why the Harvard program got accredited.  It was one of the original programs, but then 3 or 4 years later it got unaccredited.\n\nA.  Sure, right.  Exactly, and probably it qualified under No. 2.\n\nQ.  --so it was accredited in some ways under one of these second or third--\n\nA.  Probably No. 2, 'cause they had the (?) internal medicine for adult health care.  Which they had to do anyway, because it was basically a bunch of pediatricians teaching family medical care.  \n\nQ.  What happened to it?  Do you have any idea?\n\nA.  Yeah, (?) people got rigid(?).\n\nQ.  (?)\n\nA.  I think two things happened, and speaking from the outside, I don't know the inside of what actually went on in the RRC.  I think the family practitioners began to get threatening to some of the other specialties because they saw they were getting support.  And I think they began to defend against the privilege--'we're not going to lose our privileges, and you're not going to take surgery away from us, and you're not going to take OB away from us, and you're not going to keep us from doing this, and you're not going to keep us from admitting'--so what happened is in the economic and turf battles, I think the willingness to experiment and to, you know, create innovative programs that were not cookie-cutter identical models with the stupid 160 hours of this and 40 hours of that....  I heard the other day, there was a defense, the board said, 'What do you mean we're rigid?  We're not rigid in the RRC.  I mean we're more flexible than all the other specialties.'  They obviously haven't looked at the green book.  Anyway, so that one of my saddest things to see is to watch the RRC shrink--you know, here was a bunch of excited people coming out of mostly general practice--but some from pediatrics, a lot from pediatrics and some from medicine--move in, I mean Hiram(?) Curry was what, a neurologist?\n\nQ.  Right.\n\nA.  --some move, they moved in and they were full of the excitement of creating the changes they knew needed to be changed.  So there was no question it was a messianic era.  And everybody wanted to put in all the things that should have been done.  And so it was a very rich and fertile time, and there was a proliferation of a variety of programs.  And that increasingly got shrunk down and down and down so that the variation is very slight. \n\nQ.  And now when we need--I mean it's the, it's always these models that people use of, kind of evolutionary biology, which is that you get more and more specialized as an organism--when the world changes you're dead.\n\nA.  Exactly.\n\nQ.  And the reality is that the world's going to change in some direction or the other.  I was just thinking if we had had--if we now had those three possibilities, just think what you could include under the rubric of family medicine.  \n\nA.  Yeah, and what kind of exciting liaisons and associations people would develop because they said, 'You know, the program that's needed here is this, and let's bring in these folks and these folks and these folks, and let's design a program for this population that needs service, and that we can see what's needed.'  Yeah, hopefully that may happen again but I don't expect to see it in my lifetime.  I'm serious, and it's sad because--the old joke about hardening of the categories.  You know, prior to terminal illness.\n\nQ.  Faculty sclerosis or academic sclerosis.\n\nA.  Yeah, and I hope that isn't true.  But I think there's a lot in the faculty, I just think the RRC is restricting--I mean this should not be on the tape, but we may get our program on probation because we don't have two rooms for each resident.  \n\nQ.  And of course you ask them why, and they say, 'Because it's in the rules.'\n\nA.  That's right.  But we've had that rule for a long time, and they're getting increasingly rigid in interpreting it.  'We don't want to hear what you have planned, we don't want to hear, you know, that it's only four or five resident sessions in a month that that's true, the rest you have the two rooms, they don't want to hear that.  It's--so it's not just in this defensive, we'll preserve our privileges.\n\nQ.  You know, that's very interesting.  I think that it's like a lot of things, you know, this is another--that analogy of the church of the sect that Gale keeps coming up with, or it's suggested anyway.\n\nA.  Gale has been one of the most outspoken callers of this, and he can stand up and call it.  People like me cannot.  And it's partly the academy and it's partly the old boy and old girl network who, where the Academy is with their natural defense, which I think, you know, if I ran the Academy I'd see the danger absolutely.  But I think it's leading to a rigidity in the academics which I think has limited our influence.  I think if we were less defensive we might have some more listeners in academic medicine.  Not so much in internal medicine, which is, I mean it's too--we're too threatening to internal medicine.  