{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/sx6445kf4g/manifest","type":"Manifest","label":{"en":["Dr. Perry Pugno "]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}},{"label":{"en":["Date"]},"value":{"en":["2015-02-03 (created)"]}},{"label":{"en":["Type"]},"value":{"en":["Oral History"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. Herbert Young (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["American Academy of Family Physicians","family medicine","family physician"]}},{"label":{"en":["Subject"]},"value":{"en":["Perry A. Pugno, MD (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}}],"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153755/file/282867","type":"Canvas","label":{"en":["Media File 1 of 2 - Pugno_Perry_15_a.wav"]},"duration":3759.86921,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153755/file/282867/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153755/file/282867/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/282/867/original/Pugno_Perry_15_a.wav?1752681290","type":"Audio","format":"audio/wav","duration":3759.86921,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153755/file/282867","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153755/file/282867/transcript/81716","type":"AnnotationPage","label":{"en":["Dr. Perry Pugno interview transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153755/file/282867/transcript/81716/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Dr. Young: This is an oral history with Perry A. Pugno, MD, done on the third of February, 2015. I’m Herbert Young. And this is side 1 of tape 1.\n\nWelcome Perry.\n\nDr. Pugno: Thank you. I’m looking forward to this.\n\nDr. Young: Indeed. What I would like to do is ask just a little basic information at the beginning and then we’ll get into a series of questions, some of which will be very open-ended. \n\nSo, for the record, what’s your full name?\n\nDr. Pugno: Perry Alan Pugno. My mother, like many at the time, loved with Alan Ladd, so I got his name as a middle name. \n\nDr. Young: What is your present title?\n\nDr. Pugno: Retired. Former American Academy of Family Physicians vice president for education. \n\nDr. Young: What we’re going to do in this first part is talk a little bit about your early life and all and how it may have impacted your future decisions and activities and then get into some greater detail, as we go through the many positions you were in. You have the most impressive curriculum vitae. \n\nDr. Pugno: Thank you.\n\nDr. Young: So, where were you born?\n\nDr. Pugno: I’m one of those rare commodities called a native Californian. I was born in San Bernardino, California, shortly after my parents arrived from Italy. \n\nDr. Young: And when were you born?\n\nDr. Pugno: April 28, 1948.\n\nDr. Young: And your parents came over when?\n\nDr. Pugno: Just a few months before that, so I was made in Italy. \n\nDr. Young: But delivered in California.\n\nDr. Pugno: Right.\n\nDr. Young: What did your family do?\n\nDr. Pugno: Well, my dad worked as an electrician. When they first came from Italy, Dad got a job working for the Santa Fe Railroad as an electrician. And after doing that for, I want to say around six years, he started his own electrical contracting business. So, I grew up with the business in the home and did work as an electrician with Dad quite a bit.\n\nDr. Young: Any siblings?\n\nDr. Pugno: I have two younger sisters. My sister Diane is six years younger than I am and my baby sister Nancy is ten years younger. They both live still in southern California. \n\nDr. Young:  What was the community like?\n\nDr. Pugno: Well, the community in which we lived was a section of San Bernardino that was almost entirely Hispanic. I guess you could call it the barrio of San Bernardino. In fact, when my mother first came to the U.S., she learned Spanish before she learned English. And so I spoke Italian until I started school. Being able to speak Italian to someone who speaks Spanish, we could communicate fairly well that way.\n\nDr. Young: Because of the similarity?\n\nDr. Pugno: Because of the similarity of the two languages, yeah.\n\nDr. Young: So, when did you learn English?\n\nDr. Pugno: I learned English when I started school. I learned English about the same time as I learned to fight.\n\nDr. Young: Could you elaborate?\n\nDr. Pugno: Well, I was different. I was the only white kid in the school and spoke funny. And so it took a while to acclimate. I got in a lot of trouble in the younger grades.\n\nDr. Young: Any idea why your family selected that area to live in?\n\nDr. Pugno: Well, my mother’s family came to southern California shortly after Mussolini started rising to power in Italy. So, she came over when she was around ten years old. And they had friends and relatives in the southern California area, so that’s why they came there. So, it was sort of natural that after my folks got married, that they would come back an area where there was some family and friends.\n\nDr. Young: Actually, I should ask your parents’ names.\n\nDr. Pugno: My dad, his actual name is Pietro Oreste Elsino Filipo Pugno .  My mother is Vanda Dionigia. Her maiden name was Boggio, which is apparently a fairly common name in Italy, whereas Pugno is a very uncommon name in Italy.\n\nDr. Young: And what part of Italy did they came from?\n\nDr. Pugno: They’re both from the northwest corner of Italy in the province of Piedmont. Dad was a city boy, he came from the city of Turin. And Mom was the country girl, her side of the family are essentially Italian hillbillies. They live in the tiny villages and valleys of the foothills of the Alps. \n\nDr. Young: Have you ever gone back?\n\nDr. Pugno: Yes, I’ve been back twice, mostly recently in 2008. My two younger sisters, although they had been to Italy when they were young, they didn’t remember it. And so after my parents passed away, I took my two sisters to Italy and we went back to all of the towns and villages where the family came from. Interestingly, when I was in a small town, I was actually talking to a ranger who maintains the telephone relay station up in the mountains. The ranger asked me where I was from and I told her that I was from the U.S. She said that my accent was local, so apparently I still speak hillbilly Italian. \n\nDr. Young: Interesting. So, you speak Spanish, you speak Italian, you speak English. Any other languages?\n\nDr. Pugno: Hopefully not. (Laughter.)\n\nDr. Young: Thinking back to those early years, can you think of anything that might have foretold that you would end up in medicine and ended up in family medicine in particular?\n\nDr. Pugno: Well, I was a very sickly child. I was a surviving twin and was sick a lot. We were quite poor, so I was mainly taken care of at home and saw the doctor infrequently. But I saw more of the doctor than I wanted, and that may be where the interest in medicine came from. Quite frankly, other than a brief digression considering the Priesthood when I was around thirteen or fourteen, as far back as I can remember, being a physician was my career path. \n\nDr. Young: Interesting. And physician as in family physician or physician in some other field?\n\nDr. Pugno: Well, being a doctor in general. In fact, when I went to medical school, one of the jobs I had worked at was as a respiratory therapist. A family friend, a physician, helped me get a job doing that when I turned eighteen. So, I did a lot of work in respiratory medicine. So when I went to med school I was looking at either pulmonary medicine or anesthesia. In fact, I worked for the anesthesia department the first two years of medical school, so I was tending to gravitate toward that career. However, there was this new specialty that just started up as I was starting medical school called family medicine. A young, junior faculty member by the name of John Geiman ended up being my advisor. For some bizarre reason, he and the department chair, Len Hughes Andrus, told me I would end up in family medicine education. I told them they were crazy, but the reality is that once I started my clerkship rotations, I found that I just thoroughly enjoyed every specialty rotation. I couldn’t see practicing medicine without including some of all of them. So, family medicine was a fairly default position to go to because it was the specialty where I could do the things that interested me. \n\nDr. Young: And what years are we talking about doing those?\n\nDr. Pugno: I started medical school in 1970. So, when I was applying to medical school and really thinking about my medical career, the specialty of family medicine had just been established. And I’ll make one small correction – I did have one other slight career digression. When I was in college, those years were when the U.S. space program was very active and I actually considered a career in aerospace medicine. There was a lot of talk about the space program at the time and I figured out that I would be just about the right age with the right experience to compete to be part of the first Mars crew. And so aerospace medicine was an interest. In fact, in college I did some research pertinent to that, and I was seriously considering that career direction. What happened was that, when it became obvious that I would need to wear glasses all the time as I was getting a little nearsighted, I knew that I would never qualify for the astronaut program. So, that’s probably when I sort of went back to thinking about pulmonary medicine or something like that as a career direction.\n\nDr. Young: Reflecting now, looking way back to when you were growing up, is there anything about your upbringing, early experiences and all, that now makes sense for selecting family medicine? And then a related question: That informed you in terms of your practice and your educational activities and your management activities?\n\nDr. Pugno: Well, we had a good family friend who was actually my parents’ physician, Dr. Benjamin Miano. And Dr. Miano was very supportive of my talking about medicine as a career. He was a family doc, originally working as a GP, but during the war he had some additional training in general surgery and OB/Gyn. So, he practiced family medicine and he was very much a role model for me along those lines. Because our family was fairly poor, the philosophical underpinnings of family medicine, you know, taking care of the patient from a holistic perspective, the biopsychosocial model concept and how that works into the healthcare needs of families, that all started jelling when I first learned about family medicine. \n\nDr. Young: In terms of your upbringing, anything else that you’d like to share at this point before we move on to really getting into greater depth about your college and medical school and so forth?