{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/v69862dg6c/manifest","type":"Manifest","label":{"en":["Vincent Keenan"]},"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":["2017-04-05 (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":["family medicine","family physician","American Academy of Family Physicians","Family Medicine for America's Health"]}},{"label":{"en":["Subject"]},"value":{"en":["Vincent Keenan,  CAE (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: 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/3491/collection_resources/162445/file/295871","type":"Canvas","label":{"en":["Media File 1 of 2 - KeenanVincent_01_Access.mp3"]},"duration":3292.5933,"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/3491/collection_resources/162445/file/295871/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162445/file/295871/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/295/871/original/KeenanVincent_01_Access.mp3?1761144307","type":"Audio","format":"audio/mpeg","duration":3292.5933,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162445/file/295871","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162445/file/295871/transcript/85504","type":"AnnotationPage","label":{"en":["Vincent Keenan interview transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162445/file/295871/transcript/85504/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Side 1: Today is April 5, 2017. I’m Herbert F. Young working as a volunteer at the Center for the History of Family Medicine and we will be doing an oral history with Vince Keenan who will introduce himself in a moment. This is side 1 of tape 1.\n\nVince Keenan, welcome. Do we have your permission to record this oral history?\n\nYes, you do Herb. I’m happy to participate.\n\nWonderful. The subject that we’re going to be looking at today is Family Medicine for America’s Health project. Let’s start out by asking, Vince, could you give us your full name?\n\nMy name is Vincent Keenan and my day job is I am the Executive Vice President for the Illinois chapter of the American Academy of Family Physicians. \n\nCan you share a little bit more about your work history in family medicine?\n\nI started at the Illinois chapter in 1989 as Director of Student Affairs and some other things. And then in 1992, just about 25 years ago, I became the Executive Vice President. So I am the Executive Vice President or have been of the Academy chapter, its Foundation. We started a new organization called Family Medicine Midwest Foundation which holds an annual conference. I’m the Executive Director of that. So I’ve been involved at the state level, the regional level and I’ve served on several AAFP committees and commissions over the years. And then the subject for today, Family Medicine for America’s Health, I was appointed, I think it was June 30 of 2014 to the board of the Family Medicine for America’s Health. \n\nCan you talk a little bit about why it’s important for this first stage of the project that a chapter representative was part of the board?\n\nThe concept for the Family Medicine for America’s Health included two different types of activities. One was basically a public relations activity called Make Health Primary and then a second one having to do with the development of tactical groups. And so the chapter perspective was needed more for the public relations activity because it was considered for 2015 that the chapters would host an event like a family medicine get-together event to promote Health Is Primary which is the exact name of the public relations activity - not Make Health Primary but Health Is Primary. And so there were five chapters that were scheduled to host in 2015 and then more in 2016, so it was thought critical to have a chapter person’s perspective. Secondly, for the other arm of the project which is the tactical teams, there are now seven different tactical teams, it was thought that the chapter perspective would be needed for several of the tactical teams, especially the ones having to do with patient engagement, perhaps workforce activities. \n\nTalk a bit about the need for a public relations aspect. What is it that the group felt was missing that that was necessary?\n\nSo the initial activity with the Future of Family Medicine, back about 2003 to 2005, did a very good job of putting together a strategic plan for the Family of Family Medicine for the profession to move forward. But the one part it lacked was a public relations arm, a way to talk about itself, a funded way to get the message out. So as this activity which kind of started off as Future of Family Medicine 2.0 got started, having a public relations activity was seen as a very high need, a high priority for Future of Family Medicine 2.0.\n\nSo what audiences were in mind in developing that? \n\nI think when it was first conceived back in 2013 to 2014 it was strongly conceived as a large audience, the general public as well as family medicine, primary care and health care audience in general. So the idea was to not only influence policymakers and those involved in health policy but to try to reach a broader audience. So that’s how it was initially conceived. And then as we worked through the ideas it became fairly obvious fairly quickly that we would not be able to cover the general public. So the idea then began to focus more clearly on health policy, federal legislators and then potentially through the state chapters states and local health officials, legislators, government branch folks.\n\nWas business viewed as part of the audience?\n\nBusiness was as it was related to health. So businesses in the health arena and then those businesses that – for example, in the Chicago area here we have a Midwest Business Group on Health and there are several other regional groups like that. So those would be the target business people where it would be the human resource professionals in businesses that either are self-insured or buy their insurance through either a cooperative or through an insurance carrier. So those particular people within were targeted. \n\nAnd what were the messages that were needed to be conveyed?