I don't think we're as threatening to the other specialties and to pediatrics.  Though pediatrics, academic pediatricians have been very nervous.\n\nQ.  Well, I think there's been an examination for the last 5 or 8 years.  I remember Peter Bidetti(?) was one of the people in the Academy of Pediatrics who came out with this kind of manpower projection and what are the issues, and you know, the disappearing pediatrician is something that everyone's getting afraid of.\n\nA.  Right.  So they were threatened by it, they'd been threatened.  But I just mean for the reasons we talked about, in terms of congruence of view and values and self-worth as physician, I think there's a little more congruence than with the internists.\n\nQ.  The other thought I had about West Coast family practice, which--you know, when I was thinking about being a family doctor, and the rumor had it--and it actually persists, because the students I talk to now are always bring up, and God knows where it comes from, but it has come up again, is that West Coast family practice is different than East Coast.  Did you remember any sense, that regional differences or--\n\nA.  Well, not really.  I mean I think what came up is the Northeast was totally opposed to family practice.  That was the image.  That the Midwest had the GP model and that behavioral science particularly was given, was more token, if there were any regional prejudices, that it was a lick and a spit, do a psych residency and we'll give you a few seminars, but the real behavioral scientists--there were, you know, distinguished exceptions from programs like Wisconsin and others that had come out in the same way out of a common model.  Certainly Cleveland was different.  But the community hospital programs, that was sort of the image.  And of course the California programs took on the image of flakes, as the rest of California and the West Coast did.  The difference was, and I don't know--I'm sure you did talk with Ted, what brought Ted out, Ted Phillips out, but we had two very strong general practice residencies, the one in Santa Rosa particularly, less strong was the one in Natividad where Bob Reyko(?) was chief for a time.  And those were strong enough that when they got retreaded, they were--but they did, I think if there was something more California it was that behavioral science was taken a lot more seriously, though everybody had their own interpretation of what it was, and it wasn't always family system stuff, but it was a much more integral, and I think the community part got heavily influenced, because of all the stuff from the '60s.  I mean we had, our students were out of the free speech movement.  I mean they were passionate in the social values and if you weren't dealing with the social-political issues to some degree in your residency, forget it.  You weren't going to attract the most, the brightest and most engaged students.  So I think if there was any influence on the California programs it was that historical \"coincidence.\"  \n\nQ.  You know, the image I had when I was first starting out was that California programs were training superdocs.  What that meant was not really clear, but somebody who could do everything, you know, do, literally do everything, surgery and--\n\nA.  Well, there were a few program, I think John Geyman at Santa Rosa pushed that, Bob Reyko certainly pushed it.\n\nQ.  At least the ones that were visible.\n\nA.  Yeah, and they were both extremely visible.  Sandy Bloom at Santa Monica, which was another early program.\n\nQ.  I met him, I haven't talked to him.\n\nA.  Oh, he's a wonderful guy, very interesting guy, nice guy.  Yeah, but Lee Blanchard--I'll tell you, because I consulted with Lee, and I consulted with Lynn, and I went out and saw Gene Farley, I mean we all leaned on each other because you know, nobody knew any better than anybody else.  They said, 'Well, here's what we're doing, and here's kind of what we have in mind, but I'm not even sure if it works yet.'  And that was the level of consultation.  And Lee Blanchard was just the most incredible, wonderful guy, who just basically said, you know, 'I don't know either, but let me talk with you about it, and let's see what we come up with, and yeah, go ahead, try that, that sounds interesting, yeah, that sounds like a real good idea, why don't you try that?'  And it was, he was really the cheerleader and coach, not the expert.  And he was, had enough character--I think that's why Lynn reveres him so, but my experience with him, which was much less than Lynn's was exactly the same.  And this was a mean of old-fashioned character who looked like a conservative, thought like a revolutionary, but who saw his role as mentor or supporter to everyone who was willing to explore and develop what was needed.  And he would say that, he'd say, 'I'm not sure where we're going with this, but that sounds like a real good thing to try out.  Go ahead.'\n\nQ.  