\n\nDr. Pugno: I mentioned that I fought a lot in grammar school. My parents had the good sense to send me to parochial school where the discipline was a little firmer. And when I went to high school, I was sent to the parochial high school where difficult children were sent. I had the advantage of very strict teachers who helped me stay on the straight and narrow, and I credit them with some of the reasons why I didn’t get into more trouble later on. \n\nDr. Young: What subjects did you like back in your early years?\n\nDr. Pugno: Boy, in my early years I clearly gravitated towards the science courses. In high school things like chemistry and physics were clearly interests. Although the chemistry that I enjoyed the most was anything that would create an explosion. I even took extra chemistry in summer school simply because I was interested and enjoyed that. The biology part was obviously another interest. One of the things I remember best was in high school, my dad was working on the electrical for a meat packing plant. He brought home to me a fresh cow heart that I was able to dissect on my own. That was one of the highlights of my high school biology experiences.\n\nDr. Young: College, how did you decide to go? First of all, did most of the people from your school go to college?\n\nDr. Pugno: No. As a matter of fact, a relatively small percentage of my classmates went to college. In fact, during our ten year reunion, the most consistent theme that I recall from my classmates was that many of them were getting out of rehab. So, no, not a lot of them went to college. But I was hell bent to go that direction. I did well enough in high school that I got some small scholarships, but I actually held down three jobs through most of college which helped pay for the expenses. I went to the University of California at Riverside, that was the nearest U.C. campus, for undergraduate work, and it was a small undergraduate class at the time. I think there were only like 2,000 undergrads at the time. And so I had a lot of primary contact with faculty. It was a good school for me, had good job opportunities for me, and I felt I got a really good education going there.\n\nDr. Young: What was your major?\n\nDr. Pugno: Well, I started out in the pre-med track that was called pre-professional zoology. During my junior year, the university was changing curricula and was going to make everybody in the pre-med track a biology major in general biology. I just wasn’t too interested in coming out with a generic degree like that. So I petitioned the school to hold onto my zoology major and actually added a major in microbiology because I was interested in that and working in that area. And so I ended up with majors in zoology and microbiology, and I almost finished a degree in chemistry because I took a lot of extra chemistry classes because I was interested in them. And I almost finished a degree in botany because one of my jobs was working in a plant physiology laboratory and I ended up taking a few additional courses that direction too. \n\nDr. Young: Any behavioral sciences?\n\nDr. Pugno: No. The behavioral sciences was one of my weak spots. As a matter of fact, when I finished my family medicine residency (this is jumping ahead a little bit),  I had done a residency at one of the early “blood and guts” family medicine programs. When I started practice, it became apparent to me that I was rather weak in the behavioral sciences. During my practice years, I had to work pretty hard to teach myself more of the behavioral sciences. I felt that during my residency training, my behavioral science was weak enough that the only skill that I had was that I knew the dose of Thorazine to make a psychotic, aggressive person hypotensive enough that, when they sat up to try to attack me, they would lose consciousness. And so that’s sort of a summary of my behavioral science training during residency. Consequently, I really felt that in practice I needed to work very hard to learn the behavioral sciences, because if somebody came to the office bleeding, I had no problem dealing with that. But if somebody came in and said they were depressed and feeling lethargic, that was a really hard case for me to deal with.\n\nDr. Young: So medical school was on the horizon.\n\nDr. Pugno: Right. And I interviewed primarily in California. There were about six or seven family medicine programs in California at that time. I think I interviewed at all of them. I chose Ventura as my first choice and that’s where I matched. The California Academy of Family Physicians at the time published one-pagers on the different residencies in California, and they listed the curricula in fair detail, including the major surgery procedures that residents could expect to learn during their training. I frankly picked Ventura because they had the longest list of surgical procedures, and I was really glad I went there. My training was primarily surgical and obstetrics, and those were skills that I really needed when I went into practice with the National Health Service Corp right after graduation.\n\nDr. Young: You mentioned the California Academy. Were you involved at all in any activities as a medical student that involved the California Academy or the AAFP?\n\nDr. Pugno: Honestly not. It wasn’t until I had gone into practice that I started getting active with the California Academy. \n\nDr. Young: Did you consider any other fields in terms of application or almost applying for a residency beyond family medicine at that point?\n\nDr. Pugno: No. By the time I applied for residency, it was 100% clear in my mind that family medicine was going to be my career path. This new specialty with not a lot of residency programs around had the philosophic underpinnings and the practice scope that was what I was looking for. And I had decided at that point that I wanted to at least initially practice in a rural area. Family medicine was clearly the best preparation for practice in a rural area, so it was an easy choice.\n\nDr. Young: And what was the state of family medicine at that time in terms of receptivity by faculty, I’ll even name one (?) clearly who was quite committed, your fellow students in terms of their view of family medicine and any other sort of what’s going on type questions?\n\nDr. Pugno: Well, family medicine was a new specialty then. There weren’t a lot of residency programs. The year I went to Ventura, I was the first class at Ventura that started after they changed from being a GP residency. It had been a GP residency for many years and converted from general practice to family medicine with the start of my class. So I was the first class to do all three years in family medicine there at Ventura. It was a new specialty. Everybody was pretty gung-ho about the training. The preceptors, both family physicians and specialists, were clearly committed toward training people in family medicine. The philosophic underpinnings of family medicine, after the sixties and early seventies, included the care of the underserved, holistic health and things like that, buzzwords that family medicine fit well with. All of the faculty were very motivated to teach us as much as possible that we could use in our practices. And so it was an exciting time to be in family medicine. \n\nThe fact is that not a lot of people outside of that environment knew what family medicine was, and I spent a lot of time in the early years of my practice explaining to my patients and to my colleagues on the hospital staff what a family physician was, and what their training was, was applying for hospital privileges to do all kinds of things. Since most of the medical staff had no experience with family physicians who were residency trained to do a lot of the things I was asking for privileges in, I spent a lot of time orienting people to the concept of family medicine and what it entailed.\n\nDr. Young: So, your colleagues at the hospital, at the point, when you were in practice, were sort of jumping ahead a moment. Weren’t general practitioners who were doing procedures and all, it was more in the other specialties?\n\nDr. Pugno: Right. As a matter of fact, in the community where I was, there was one other family physician who was partially retired. Now there wasn’t a large medical staff because it was a rural community. So there was a Mayo trained general surgeon, there was a semi-retired obstetrician and several internists in the community, and that was about it. There were no sub-specialists to speak of. In fact, some of the sub-specialty exposures that I had during residency and my other training, I developed somewhat of a referral practice as a family physician, caring for diabetics because I was interested in diabetes and had done some initial work in it during my fourth year of medical school. And because of my interest and experience in pulmonary medicine, I became the community’s pulmonologist and was doing pulmonary function tests and consultations and things like that. So it was a very interesting community to work in; clearly one where a family physician could use their skill set.\n\nDr. Young: Share more about the community that you did practice in after residency and how did you get there?\n\nDr. Pugno: I was an enrollee with what was called the Senior COSTEP program of the National Health Service Corps. It was the Senior Commissioned Officer Student Training and Education Program. And so I received a commission in the National Health Service Corp during my second year of residency. I therefore had an obligation to practice with the National Health Service Corps once I graduated from residency. I ended up in Barstow, California, which is in the middle of the Mojave Desert. The geography is... Barstow is where you stop to get gas on your way from Los Angeles to Las Vegas, and where you have your myocardial infarction on your way back from Las Vegas to Los Angeles. So that’s where I ended up. \n\nThat’s not the community I initially targeted. I had made initial arrangements to practice in a small, central California community. It was an agricultural community, and I had even done a rotation there with a family physician in the community. And that was where I was planning to go and where the National Health Service Corp was planning to send me. That was also the time when the California malpractice crises hit its highest and family docs were discontinuing doing maternity care. And because so many were giving up OB, the fact that I planned to do maternity care in that community was considered by some of the medical staff to potentially make others in the region look bad. So they cancelled their assignment as a National Health Service Corp site after the matching program to communities. I was therefore leftover in the National Health Service Corp match. The only community left that nobody wanted to go to and match with was Barstow, California, so that’s how I got sent there. \n\nDr. Young: What was Barstow like in terms of population and …\n\nDr. Pugno: Barstow was really the service community for the Mojave Desert. So although the community itself only had probably around 5,000 or 6,000 people, its service population was probably closer to 25,000. There were a lot of people who lived out in remote parts of the Mojave Desert and they would come in to Barstow to go shopping, to get their healthcare, fill their prescriptions, and then go back out to their worm farm in the middle of nowhere and talk on their CB radios to the truckers that drove along the freeways.