\n\nI think the overall message was actually as simple as what is primary care, family medicine and how do you spell it (that’s a little tongue-in-cheek there). But I think the idea was there was a critical need to get the message out that primary care, family medicine services to the public, to employees, to dependents, the way it’s configured, the way it’s thought about and constructed actually provides healthier outcomes and lower cost to employers and others who are paying for primary care and family medicine services. So the idea was how do we get that idea across. So the idea of Making Health Primary or Health Is Primary was the conclusion that it came to, was use primary colors, they’re the basic starting set for any color scheme. So all the promotional activities around it included primary colors, very simple taglines. And then from those kind of general impressionistic type of things we tried to develop a series of stories about family physicians doing innovative activities in the transformation of medicine. So stories were gathered in five state chapters, within cities within them, that held events during 2015.\n\nDid you say that one of these occurred in Chicago?\n\nYes, it was May of 2015 we held one. And we were very fortunate – it was a fun event, it was held at a place called Matter which is a health industry incubator of a health innovation industry incubator located at the Merchandise Mart in Chicago. There’s an organization there called 1871 which was the year of the Chicago fire which led to the transformation of Chicago from a series of wooden buildings into the beginning of the skyscraper and the organization of the city into a better point of view. So 1871 had started as an incubator for businesses in the Merchandise Mart. And then Matter basically opened in April of 2015, so we were one of the first groups in there in May of 2015. So we were trying to give that impression of here’s family medicine, its cutting-edge, and we featured two different panels of family physicians from Illinois doing a variety of different activities. It was very well-planned. The biggest challenge we had, and I think this occurred for most of the cities around the country, it actually ended up being a pep rally for family medicine. So it failed to achieve one of the early goals we had which was to use these city tours, as we called them, as a way to catalyze interest in the Health Is Primary, the big health is primary idea. I said kiddingly that really the only way to get the Chicago media’s attention about doing some type of activity like Health Is Primary would be to get our then 67-year-old president of the Illinois chapter and have him jump off the top of the Hancock Building wearing a Health Is Primary outfit because the Chicago marketplace is filled with seven medical schools, tertiary, quaternary, quintenary medical centers and the activities that take place at that end of the healthcare world attract attention – you know, the latest zebra (?) patient case like we just had recently, a child brought from Africa who had four legs and two spines. And that took up probably four days on the 24-hour news cycle. We got no bounce out of that and really struggled. Though we filled up a room with 150 people who were all jazzed by the time we left, there wasn’t that catalyzing force. So it was a good pep rally but it really wasn’t a catalyzing force. So the same thing happened in Seattle, North Carolina, Detroit, Denver. And Kansas City was just a little different because we did that at the National Conference of Residents and Students. So that was a very successful pep rally but it was really kind of staged as a pep rally.\n\nSo is this a continuing challenge for the specialty in terms of telling its story and trying to get the right policy and purchase decisions?\n\nI think it is. Herb, as you know from our shared experience in the public health realm, prevention doesn’t sell. My family physician seeing me and my wife and two children now for the last 30 years and all the things he’s prevented and things that didn’t happen to us are not really quantifiable. And so that’s the struggle that family medicine often has is that its successes often aren’t quantifiable. Where we’re blessed now is as we work towards population health, and we really used that message in the 2015 and 2016 for Health Is Primary, is that population health begins to help us explain what family medicine does and use the triple aim of better access, better care at lower cost, which we’ve expanded to the quadruple aim and that’s to the health satisfaction of providers too, we’ve been able to tell that story a little bit better as the Affordable Care Act moved along. So while we were almost kind of like right place, right time for the message, it still lacked traction in a general way. I think the Health Is Primary campaign funded at probably about $13 million sounds humongously big to family physicians and certainly to those who were on the board it did, but in reality it’s kind of small drop in the ocean of promotion. So I think we made some good efforts and moved ahead but the ability to actually measure the effect of the public relations wasn’t making changes. You know, the type of quality improvements evaluation that family physicians put on themselves in their practices, we really weren’t able to get that type of data. We had some general information about that that was somewhat reasonable. But I think the family physicians on the board there was this sense that, yes, we need to do this public relations activity but its short-term effect might be interesting but there’s really no way to measure its long term effect.\n\nTalk then a little about the other arm that you mentioned for the project.