As you talk it, I don't think I've heard this from other folks I've been talking to, is how important somebody at that very transitional time, when you--it somehow is in your heart, you know that what you're doing is the right thing to be doing, and there's all sorts of ways of justifying it and so on, but still it feels very uncertain because it's something very different.\n\nA.  It's a blank slate.\n\nQ.  And you've got to have somebody around to say, 'You can do that.'\n\nA.  'That doesn't sound stupid to me, that sounds like an interesting idea.  That's a good idea.  Or had you thought about doing this with it.'  You know, it was that kind of consultative mentoring, but without expertise.  And so I think that's why, you know, I look to Lynn so strongly, and to Gene, were the two people who were out actually running programs.  'Cause Lee wasn't running a program, he couldn't get Stanford interested at all.  But those two people, and I had talked with Gale, but sometimes we had never connected at that point, I didn't connect with him till later, though he had been mentioned.  And then 'cause I knew Ted Phillips from Gene's program, I--when Ted moved out to the West Coast we had some contact.  But yeah, it's a--it's very important, and it's also, it also was exciting and scary and scary in the sense that, you know, you didn't know quite what you were doing, but what I think was clearer to those of us who got involved is what was needed.  We didn't know how to get from here to there, but we knew enough from our own practice what was needed, and what wasn't being provided in the medical education model, including pediatrics.  Because while pediatrics gave lip service to behavioral science, it too had psych rotations or psychological testing, I mean it wasn't--there weren't any family systems, views, with a few exceptions, in pediatrics.  It was another subspecialty.  Developmental pediatrics or child psychiatry.  It wasn't an integrated--it wasn't that somehow this stuff had something to do with everyday health care and patient care in an office or in the hospital, it wasn't that linked.  Although pediatrics places developed, you know, the child programs, the psychological programs for kids admitted to hospitals, and there were care-by-parent units, and there were all kinds of other experiments going on in parts of--but it wasn't in the mainstream of pediatrics.\n\nQ.  And it was around illness rather than health.\n\nA.  It was around illness, right.  It was around illness.  Although health was a high value in the profession, that is, the ability to do quote anticipatory guidance--I never, for instance in my program I never got the message that because I was taking care of a well child that I was a lesser doctor than when I was taking care of, doing an exchange transfusion in the nursery, which we used to do ourselves.  So the message was very much that this is important.  But I think that was strange because of my funny program, and my funny program director. \n\nQ.  The University of Chicago, that's what knocks me out, of all places I'd least expect that to be--\n\nA.  Just one guy--again, he so influenced it.  But he had spanned the sub--the generalists to subspecialty, I mean you know, the general pediatrician, the general internist when I started practice were still consultants.  I mean they were in practice but there were highly regarded generalist consultants in pediatrics and internal medicine.  So it wasn't--again, for illness care.  \n\nQ.  What's your sense about how everything has gone, based on what you, how you thought they would go then.\n\nA.  I think at some level the level of public support was faster and more than I expected.  I thought it was going to be a much slower growth.  And I think at some level we suffered from, you know, rapid expansion and the pressure to get many programs and get a lot of residents in, and the direct money, which I thought was great, that we never got but a lot of states got, I thought was wonderful.  It went much faster than I thought.  And then I think we hit this sort of snag because I think we still have a gap between what we promise and what we deliver.  Both in training and in practice.  \n\nQ.  Although I'm convinced that the training gap has remained wider than the practice gap.  Somehow I think we're more adaptable when you get into practice.\n\nA.  Well, we're better--it depends, you know, compared to what?  Compared to how other specialties are training, except for maybe surgical subspecialties, we have much better training for practice than pediatrics or medicine and many other fields, psychiatry and many other fields, no question about it.  So the suitability of our training for practice is good.  I don't know that we've, I'm not sure how much family systems is part of our practice, the practice of most family docs.  That's what I meant when I said gap.  I don't know how prepared how residents really feel to deal with psychosocial problems and how much it's more convenient to refer them on, turf them on, and not deal as much.  