\n\nDr. Young: So this was a completely different environment than what you grew up in?\n\nDr. Pugno: That’s right. \n\nDr. Young: Or where you trained?\n\n Dr. Pugno: That’s true, although the training in Ventura was specifically oriented toward rural practice. The majority of graduates of that program would move to rural communities to practice, and so I felt that I was well-trained, and, frankly, socialized to practice in a rural community when I finished my residency. So with the exception of being weak in behavioral sciences, I felt that I was very well-trained for the location I was sent to.\n\nDr. Young: What was social life like?\n\nDr. Pugno: It was pretty limited because I was originally assigned to develop a practice in Barstow with another member of the National Health Service Corps, an individual who had only had an internship. That individual lost hospital privileges shortly after coming to the community because of her training shortcomings, so I ended up doing a lot of hospital work by myself. Because I was doing maternity care and because it was during the California malpractice crises, no one would share call with me doing maternity care. So I basically was on call 24/7 for the entire year that I was in that community. And it was difficult because I couldn’t leave the community because the pager would only reach to the city limits. So I was pretty much trapped. Our social life was limited to cooking together with some of my co-workers. And I picked up the banjo at that point, so that was part of my entertainment... learning to play the banjo.\n\nDr. Young: Was that entertaining to others?\n\nDr. Pugno: Probably not. I was never very good at it. But social life was pretty limited. We had three small children at the time, and I know that it was pretty tough on my wife too. So after my National Health Service Corps obligation was done, we did move from there. I had been very interested in teaching. I did a lot of teaching during my residency. My wife and I taught prepared parenthood. As residents we weren’t allowed to moonlight. But one of my moonlighting jobs during residency, that I had to drive fifty miles away to do, was teaching EMT. And so I learned some emergency medicine doing that, and I really enjoyed teaching. \n\nSo, when I left the National Health Service Corps, I had applied for and took a teaching position in Riverside, California sight-unseen. I interviewed over the phone and went to my first day of work in an academic position totally blind to what I was going into.\n\nDr. Young: What was the state by the time you were leaving practice and entering the educational arena? What was then the status of family medicine?\n\nDr. Pugno: Well, family medicine was in a fairly rapid growth phase at that point. I went to a relatively new residency program that was being sponsored by Riverside County, and it was based at the Riverside County Hospital. Family medicine, like I said, was in a rapid growth phase and the training program, though relatively new, was anticipated to grow rapidly. It was, like I said, an exciting time in family medicine. So, I went my first day at work to the residency program, I went to the double-wide trailer that was the Family Medicine Center and met Dr. Walter Ordelheide who was the program director at the time. He was very enthusiastic to have a residency trained faculty member. He welcomed me, told me that he was actually the chair of the department of family medicine at the affiliated university of Loma Linda, and he was particularly glad for me to arrive because that would allow him to go back to the university as chair. I was being welcomed as the new residency director. He said, “Oh, by the way, here’s a list of the faculty members of the program, you’ll be meeting them later today. And you have a residency accreditation site visit in approximately one month.” So that was my introduction to family medicine education at the residency level.\n\nDr. Young: So when you said that there was rapid growth and therefore rapid demands on everyone involved, you weren’t kidding.\n\nDr. Pugno: I wasn’t kidding. In fact, the residency program, while I was there, grew rapidly. We outgrew the double-wide trailer, and I had the opportunity to build, let’s say assemble, a new Family Medicine Center. County hospitals weren’t very well-funded in those days. But I discovered that San Diego County was building a new courthouse, and they had left over a number of what they called “surge buildings”, sort of like trailers that you can bolt together. They had a number of them available because they were moving the courts from these trailers into the new courthouse. So I bought several of these surge buildings for $1 apiece, had them shipped up to property on the Riverside County Hospital land, bolted them together and built a large, new Family Medicine Center out of them. So we rapidly grew as a residency program at that point.\n\nDr. Young: How large a faculty did you start with? And then what did it build to?\n\nDr. Pugno: Well, the faculty was fairly small. I was the only full-time person. If I recall, there were two half time community physicians working in the residency and a handful of people who would do a week here and there. And so it was a very challenging time to recruit faculty and to try to operate a residency program with largely volunteer family physicians. But we did it. The program grew and is still in operation, so I guess we put something together that was worthwhile. \n\nDr. Young: So this was based in a county hospital setting. Talk a little bit about the patients and the challenges that you faced in terms of a residency like that.\n\nDr. Pugno: Like Ventura where I was trained, Riverside County Hospital was part of the county hospital system in California that basically was the healthcare provider for the poor and disenfranchised communities of the state. So I was used to working in that environment. In fact, the resources were so poor, that’s one of the reasons I gravitated toward needing to get better in my administrative and management skills. \n\nShortly after I got there, one of the things I discovered we needed for the residency was an EKG machine. I went to the hospital administrator and told him we needed an EKG machine, and he basically pat me on the head and said, “Oh, you foolish young child, we don’t have money for anything like that. Your residency costs me money; don’t ask for anything.” I frankly didn’t believe him, but the residency finances at the time were managed by the finance department of the hospital, and they were very secretive about that information. So my strategy was to actively recruit a patient that worked in that department, in the finance department, and she became my mole in finance and would send me computer printouts of the finances of the residency program. I discovered at that time that the residency program was actually making a lot of money. Those were in the “olden days” when county hospitals got paid cost-based reimbursement. And so although we were taking care of the county poor, the public reimbursement for that care was actually pretty good, and the residency program actually made quite a bit of money. That was also the time when the graduate medical education funding from the federal government was very good. The indirect medical education funding percentage then was 11%. I say that number because today it is less than half of that. And so comparatively, graduate medical education funding back then was quite good. So the residency program was clearly a revenue line for the residency. Which taught me the management skill that if you understand the finances and know how the finances of your residency program function, that is a power leverage position as the residency director. And I started negotiating with the hospital administrator on a totally different basis. And although I had grown up with an electrical contracting business in my family and I knew business from that side of it, I learned residency finance fairly early (and out of need) and recognized that understanding residency finance was a critical skill for residency program directors. Later on, one of my missions in academic family medicine was to teach family physicians residency finance in order to empower them as program directors to generate resources for their residencies.\n\nDr. Young: You mentioned that the man who hired you was the chair of the department of family medicine. In your CV you have listed some work in emergency medicine and in public health. Was that where the connections got made or was that a different point in your life?\n\nDr. Pugno: Well, that’s some of the public health connection. Loma Linda University is a very public health-oriented medical school. They have a huge School of Health with lots of international health initiatives as part of the Loma Linda religion and service framework. \n\nAnd so public health was a high priority within that school. And because I got a faculty appointment through Loma Linda, I had access to Loma Linda education programs at a discount. That was at the time when Loma Linda built their first what they called an extended MPH. It was a Masters in Public Health program for working health professionals. It was designed for people who had a job, and I was able to take one course a semester. Over a five year period I complete my masters in public health. And so I took advantage of that opportunity and finished my MPH five years later, working through it on a part-time basis. So that’s where the public health part came in. \n\nWhile a resident at Ventura, we rotated through the emergency department not only for our training rotations, but throughout the three years we providing coverage to the emergency department. So, every third night I was working in the emergency department, so my emergency medicine skills were pretty good. They were augmented some while working in a rural area where we provided our own emergency backup care for patients. I also had a young family and working as a residency program director that doesn’t get paid very well when you’re an employee of a county, so we needed money. n weekends and nights I did some moonlighting in emergency departments in the region. I joined a group called California Emergency Physicians that was one of the larger emergency medicine groups back in those days. They provided me the opportunity to not only work in emergency departments but to also do some developmental work in emergency medicine. I was involved in the piloting of the first base station physician training programs in southern California through that program, and after I had been part of that group for a while, I helped them build a primary care family medicine component to their corporation that was establishing family medicine practices around the state. So, working in emergency medicine and then working with that group allowed me to do a number of things that helped out, not the least of which was to earn a little extra money.