\n\nI joined the board just as the organization was getting started so I wasn’t part of the Future of Family Medicine 2.0 activities. So I came on right as the organization was being put together. So it’s a separate limited liability corporation under the American Academy of Family Physicians – which was another reason they wanted a chapter exec on, they wanted someone who had some of that organizational type of experience to help them move through the six months it took us to go through the paperwork and legal stuff around that. And now I’ve forgotten your question Herb. Oh, the tactic teams. So the tactic teams, originally they were supposed to start first and then followed by the activity of the public relations Health Is Primary. But what happened is, a really excellent consulting firm was brought on to help stand up the organization and get the tactic teams going. Well, the amount of effort it took to bring together the eight organizations, to sign contracts, to set up the FMAHealth corporation or the limited liability corporation and all that really chewed up a lot of time of the consultants who were supposed to start the tactic teams. So it was decided that we needed to get this project going because the funders, the eight family medicine organizations, were literally chomping at the bit to get some results because they were being invoiced already and they wanted to see some activity with regard to that and telling people that the lawyers signed three contracts today wasn’t all that exciting, so we decided to move ahead with the public relations activities. So the idea around the tactic teams was to try to pull together the quote “Family of Family Medicine,” the eight different organizations that got together twice yearly in what are called Working Party meetings. And for people who had been there, they said it’s really not working and it’s really not a party. And it was like an ongoing diplomatic and collaborative activity, from what I could understand. And what Family Medicine for America’s Health did, what the tactic idea and the state organizations putting their money together did was it really focused these organizations to work together in a fashion maybe unlike any way that they had worked together before. So we had tactic teams on research, on workforce, on payment, on practice, on engagements. A new one was just set up on health equity. And I’m blanking on the other two right now. But the idea was how can we put together a game plan for family medicine much like was done for Future of Family Medicine 1.0 back in the 2005 range and this time not only pull in people from the Family of Family Medicine but how also can we bring in others. How can we expand that activity. And the concept really was based on community organizing framework. And I think that’s what really made it exciting for me to join was coming from Chicago and with our former president Barack Obama being a huge organizer, I had been part of a community organizing type of framework in the business I do in my life and professional work styles. So this idea of bringing together experts from family medicine and also colleagues near us in family medicine to work on these different issues was terribly exciting from my point of view.\n\nSo the Working Party meetings held in January and August were used in 2013, 2014 and the first one in January 2015 to really shape up what the work agendas would be for each one of these groups. And then there was the recruitment activity which took place between, I want to say, October of ’14 to March of 2015 to bring folks on board for meetings of these groups that happened mostly via webinar and teleconference. And then we had what we called an all-hands meeting where everyone would get together from the different groups twice a year in April and October. The groups themselves, the tactic teams, had varying types of responsibilities. Just, for example, the research group was really trying to pull together. Even though there is an organization called NAPCRG, North American Primary Care Research Group, the research is really done in a very organic fashion across family medicine. So the research group said why can’t we set up a prioritized suggested schedule of where family medicine research could go? So that group worked very well together. And in fact the NAPCRG, I believe as of last December actually took back the activity fully into their scope. So they have been successful in getting a wide range of family medicine researchers together to discuss these things. They held a meeting called the Starfield Summit, I want to say it was April of ’16. And that really pulled together an agenda and got agreement on the agenda for research in family medicine. So that’s just one example of what one tactic team was able to do.\n\nIt sounds like the tactic teams were dealing with important issues within the specialty, issues that do require involvement of the rest of society in varying ways, payment, policies and so forth, but were more internally focused, in a sense, as opposed to the public relations side. Is that a fair assessment?\n\nThat’s a fair assessment, yes. I’ll use another one as an example: On the Payment Workforce, when payment workforce was conceived and brought about the payment mechanism under Medicare was still the Sustainable Growth Rate index, the SGR, Sustainable Growth Rate under Medicare. And so the conceptualization of this was that the payment group would think about what is going to happen next. Where is payment going to go or where would family medicine like payment to go? So the idea was like can we do the three year, five year, ten year steps going out of what payment will look like for family medicine, what tools can be developed that will help family physicians make those next steps, understand what those next steps are. Because I think the idea was while payment through Medicare had been stuck on SGR, the probability that if it ever got changed, that it would move to a next ten or fifteen year this is the way things will get done did not seem to be the guess of experts in that area. They really thought it was going to be a series of steps that would need to be taken. So the payment work group said we’ve got to look at what are those next steps and how do we get family physicians to visualize ten years out and to get through whatever the next couple of iterations of payments mechanisms are so that you can be successful ten years out because maybe some of those intermediate steps are going to be not interesting, not helpful or not useful. So that’s the conceptualization of another group. So yes, it was internal but it did require us to bring in expertise from health plans, from Medicare and other organizations like that to inform the payment work group.