And part of this reimbursement system, and part of it's we're not comfortable with this, so let's take care of what we're comfortable with.  And that's okay, I mean I don't think that's a bad thing given the cost efficiencies that are needed right now.  Maybe an expensive doctor is not the way to treat those.  So that's what I meant by gap, in terms of--compared to other specialties, in other specialty training, we're I think far superior, far superior, and I wish, you know, and pediatrics has stayed where it was in the late '60s and '70s in terms of this kind of thing.  I mean they finally, you know, set up a continuity clinic as a requirement, half a day a week.  But most pediatricians, unlike, well, and most internists too, most pediatricians are spending 90-plus percent of their time in office practice.  Even if they're subspecialists, they don't--you know, if they're not in an academic center, I'm talking about the people in practice.  And you know, the general pediatrician doesn't go in the nursery any more, the general pediatrician doesn't do a lot of stuff.  And they go and do a well baby exam, but they don't do any more in the nursery than family docs do for the most part.  And the natologists(?) have taken over the nursery.\n\nQ.  Students have this--in which the internal medicine people spend all their time in the hospital and family docs are out in the community, I said 15 percent of their day, I mean a kind of average week?\n\nA.  Exactly.  And 80 percent is geriatrics.  Already.  Seventy-five, 80 percent, unless they're in some student health center or some peculiar location where there, or community health center or something, but they're doing, yeah--so I think the congruence between training and practice we are one of the best specialties.  As I say, I think some of the surgical subspecialties are pretty good too.\n\nQ.  If you had the power to--there was a blank slate and you could just design training programs in family practice, what would you do, how would you do it?\n\nA.  Been a long while since I thought about that one.  I'd have a much higher ratio, I would train them with more, side-by-side with more practice people.  And I would see that the practices were more square(?).  The practicing in managed care or large multispecialty groups, in other words more actually--instead of in the isolated fishbowl of the resident-only center where I think certain habits and attitudes develop, particularly if you're dealing with certain low-income populations too, I think I'd do more training in systems of care regardless of where the system is, and with a much higher ratio of practitioners to residents.  So our ratio of supervision over residents and the faculty practice over here, I think I would like to see much more integrated practice models.  'Cause I think residents and students learn as much, I've come to see they learn just as much by modeling as by curriculum, in fact more, and they get comfortable and feel more skilled quicker in that environment than they do, and packing more information in the curriculum, which has been most of our effort to better train our people, including me, over the years.  Oh, we've got to get this in, we've got to get this in, we've got to get this in, until they regurgitate.  The Strasburg goose method of medical education, which we are as guilty of as anybody else, witness our residency requirements.  I think we should do less of that and rely, and realize that the experiential learning, adult learning model, to put a fancy name on it, because apprentice is not a good word to hear these days--\n\nQ.  Wait till Tuesday, you'll hear (?).\n\nA.  Okay, but that experiential learning model is probably--the very things that make family practice residency successful, like the continuity practice, which I think was the brilliant idea of the conceivers of the residency.  If there was one brilliant idea, that was it, as far as I'm concerned.  That that would be better accomplished in that kind of setting.  That's the first thing, the thought that comes up to me right now.  I don't know what you thought about that.\n\nQ.  That's what I'll talk about on Tuesday.\n\nA.  Oh, you are, oh, you're actually going to discuss that.  Something along that line?\n\nQ.  I'm going to try to resurrect the idea of an apprenticeship.\n\nA.  I haven't been coached, huh?\n\nQ.  Just be there and say, 'That's a great idea.'\n\nA.  And that was totally spontaneous, because I had not, I mean that's not a conclusion I'd come to.\n\nQ.  We may have gotten to that point from different perspectives, but I think that's truly what--if I'm going to teach in a residency program any more, that's what I want it to be.\n\nA.  And yeah, the truth is the model family practice center is almost as artificial as the inpatient service, has become almost as artificial.  And I like a lot of the things we do in our program.  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