\n\nDr. Young: So there seemed to be a point in which your professional activity broadened from a practice in one community, Barstow, or the residency program that you went to, into relationships that were much larger systems.\n\nDr. Pugno: Yes. I had a tendency to get involved in things. While I was a residency director, I also established a number of contracts to do employee health for local employers through the residency program, and we became the healthcare provider for the employees of the county. We even took over providing care for the Student Health Service of Loma Linda University. And so we got involved in a lot of different things. And like I say, family medicine was relatively new. Someone who had residency training and a broad skill set had lots and lots of opportunities to develop new patient care opportunities.\n\nDr. Young: And it sounds like you maximized those opportunities. Anything else you want to talk about at the residency level before we move on to Mercy and Catholic Healthcare West?\n\nDr. Pugno: Well, the short version of the story is that I took a brief digression from family medicine into emergency medicine. After I had been a residency director in southern California for a few years, my wife was interested in going back to school and doing some graduate work, but we had three young children which would make that relatively difficult. And so I recruited a new residency program director, and I left that position. Because I was working for California Emergency Physicians, they were offered a new contract to take over the emergency department of Riverside Community Hospital. And so I had the opportunity to become the director of the emergency department at Riverside Community Hospital. As the director of the department and practicing emergency medicine, I could earn a little bit more money. But the big advantage was that I could schedule the bulk of my work at night, so that way I could be home with the kids during the day. And actually those were some of the best years of my life. When I look back at having three young boys and being home with them all day every day, that was very nice. It was a little tough working nights. I learned to really hate door-to-door salesmen and bothersome phone calls during the day, but it was a good time with my kids. My wife was able to go to school, and I was able to generate enough hours in the emergency department to allow me to qualify to take the board certification exam in emergency medicine, which I eventually did. And that credential has been helpful to me as well. So, a lot of people don’t know, but I took a two year digression from family medicine at that time.\n\nDr. Young: Well, some would argue that emergency medicine is simply one part of family medicine; though I know the field has developed extensively.\n\nDr. Pugno: Well, I learned something important about emergency medicine. Emergency medicine is fun, it’s great making all those diagnoses and the excitement. But emergency medicine is not the time to have any follow-up with patients. So, you make all these cool diagnoses and you never get feedback to find out if you were right. And so I was frustrated by that and I found myself going into work early and going into the hospital and making rounds to see if the diagnoses I made the previous shift were correct with the patients that got hospitalized., That way I could have sort of an educational feedback for myself. That I felt was a major shortcoming of practicing emergency medicine.\n\nDr. Young: Has the field taken advantage of the push for quality and electronic health records and other things to provide that feedback?\n\nDr. Pugno: I honestly don’t know. Emergency medicine, as one of the newest specialties, has worked very hard to establish its identify. And I think that’s one of the reasons that emergency medicine has resisted collaborating with family medicine in many settings., How they actually see themselves is somewhat as competing with family physicians. Although the emergency medicine community has in recent years made peace with the fact that their training is really better suited to practice in an urban tertiary care center, and that family physicians are actually probably the best trained physicians for providing emergency care in the rural setting.\n\nDr. Young: Perhaps we can move on then to talk about the next stage of your career, at least if I were sort of dividing it into segments, into the graduate medical education activities with Mercy and with Catholic Healthcare West. Or am I missing something in between?\n\nDr. Pugno: Well, in between those two … My wife is a research historian and we wanted to live in New England for a little while since that’s an area of interest. So we moved to Connecticut for a couple of years and I worked at the University of Connecticut in the Department of Family Medicine there. It was a very turbulent time. The university was not a very user-friendly setting for family medicine. They had a branch of their residency program in Hartford downtown at St. Francis Hospital. So I shuttled between the two as their education director, supporting the residency program directors and the curriculum. It turned out that we closed the family medicine residency at the university. It was simply not a user-friendly environment. And we moved everything to the St. Francis campus in downtown Hartford and expanded the residency there. Again, I had an opportunity to really leverage management skills in that setting. \n\nBut after we had been there for a few years, our parents started getting sick and we felt the need to move back to California. So at that point we moved to Redding, California. Again, it was a relatively new residency program based in a county hospital. Shortly after I got there, I ended up taking a dual position of both the residency director and the medical director of the hospital. And it was about the time then that the county decided to close the hospital, so I was responsible for not only the shutdown of the county hospital but to transition the residency program from the county hospital to the community hospital in Redding, Mercy Medical Center. So I was successful in transitioning the residency program while maintaining accreditation through the process, and we moved it from the county hospital to the community hospital. \n\nBeing based at Mercy Hospital in Redding was my entrée to the Mercy Healthcare System, and Mercy started using me and my experience to help other residency programs in the state when they had organizational, logistical and financial problems. That gave me some visibility with the Mercy system. In 1994 I was recruited by them to leave the directorship of the residency program at Mercy in Redding, move to Sacramento where the corporate offices for Mercy Healthcare Sacramento, a branch of Catholic Healthcare West, was, and take a position as vice president for graduate medical education and medical affairs. So I became a corporate officer. My job initially was to develop and establish a new family medicine residency in Sacramento at one of their smaller community hospitals, Methodist Hospital, and to also play a role in the development of residency education and collaboration between their system of hospitals and the graduate medical education system that was taking place in all of those hospitals. The Catholic Healthcare West system was spending a fortune recruiting new physicians for the hospitals with which they established new contracts, totally ignoring the fact that there were roughly 600 residents being trained in their system of hospitals. And so my job was to coordinate graduate medical education throughout the entire system and to help them do a better job recognizing the talent that they had in their own institutions, develop more internal recruitment, develop more residency programs within the system, and to capture the graduate medical education funding, the millions that they were leaving on the table. They were doing a relatively poor job of capturing that money out of the federal government. And so that was one of the key roles that I played in the system at the time.\n\nDr. Young: How large a system are we talking about?\n\nDr. Pugno: Well, a lot of people aren’t aware, but if you ask somebody, “What’s the largest hospital system in the western United States”, almost everyone would say Kaiser Permanente. The reason for that is because the Kaiser affiliated hospitals take the name Kaiser. In fact Catholic Healthcare West is the largest hospital system in the western states, but it’s relatively invisible because hospitals are allowed to keep their names. And so CHW was a big system, a very active system, and the largest in the western states at the time that I was involved there. I got very involved in the corporate operations of the organization. Unfortunately it was at a time when managed care was the grand experiment, when cherry picking of patient populations was how people were manipulating managed care. Primary care was being left with the sickest patients, the most complex patients with marginal funding for them. Residency programs, obviously, again became the access point to health care for the disenfranchised populations. And so it was a difficult economic time. \n\nCatholic Healthcare West started a major downsizing process in the late nineties, and by 1999 I was the last person, as part of the senior executive team, who had been there five years previously. Almost everyone else had left and transitioned out as things were being downsized. That was about the time when the American Academy of Family Physicians decided to convert their education division into two divisions, a continuing medical education division and establish a new division of medical education. I was recruited by Dr. Norman Kahn to come establish and develop that new division. So, because I knew that my position was sort of on the bubble within Catholic Healthcare West, but I hadn’t been downsized yet, before leaving I was able to leverage the salary I was being paid. The deal was that I would leave the job, would not ask for severance, and go to work for the American Academy of Family Physicians under the condition that the money that was earmarked for my salary would be transitioned to the Family Medicine Residency Program budget to help support the residency’s operations. And they bought that deal. So the residency program has done well and is still active. And I came to the American Academy of Family Physicians in 1999. My first day of work was the first day that they opened the new building in Leawood, Kansas.