\n\nTo what extent have other primary care clinicians been involved within Family Medicine for America’s Health?\n\nVince Keenan: So that was an early on discussion Herb. You know, there’s basically two different styles of thinking and one is I think a movement and then the other is a guilt (?). So we had several board meetings where we went through discussions about should we make this a movement or a  guilt (?). And as the board representatives from the eight different organizations went back to their organizations and as we investigated the possibility of teaming up with our colleagues in pediatrics, general internal medicine, maybe psychiatry and obstetrics and gynecology it became clear that we did not have the bandwidth to bring all those folks together and onboard with us. So I’m kind of on the side of the movement rather than the guild (?). So it really became a matter of dollars and cents. And we probably would have needed to double our $8 or $9 million dollar budget on the tactic team side to be inclusive on building the tactic teams using our colleagues from the other primary care specialties. So what we did was we tried to include folks who were generally representative of primary care, so there’s a patient-centered primary care collaborative piece, PCPCC. So they were brought into the tactic teams. In fact, some subcontracting was done to them to get some activities going. Another organization, FMEC Incorporated was holding an annual meeting with regard to innovators in family medicine or entrepreneurs in family medicine, so a grant was made to that organization to try to bring some influence there. So we took some of the funding that was made available and then either did contracts or made grants to other organizations kind of outside the eight members of the Family of Family Medicine to expand its reach. But this would have, instead of being like a $21 or $22 million project it would probably would need to be a $50 million project. Also, I think when we look at the public relations end, my point of view as an association executive is that of all the things to work with in another organization, public relations is the most difficult. You know, you can do advocacy work together where you can agree to agree and agree to disagree and find your way along there that a next step might be to do some cooperative education activities. But public relations, at least in my career, has been the hardest one because the messaging is always very particular to each professional group, so that probably was a big stumbling block for us too. \n\nDr. Young: Can you say a little bit more?\n\nVince Keenan: What I wanted to comment on is with regard to the payment tactic team. So as I had described before, the payment tactic team was really involved in trying to anticipate the steps and payment mechanisms past the Sustainable Growth Rate Medicare payment mechanism. And so when that payment mechanism was changed in 2016 there was a lot of consternation on the board at that time and there was kind of a wrestling match that went on between the Academy of Family Physicians and the FMA Health board about thinking about what was advocacy. So the payment tactic team was really trying to anticipate the next steps along the way. As the American Academy of Family Physicians realized that there was going to be a new payment mechanisms, and pretty quickly, and that the idea of getting rid of the Sustainable Growth Rate and movement to this new payment mechanism called MACRA would take place quickly, the American Academy of Family Physicians was very concerned about any advocacy going on in the payment world, the payment end of things by anyone associated with them. So they were building up an internal team of staff who would help to develop any policy or actually language that could go into MACRA and the MACRA rules and the tactic team, for payments on the FMA health side, was trying to reach   and talk with folks at Medicaid and Medicare, the Center for Medicaid and Medicare Services and a couple of other agencies. So advocacy in a very broad sense on the executive branch side not on the legislative side. So that became pretty much of a crises point within the FMA Health and AAFP and so FMA Health decided to stand down. So the activity of that work group which was initially to take a look at some intermediate step points said, well, gosh, we’re going to look out to 2025 and try to anticipate if we are successful in making a payment mechanism change that pays for a population health-based payment, so anticipating that family physicians would take care of a population of people and that the payments would be some for preventative services, some for acute care, some for chronic disease management for a population of people, how would that look and can we come with a quote calculator that family physicians can use to try to look forward to that. So that calculator actually will come out in the summer of 2017, so that is a success for it. But it certainly was the change in health care transformation payment environment was one that caused a significant bubble or burp in the plan for FMA Health. So that just shows how we plan a project, then how it changes over time because of good things that happen but also organizations struggling to figure out where they