\n\nDr. Young: Which is where we’re conducting this interview.\n\nDr. Pugno: Exactly.\n\nDr. Young: Well, the Academy was an organization that you had involvement in before getting recruited here. Can you talk a little bit about that?\n\nDr. Pugno: Sure. I had been involved with the California Academy while working in that state and actually chaired their education committee for several years. So I was involved locally but not too involved nationally - except as a residency program director. I was very involved with the residency program directors. I was fortunate to be involved at the time when the American Academy of Family Physicians helped the program directors establish their own organization, and I was part of the association board the second year that the Association of Family Medicine Residency Directors was established. I was active organizationally in the Program Directors Association first as a board member and eventually as a president of that organization.  \n\nSo I had a lot of involvement with the Academy through that angle. The fellow who recruited me, Norm Kahn, he and I had been friends for many years. Norm had actually been a program director in the Catholic Healthcare West affiliated system many years ago when we were all affiliated in the University of California Davis network of residency programs. So I had known Norm for many years, and he’s the one who recruited me to the Academy. And as I was saying that, I just lost the track of what I was starting to say.\n\nDr. Young: You were exploring things that you had done …\n\nDr. Pugno: Oh, involvement with the Academy, right. So, being involved with the Program Directors Association, I had a lot of interface with the Academy. I applied for and got appointed to the Commission on Education and so became part of the volunteer infrastructure for the Academy through that venue. Because Dr. Kahn and I were friends, he would occasionally ask me to represent the Academy to various meetings that he didn’t have time to attend.\n\nDr. Young: We’ll stop at this point so we can flip the tape and pursue it from there.\n\n(Side 2)\n\nDr. Young: This is side 2 of the oral history with Perry Pugno, MD, recorded on the third of February, 2015, at the Center for the History of Family Medicine.\n\nPerry, you were talking about your involvement with the AAFP prior to coming to the Academy. \n\nDr. Pugno: Yes. Having been a member of the Commission on Education was my entrée into being a volunteer for the Academy. I found myself, because Dr. Kahn and I were friends, volunteering to do a number of things that came up on behalf of the Academy. And so over the years, my sense of familiarity with the Academy continued to grow. While I president of the Program Directors Association, because the Academy was providing management services for that organization, I had a lot of contact with the Academy staff and really felt pretty well-oriented to the Academy. So when in 1999 Dr. Kahn contacted me to recruit me to come to the Academy as an employee, it was an unprecedented opportunity for me to become part of the staff of an organization that I loved, had been a member of for a long time, and had been volunteering for, for a long time. The year before I started working at the Academy, I did a lot of volunteering. So when I had the opportunity work for the Academy, my wife’s reaction was, “Well, you traveled sixty days this last year as a volunteer for the Academy. If you take the job, they’ll pay you for that travel.” And so she was very favorably disposed to my taking the job here at the Academy.\n\nDr. Young: In terms of the amount of travel one does, did you find that sixty days as a volunteer was different than as a member of the professional staff?\n\nDr. Pugno: Yes, because I found myself traveling more than twice that amount as an employee of the Academy. The job clearly entailed being a road warrior. And it was a management challenge to develop a new division, to establish myself as part of the infrastructure of the Academy while being gone from the office a great deal, making the personal connections and organizational connections necessary to really develop the medical education component of the Academy. I was grateful to be well-supported by the Academy in that endeavor and feel proud of the fact that the Division of Medical Education now plays a key role, not only in student interest, but also in graduate medical education policy and even Academy policy related to the family physician workforce.\n\nDr. Young: What was your understanding of why the Academy decided that two divisions were needed?\n\nDr. Pugno: What Dr. Kahn told me was that CME was clearly a priority for the Academy at the time that the education division was developed. But family medicine education was growing in the country at the time. There were some early inklings of challenges of student interest. And the complexity of graduate medical education financing and the political intrigue involved in that was escalating rapidly, and it was clear that for the Academy to fully respond to all of those needs, an infrastructure built around those needs would be the most efficient way to do that. So, I think it was a wise decision on the part of the Academy. And I think history has proven the fact that the Academy’s role is an extremely important one along all of those avenues.\n\nDr. Young: What does that division do – and maybe that question could be divided. When you came aboard, what were its activities compared to when you retired?\n\nDr. Pugno: When I came on board, the Division of Medical Education’s activities were primarily focused around student interest and operating the Commission on Education. Over the years, the student interest needs escalated clearly. The Graduate Medical Education funding and the support for our residency programs, beyond just the political support that the program directors were providing, but the educational infrastructure support was escalating and the division started putting more and more resources into that. The Residency Assistance Program (RAP) was operated out of the Academy at that time and RAP was evolving to be a consultation service, less to develop new residencies, more to help existing residencies do a better job educationally and to do a better job organizationally in the management of the training programs. Obviously the politics of Graduate Medical Education funding became very controversial during those years, and a lot of political activity was taking place. And the implications of the nation needing a family physician workforce foundation in primary care escalated the political dimensions of the division playing a role in the workforce. So the division’s activities escalated along all of those avenues, helped significantly by the establishment of the Robert Graham Center that provided much of the data underpinning that helped the political advocacy components for the Medical Education Division. So the division grew and evolved in its sophistication along all of those lines. And by the time I left the position as division director, I think the Division of Medical Education’s role in all of those avenues had been well established, not only with the Academy but also with the other organizations and entities that they interfaced politically.\n\nDr. Young: Does it frustrate you, looking over all these years, that the specialty and its graduates has to be sold and resold and resold to policymakers, to various other players in the healthcare system and in the nation?\n\nDr. Pugno: Well, it doesn’t frustrate me but I do find myself singing many of the same songs I did in the seventies. The fact is (and this is only slight hyperbole) family physicians are their own worst enemies. Family physicians as a population are reluctant to advocate on their own behalf, are reluctant to advocate on behalf of their own specialty, and the important and positive things that family medicine has done for the nation. And we need to get over that. The initial Future of Family Medicine project was hopefully going to do that. I think that was the key unfinished business of the initial Future of Family Medicine project... the communication component of the importance of family medicine and its contributions to the healthcare system of the nation. And so I’m cautiously optimistic and very hopeful that the new Family Medicine for America’s Health initiative will emphasize and focus on the communication and public advocacy component of family medicine, and it will hopefully achieve the visibility and public familiarity with what family medicine offers this nation that really needs to happen. \n\nDr. Young: Why don’t we take a moment to talk a little bit about both of those two endeavors and we’ll cover some other issues afterwards. But Keystone, I believe, was the original meeting that sort of looked at the specialty?\n\nDr. Pugno: Right. And although I wasn’t involved in that event, I did become very familiar with the materials that came from it. Keystone basically said what I just said, family medicine needs to get out there and let the public know who we are and what we have to offer. What is a family physician? We still answer that question for patients. So Keystone established the need for a project to better establish the nation’s understanding of family medicine. I think the initial Future of Family Medicine project, with which I was happy to be involved and to chair the task force on education component of it, I think did a good job raising the visibility and understanding of family medicine to the audience of the national political infrastructure. I think the other specialties are well aware of us now. And, frankly, I think the legislature and clearly the White House are familiar with family medicine and the potential that family medicine can offer. Corporate and organized healthcare is very interested in capitalizing on the good things that family medicine brings to healthcare, both from the patient care quality perspective and the financial management perspective. \n\nThat said, it’s the general public who doesn’t really know who a family physician is and what they have to offer. And that was the unfinished business of the initial Future of Family Medicine project. So, I was really gratified to have the opportunity to get involved in the kickoff and development of the Future of Family Medicine 2.0 initiative that evolved into the name Family Medicine for America’s Health. And this initiative, I think, is going to hopefully directly address those unmet needs. The Academy and actually all of the family of family medicine organizations have bought into the concept and are actively participating and financially contributing to support this new project. I’m very optimistic it is going to help us get where we need to go in the visibility of family medicine nationally. \n\nDr. Young: What sort of activities do you anticipate coming out of this?\n\nDr. Pugno: I think there are two: One is some clarity on what is a family physician in the current day and age. Family medicine has become a very diverse specialty. Family physicians do a lot of different things in their practices, and it’s somewhat difficult to communicate that diversity to the general public. And so we need some clarity on what are the components that make one a family physician. Clearly it’s the philosophic underpinnings, but you can’t really sell that to patient populations because they’re looking for healthcare, not philosophy. And so that’s one component to it. \n\nThe other is the pubic communication component of what is family medicine and what does family medicine have to offer this nation, and to get the word out to the general public to help them understand what family medicine has to offer. Those members of the public who understand what family medicine has to offer, that’s what they want out of healthcare. That’s what they want out of the healthcare system. They want someone who will provide the majority of their care, will understand their individual care in the context of their family environment and community and do so in a cost-effective manner. And when they need more complex, high tech care, they want somebody who knows the system, who can help them navigate it and look out for their individual best interests. That’s what the public wants. That’s what family medicine has to offer. We need to make that connection on a communication basis.\n\nDr. Young: What are the implications for medical education, of success of the effort you just outlined?\n\nDr. Pugno: Education implications are many, not the least of which is: what is the future practice for which we are training today’s family physician? And that question is up in the air right now and there is significant work to get some clarity. In the olden days when I was training, it was clear that broad scope of practice was what family physicians did. In the ensuing years and with some generational priorities, many family physicians today practice a significantly truncated scope of practice. Many family physicians have given up inpatient care, have given up maternity care. Some of them aren’t even taking care of children. Some have an outpatient adult only care practice which is a fair step away from the philosophic underpinnings and the holistic and contextual care perspective of the specialty when it was established. \n\nI think there is a significant interest now in swinging the pendulum back toward a broader scope of practice. It’s clear that all of the research literature demonstrates that breadth of scope of practice is one of the key variables that makes family medicine so effective both on a quality of care, patient care, health parameters outcomes basis, and on a cost control basis. So, if family medicine is going to achieve what the public and the legislature thinks it can achieve for this nation, scope of practice is going to be a key component of that. So there’s going to be a significant challenge in pushing the pendulum back toward a broader scope of practice. \n\nAnd faculty development is going to be a big part of that because there has been some loss of skill set breadth among residency faculty in the nation. And so we need to provide resources for many of those family physicians to recapture the scope of practice skills that they had that they may have given up. Some of the procedural skills that family physicians were less interested in doing because they were inpatient procedures need to be recaptured. So, not only our graduate medical education curriculum needs to address that, but now our continuing medical education system needs to readdress that for the practicing community that realizes the need to recapture some of the scope that they had as residents and start reintegrating that into their practices. Many family physicians now are actually doing that, are going back into doing the inpatient care that they found that they missed when they had an outpatient only practice, and are going back to doing maternity care that they used to enjoy in practice. I think that’s going to be one of the key educational challenges that the discipline is going to face as this Family Medical for America’s Health project evolves forward.\n\nDr. Young: So, early on in the establishment of residencies there weren’t many formally trained physicians in the faculty. Faculty development was a very major enterprise, as I understand it, in the early seventies, for example. You’re describing a little different one, it seems to me, as a challenge for the specialty which is refreshing or maybe learning certain procedural skills, some of which can be done now in an outpatient setting that used to be traditionally done in hospitals where privileging issues pop up.\n\nDr. Pugno: Right. And CME has evolved and the technology of simulation is going to help and facilitate that process. So I think the family physicians are going to be very gratified to see how many new procedures they can learn, how many new procedures they can integrate into their practices on an outpatient basis simply because our simulation training opportunities are so much better. I think that that’s really the future of continuing education as well as graduate medical education, simulation.\n\nDr. Young: So, what’s the role of the Academy in that regard? And attached to that is, who’s going to make the decisions about what training to undertake by those who are already in practice and how will it get paid for?\n\nDr. Pugno: Wow, those are huge questions. The how will it get paid for I think will come when the payers figure out that that’s where the economies are going to come., Namely, it is paying family physicians to do things and to decide whether things need to be done. That’s what’s going to control healthcare costs. I think that’s where the evolution of payment is going to happen. Family physicians need to be compensated for the important role they play in the coordination of care, and I think that payment evolution for things like that is where family medicine is going to clearly make some inroads in the near future. \n\nEducationally, and as far as who is going to make the decision, I think the Family Medicine for America’s Health project is made up of people who represent all of the diverse communities and perspectives within the family medicine family. Not only organizationally but the generational community, the senior family physicians and the new physician communities are speaking loudly as to what they need, how they would like to get it, and how that’s going to work in their new, reframed practices. So I think that’s going to be an important part of this initiative and is going to revolutionize both graduate medical education and continuing medical education. Graduate medical education is going to be challenged by that revolution because they’re being challenged right now on a lot of levels. \n\nGraduate medical education is being whipsawed by new requirements. The Accreditation Council for Graduate Medical Education has made broad, sweeping changes in how residency training is supervised on a national basis by the accrediting bodies. Program directors are being faced with new requirements. New technology is being necessary for them to gather data and report that data to these national accrediting bodies. Program directors have always had a hard job and that job difficulty is going to continue to escalate. \n\nOne of the things I’m most gratified about was the Academy’s role in the establishment of the National Institute for Program Director Development. NIPDD is an entity that I think may well have saved the educational community of family medicine. When NIPDD was established, the average life expectancy of program directors in that job was about three years. Just about as long as it took someone to learn the job, they would get burned out and leave that position. NIPDD gave program directors the administrative as well as educational skills to be much more comfortable in that environment, to learn the management skills that they never learned in medical school but were absolutely necessary to their role as the administrator of a multi-million dollar business entity called the residency program. And NIPDD has made a huge difference in extending the longevity of program directors in that role and their comfort in it. \n\nWell, NIPDD is going to be challenged now to add to that training skill set all of these new components, and the new requirements, and the new reporting issues, and how do you evaluate resident milestones and educational parameters to these national entities. I think that it’s a very dynamic environment right now that’s very challenging. There is a huge national need for faculty. That may well be the rate limiting step in residency programs continuing to develop and evolve as they need to in order to accommodate the changes in the discipline that are going to go forward in the future.\n\nDr. Young: You sort of diverted into the future of family medicine activities coming to sort of the end of your comments on being division director. But you then became a vice president. Would you talk a bit about what that transition was like and how it positioned you to do some things that perhaps you had been thinking about for quite a while? And you’ve talked, for instance, about making sure that there’s an understanding by residency directors of the administrative, fiscal, political, etc. beyond just the education process itself.\n\nDr. Pugno: Well, the transition into the vice president position was an interesting experience for me. I was not aware of any interest on the part of senior leadership in establishing a new vice president position for education. So, as division director for medical education, I received a message from Dr. Henley’s office saying that he wanted to meet with me on short notice.\n\nDr. Young: And Dr. Henley was executive vice president?\n\nDr. Pugno: Yes, executive vice president for the Academy. My anxiety level went very high. I have a tendency to press the envelope edges in the way I interface with senior leadership for the Academy, and so I fully anticipated that the meeting was an opportunity for Dr. Henley to scold me for something that I had done that was beyond my job description.\n\nDr. Young: Just one thing?