belong and how are they going to do this, it can become a challenge, at least from the FMA Health side, on trying to get the job done. \n\nVince Keenan: There was a second comment I wanted to add onto and that had to do with reaching outside the Family of Family Medicine. I think, as I described before, we struggled to conceptualize how to involve other primary care organizations and came to the conclusion that being on target for the same message, the same type of public relations activity would be difficult, if not impossible to pull together. And the idea was that it was a struggle to get the Family of Family Medicine to agree on messaging with regard to the profession of family medicine how much more difficult would it be if we involved other primary care organizations. So that concept,  we kind of stood down on that. So where we expanded our activity, as I alluded to just a little bit earlier, we started to engage other organizations that were more broad in scope in terms of primary care such as the Patient-Centered Primary Care Collaborative out of Washington, DC, Primary Care Progress which is a group that focuses on primary care influence into medical schools, so it included family medicine, internal medicine, pediatrics. Another organization, FMAC, which is really very family medicine-oriented but has developed kind of annual conference of entrepreneurs in family medicine but also seems to draw other primary care entrepreneurs. We also have on our board of directors someone else who I think you will be interviewing who was from a maternal and child health advocacy organization. So they were on the board to try to give us a broader perspective. I would say 90% of the time was all about internal family medicine profession activities, where we were going, how we could describe ourselves and probably 5% to 10% was spent outside of that. I don’t think anyone anticipated how much effort would need to take place in order to do that just to organize the family medicine side of things, so the idea of reaching out much further was a struggle. Probably the best thing that elucidates that thought is as we were trying to develop (and my computer went down, so sorry that I can’t pull up the right words here) … but we were trying to develop basically something we could deliver to the public, a promise to the public on what does family medicine deliver. In Future of Family Medicine 1.0 we   \n\nused a term called basket of services that nobody liked. And in Family Medicine for America’s Health, and I can’t pull up the name of it, we had a different word for that, so I’ll call them principles. But the struggle to come up with what is a family physician and what do family  physicians provide the patients seemed to be an enormous struggle and it really took us, I want to say, a whole year to get through that activity. And it was anticipated because it was thought to be modeled off of the pediatric profession which kind of did it on the back of a napkin over a weekend, to develop theirs, that family medicine could do that fast. But it wasn’t such. And a lot of the struggle, because I’m not a clinician and not a family physician, to me seemed to come around let’s be careful about what we say a family physician is. So instead of saying here’s what a family physician is and does, we came to the conclusion we will describe what a family physician is trained for and what they can do once they finish training. So I think there’s a wee bit of disappointed in some folks around the board that this was not helpful in effect public relations document. It ends up being more about academic exercise. Because what we wanted to do was to take the document so that it could be distributed to employers, health policy people and the like to try to say this is family medicine. So I think that covers those two topics that I kind of left unfinished.\n\nDr. Young: You’ve pointed out I think a number of times the complexity of the world that we’re living in where things happen such as the SGR going away. We have a new administration, a new  Congress, the larger integrated healthcare systems continue to evolve, direct primary care is growing. I can see where trying to say what a family physician does could be a challenge because in bunches of different settings they may do lots of different things. But let me come back to this issue of trying to do planning and then executing that plan in a world that is forever changing. Any insights in this?\n\nVince Keenan: Sure. So this is a very personal opinion of mine. But I think it was in August of 2016, maybe it was May of 2016, but the eight funding organizations came to Family Medicine for America’s Health and sent us information that said we’re a little disappointed with how the tactic teams are moving and we really like what’s going on with the public relations activities. And I think what was happening was in the anticipation of the 2016 presidential election the idea was – I’m making this up, but I think some of the organizations thought our best money and time is going to be spent influencing the new legislators in Washington, DC as well as because of the new administration, the new leaders on the health committees in both the Senate and House. So we (the organizations who put in the money) would rather see our money spent on public relations activities that would help supplement our lobbying efforts in Washington, DC and the like rather than spending any more time even thinking about doing city tours, which I described earlier, or spending more time on these tactic teams which are doing nice work but the critical survival of the profession depends upon us landing a good mark in the next administration. So what happened was, there was, again, kind of a wrestling match or a rugby scrum between FMA Health and the eight organizations to the point where the eight organizations executive directors were brought in to speak to the board in September of 2016. So the board of FMA Health was to listen to