\n\nDr. Pugno: Just one thing. So, I went into the meeting with significant trepidation. I was surprised that Dr. Henley proceeded to tell me that the senior leadership had decided to establish a new position and do some reorganization such that a vice president for education position was going to be created that would supervise both medical education and the continuing medical education divisions. Dr. Henley gave me the choice of either accepting the position or taking primary responsibility for recruiting somebody to take that position. So, after a very challenging evening at home with my wife, I came back the next day and decided to accept the position and worked to recruit a new division director for medical education. \n\nAnd so I transitioned into that position on fairly short notice. As it turned out, I ended up doing both jobs for a good year, I think it was. But it provided me an opportunity to do something that I really wanted to do... and that was to bring the two components of medical education and CME of the Academy closer together. There is significant overlap in the priorities and the kinds of things that need to be done on behalf of the Academy within those two divisions, and taking the vice president position provided me the opportunity to do that. And I’m gratified that upon my retirement they maintained that position as it was so that those two divisions could continue to work, not only more closely together, but more collaboratively and in a more integrated fashion on issues of mutual interest. \n\nOne example is that as we think in terms of generating educational resources for our residency programs, many of the same pieces of information need to be gathered together and the same sorts of communication modalities need to be mobilized to create educational resources for residents and educational resources for the practicing community on the CME side. And so there is the opportunity for some significant economy of scale and development. And over the last few years, I think the Academy has taken good advantage of that. \n\nI think it’s fairly apparent that the CME enterprise of the Academy has expanded and escalated significantly. Continuing medical education offerings and resources to our members have never been greater. They are available not only for diverse subjects but in diverse modalities. Do you prefer to read it? Do you prefer to hear it as an audio? Do you prefer to watch it as a DVD? Do you want to go to a live course? Do you want to do something on your own? All of those opportunities are available to the Academy members with the new CME resources that are being developed. And those same resources are becoming educational resources for our residency programs to take advantage of and leverage the high hurdle of training family physicians in today’s environment.\n\nDr. Young: There are several trends in the practice of family medicine. One is the increasing number of individuals who are employed as family physicians. And a lot of that employment may be in larger healthcare systems. The second one is direct primary care which may have overlap or it may be freestanding. As you look to decisions that members are going to make about where to get their CME, what are the forces at work and what is the Academy’s positioning in terms of these?\n\nDr. Pugno: I think the Academy’s positioning is really fairly a straight-forward one. There are lots and lots of CME resources out there. They vary substantially in cost. They vary substantially in the modalities by which they are delivered. But there is one consistent theme that AAFP members benefit from and that is the continuing education produced by the Academy is of absolutely the best quality that can be created. With Academy CME products quality is the No. 1 parameter. Yes, the information is developed by family physicians, for family physicians, with the right kinds of contextual considerations that are taken into account as the CME is assembled. But it’s the high quality of the CME that the Academy puts forward that members can depend on 100%. And I think the Academy has done a really good job becoming one-stop shopping to address the educational ongoing needs of family physicians in this nation. I think as long as the Academy continues to make quality of the products and services that they provide the key variable, the Academy members and non-members will continue to take good advantage of those resources. \n\nDr. Young: Do you think that healthcare systems, as they have increasing measure to deal with quality measures, would ever consider developing their own CME in competition with what the Academy offers?\n\nDr. Pugno: Well, a lot of corporate entities do look to developing their own educational resources for their employees. They try to leverage those towards the specific needs of the organization. They leverage those needs of the organization in priority to the needs of the individuals. And I think the insight that individuals will continue to have of their own educational needs are the key things that are going to keep the Academy as a primary resource for CME. Even though, yes, corporate entitles will develop competing products and services, the Academy’s are those that family physicians can depend on as being for them, by them, and of the highest quality. So, I think that as long as the Academy maintains those priorities, CME is going to continue to be an important component of the Academy’s operations.\n\nDr. Young: Has the Academy been able to adapt to other trends like direct primary care?\n\nDr. Pugno: I think there are lots of trends out there. Direct primary care is one of the most visible right now. Direct primary care is a highly functional practice framework in many environments. Not necessarily all environments, but certainly many environments. And it’s a new approach that family physicians are interested in. The Academy, I believe, has an obligation to the family physician community of the nation to bring forward information about direct primary care, help those family physicians who decide that’s the direction they need to go to get there, but to be sufficiently clear about what direct primary care does offer to help family physicians decide if it’s right for them and their practices and their setting and their priorities and what they want to accomplish in life. And direct primary care is only one of probably many trends that are going to come up in the years to come that will be something that the Academy will need to learn about, investigate in detail, and find a way to share with its membership.\n\nDr. Young: Are there any other trends that maybe aren’t as obvious to others at this point that you see coming regarding family medicine?\n\nDr. Pugno: I’ve mentioned faculty development as a huge need. I think there is great competition right now for family physicians as teachers. Family physicians are not only among the most valuable teachers of family physicians, but because of their breadth of practice and their flexibility, they are also among the best teachers of medical students, of nurse practitioners, of physicians assistants. And so family docs are in great demand as teachers. My personal bias is that teaching is the best continuing education you can possibly get. And so I’m always motivated to encourage family physicians to get involved in teaching because it keeps you current, it keeps you stimulated, it keeps you sharp. Students of all types ask a key challenging question to their supervising preceptors. That question is, “Why do you do that that way?” Forcing you to think about, yeah, why do you do that that way? Why did you care for this patient this specific way? And that’s what keeps you current. Students also bring information to people in practice that isn’t going to hit the medical textbooks for several years, aren’t going to hit the CME system for at least a year or two. Really, staying cutting-edge is possible … the strategy for doing that is staying involved with students and learning from them as well as teaching them. So, I think that our efforts to engage family physicians in the educational process is a trend that I hope that we will be able to stimulate.\n\nDr. Young: Do you think employers understand that? And I say that, having had a conversation with a physician who said, unfortunately he could no longer be a preceptor because of the demands that were being placed on him by the organization for whom he worked.\n\nDr. Pugno: Yes. I think employers are totally blind to that. In our current society we have truncated our vision of business operations to the end of the month, the end of the quarter. It’s very short-sighted. And the long term benefit of having a well-trained, currently practicing physician in your system, and the ultimate economies and benefits to the patients being served on a long term basis, that’s what employers should be looking at. But our business environment right now is so short-sighted that they don’t see it. I think that’s an important communication message that needs to get out there. But I think that message will not be embraced by the business community until and unless the patient community demands it. And I think our focus on quality may help that process because the quality measure of how patients are doing is something that corporate entities are going to need to be answerable to as time goes on. I think that demand of quality is going to force organizations to think in longer terms, because you can push quality on a short term basis just so far. We really need to be leveraging a more long term strategy if we’re ever going to get our arms around the diverse healthcare needs of this nation.\n\nDr. Young: As you reflect on your years at AAFP, what things stand out in your mind as successes that you led or contributed to that you’re very proud of?\n\nDr. Pugno: I’m proud of the contributions that the Division of Medical Education make on an ongoing basis to the Academy. I’m proud of the growth and organizational sophistication that the Continuing Medical Education division has evolved to with my involvement. I am proud of several individual programs that have evolved over time. The National Institute for Program Director Development is something that I was intimately involved in the development of. It is a resource to program directors that is unparalleled in any other specialty, and I’m proud of having had a hand in that. I’m gratified to have been involved in the Future of Family Medicine, the two projects. The initial one and now Family Medicine for America’s Health. Though I take no credit for what those have accomplished, I’m gratified that I could be a part of them going forward. \n\nAnd I think there’s one other thing that I feel particularly good about, and that is that when I first came to the Academy, I was heavily involved with the Program Directors Association. I had been a member of the Society of Teachers of Family Medicine since the late seventies when I first got into academic medicine as part of my career path. And I had an appreciation for the contributions made by the Department Chairs Association and the bi-national entity for research, the North American Primary Care Research Group. I had to think of the acronym letters. What NAPCRG has contributed. And so one of the things I feel gratified about is that when I came to the Academy, I appreciated the proximity of staff and leadership from those organizations pretty much all being here in the building.  I established an infrastructure where the staff leadership gets together on a monthly, and sometimes more often than that, basis to talk about working together, sharing resources, avoiding running afoul of one another and avoiding duplication of effort. But mainly the facilitation of lines of communication among the family. And even with the certifying board now, we have established a working group between the staff of the Academy, mainly continuing medical education staff, and the staff of the American Board of Family Medicine. This facilitation of lines of communication I think is going to be critically important to us being able to respond promptly to needs and trends and demands from the family physician community of the nation. I feel good about having played a role in the establishment of those lines of communication because I think they’re going to pay big dividends in the future.\n\nDr. Young: You’ve talked about the family of family medicine organizations. But looking at your CV, you clearly have had relationships with other medical specialties in other organizations that care about primary care, maybe in part rather than in full, because our colleague organizations like AAP and ACP represent also subspecialty within their areas. Any comments on those relationships or with government entities or others outside of the family of family medicine?\n\nDr. Pugno: Well, I will admit that I find it personally challenging dealing with government entities. The glacial pace at which things happen, the comfort with prevarication within the political environment... I find those difficult to deal with. But I think family medicine has done a particularly good job of establishing functional lines of communications with government and national entities. I think we’ve established good lines of communication with our primary care colleagues, pediatrics and internal medicine. We’ve done a number of collaborative projects. The current Primary Care Faculty Development Initiative, for example, that was kicked off by the three professional associations and the three certifying boards in primary care, has been highly functional and has facilitated lines of communication that wouldn’t have been there otherwise. Our direct involvement in the Council of Medical Specialty Societies being led by Norman Kahn now, a family physician, I think has raised the visibility of family medicine among the other specialties, contributed significantly to our legitimacy, if you will, as a specialty and to the special things that we contribute and the special roles we play in coordinating patient care and resources and things like that. I think there’s a much greater appreciation for that. \n\nI think the fact that the AAFP has been active politically when it really matters has put large organizations like the Association of American Medical Colleges on notice that we are a voice that has leverage, that carries more than 100,000 family physicians behind it, that carries the care of a large proportion of the nation’s population behind it, that we are a voice that needs to be listened to, a voice that has something important and significant to say. And I think in the last decade or decade and a half, the Academy has made great progress along those lines. \n\nI’m not only proud to be a family physician but proud to have been a part of an organization, now as a member only but before as staff, but being part of an organization that is doing good things for the nation, doing good things for the people of this nation. One of the best things about working for the Academy is that everyone who works here has drunk the Kool-Aid, is here because they support the mission of the Academy, the mission of family medicine to improve the healthcare of the nation on an individual basis, on a community basis, on a national basis. I think everyone understands that mission and sees how they contribute to it directly in their day-to-day jobs. It’s very special to have been part of that. \n\nDr. Young: Has that brought up some challenges for the organization as it has reached out in terms of bringing in expertise that deal with technologies or marketing or other areas that we didn’t have necessarily within the building?\n\nDr. Pugno: I think the challenge is for each component that is brought into the Academy, that component needs to be educated and socialized to the philosophic underpinnings of family medicine. And once they get that, they drink the Kool-Aid, and they’re part of the team. Sometimes it takes a little while for that to happen, but it inevitably does happen because it’s an unstoppable force to be on the side of right, if you will, when you’re working that direction. And I think that we have brought lots of new resources into the Academy... expertise in electronic health records, expertise in marketing and communications, and even how we operate our national meetings. But I think we’ve done a good job educating and socializing them and getting them to drink the Kool-Aid along with the rest of us. \n\nA good example is how we brought in a strategy firm to assist the Academy in the Family Medicine for America’s Health project. Actually, we brought two, a strategy firm and a communications firm. Both of those firms had to educate themselves about what family was and what the Academy was. Both of those organizations have overtly embraced the philosophic underpinnings of family medicine to the extent that the strategy people can speak family medicine as well as any family physician, and at an intrinsic level resonate with those philosophic underpinnings and the value of them. And the marketing people have engaged it to the point where some of the key staff that started with us in that project are now targeting going to medical school to become family physicians because they were so impacted by what drives family physicians, what drives the discipline forward, that they want to be a part of it. So, I think that that’s the best validation you could possibly ask for that says we’re going in the right direction.\n\nDr. Young: Indeed. What else would you like to share as you look over our conversation?\n\nDr. Pugno:  The final thing I’d like to share is that I want to point out how much I appreciate the value of capturing this conversation. I think it is unfortunate that many entities lose the philosophic basis from which they were created, lose the mission, that the environmental noise clouds out that part of it and that the AAFP and the family of family medicine has made an overt effort to remind itself from whence it came and what are the values that built the specialty in the first place. As long as we hang onto those primary values and we have an organization that does things like these recordings to capture the history from which we came, I think as long as organizations do that, they have a bright future. I very much appreciate having had the opportunity to be part of an endeavor that hangs onto that foundation and thank the Academy for this opportunity to contribute to it. \n\nDr. Young: And then the Center which is an organization support by all of the family of family medicine. So, make a prediction: Ten years from now, what will family medicine look like? What will the Academy look like?\n\nDr. Pugno: Predicting the future is always difficult, especially since we can count on being about 80% wrong most time. But I believe in family medicine, the specialty, and the direction that we’re going. I believe ten years from now the voice of the Academy will be even stronger. I would like to think that the legislature will have finally figured out that supporting primary care in this nation, paying it properly, supporting it operationally the way it needs to be, will provide the ultimate economy and health benefit to the people of the country.  And ten years from now we will have made good progress. \n\nI don’t think we will accomplish it all, but I think ten years from now we will look back and say we’ve made good progress in establishing family medicine as the foundational specialty of primary care delivery to the people of this nation, and that country is better off for it. I believe that the Academy will continue to be a healthy organization. I believe that the other family medicine organizations, the smaller organizations, will continue to grow and mature and make greater and greater contributions on their part to the priorities of family medicine for the country. I believe that ten years from now the Center for the History of Family Medicine will have even more things in its archives that will support this mission of family medicine and all of the entities trying to help us go that direction.\n\nDr. Young: And then perhaps a slightly easier question: Think back when you entered family medicine, back to practice time and early educational, what has happened that surprises you in terms about where we are today and what hasn’t surprised you at all?\n\nDr. Pugno: Well, I’m surprised that this message of what family medicine can contribute to the nation hasn’t been better communicated, that the public hasn’t embraced it. And like I said a little while ago, we’re our own worst enemy, and we’re reluctant to blow our own horn. I’m disappointed that we haven’t done more of that and would hope that we will correct that in the future. I’m gratified that the underpinnings of the specialty, the priorities upon which the specialty was built are alive and well. And I’m gratified that the specialty is making an overt effort to hang onto those and to insure that those are preserved and nurtured to support us in the future.\n\nDr. Young: Thank you Dr. Pugno. Any final remarks before we end?\n\nDr. Pugno: No. Thank you for this opportunity. This has been great fun and more than a little challenging. I hope that I was able to contribute to the historical basis for the specialty.\n\nDr. Young: Thank you.","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153755/file/282867#t=0.0,3759.86921"}]}]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153755/file/282866","type":"Canvas","label":{"en":["Media File 2 of 2 - Pugno_Perry_15_b.wav"]},"duration":3458.98145,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153755/file/282866/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153755/file/282866/content/2/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/282/866/original/Pugno_Perry_15_b.wav?1752681235","type":"Audio","format":"audio/wav","duration":3458.98145,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153755/file/282866","metadata":[]}]}],"annotations":[]}]}