them, what they wanted to do and where they wanted to go. So a pivot was done. A pivot meaning let’s try to send as much of the tactic teamwork back to the eight organizations as possible, quicken the timeline of the work of the tactic teams, diminish the funding available to the tactic teams and then turn that over to the public relations activity. Because in effect the public relations activity would have ended in, I want to say, July of 2017 – and so with the savings achieved by quickly … As I described before, the example of the research tactic team, since they took up that activity faster than was originally anticipated, then that funding could be made available for public relations activities. So in effect what this did is instead of the public relations activities ending earlier in 2017, they actually continue into 2018. We probably bought another six months at the regular burn rate and then another six months at probably half the burn rate of the consultants who are involved on the public relations activity. So that shows a real change in the conceptualization in 2013/14 where we hadn’t even had our successful change to the Affordable Care Act when this all came about. So our ideas were we think we’ll be successful but it’s going to take this type of work to get it done to just a few years later saying, our money and time, the funding agencies or organizations is better spent influencing Washington policy makers and legislators.\n\nDr. Young: So if I’m hearing correctly, because of the dynamic situation in terms of health within the United States, obviously Family Medicine for America’s Health has had to face a changing chessboard, the organizations themselves as well. And let me ask, is that true for the average family physician in terms of what’s going on in their professional situations?\n\nVince Keenan: I can only speak to that from the Illinois family physician’s point of view and our marketplace in 2017 is about 65% of the members of the Illinois Academy are employed physicians, then another 20% are owners or part owners of their practice. Then the others are doing a variety of different activities that might not be involved in their patient care. So I would say in Illinois, for the employed physicians who are not in leadership activities, the changes going on are --, but their ability to control those changes or influence those changes or influence those changes are little. For the physicians who are leaders in employed situations, they do have some influence. Some more than others as some of the health systems or medical groups are more strongly oriented towards primary care, family medicine, so are heading in the direction where those family docs can make a difference. For the family docs who own their own practices or are part owners of their own practices, one of the tremendous changes going on that they’re dealing with in addition to going from SGR to MACRA is for the family physicians who are in middle- income to upper-income is the changing way that employee health insurance is covered. So the move to high deductible health plans has caused family physicians to scramble greatly on that because they still have to do all the insurance paperwork for the patients but the patients hardly ever reach their deductible on that. So the growth of something called direct primary care has been an interesting wrinkle, a challenge. So I think going from most difficult to least difficult in terms of the ability to do something, the physicians who own or part own their practice have the biggest challenges. The family physician leaders in employed situations are next, then the family physicians who are not leaders do as they can but don’t have a lot of influence or sway about how things are organized.  \n\nDr. Young: The Family Medicine for America’s Health project is, as I understand, a time limited project?\n\nVince Keenan: Correct. It was conceived as a five year activity. So I think it was scheduled to end like June 30th of 2019, is when everything is to come to an end. The advanced schedule to get out of the tactic teams I think ends up with just two tactic teams, maybe three still working in 2018. I’m off the board on December 31, 2016 so there’s been probably at least two, if not three, board meetings since then. So there might be a few changes. But the idea was to have four of the seven tactic teams turned over to one of the Family of Family Medicine organizations in 2017 and then probably two of the other three in early 2018 and then one continuing to the end of the project which is the health equity one.\n\nDr. Young: So a strategy for continuing the work of the core teams is for them to end up within one or more potentially of the organizations?\n\nVince Keenan: Yeah, I think the idea from the board of FMA helps. So all we could do, as the surgeon general used to say (I’ve had the privilege of working with a few of the surgeon generals) … You have moral suasion. You can’t make people do anything but you have a lot of moral suasion. So the moral suasion from the FMA Health board was to make one organization take the lead and be responsible. There might be other of the organizations who were participating in it, but it really needed to be one organization to take the lead on each one of the different tactic teams.\n\nDr. Young: Looking at the titles of some of them, clearly there is overlap among organizations. Work Organization and Development Core Team, for example, I would imagine STFM has a major interest in. But likewise the American Academy of Family Physicians has an education activity. But there’s also partnerships that have been longstanding across organizations.\n\nVince Keenan: Right. \n\nDr. Young: As you view this with your many years of work within the family medicine community, how optimistic are you about the success of the various components?\n\nVince Keenan: I think some will do incredibly well. Again, research is just … My first example, that I think catalyzing activity for family medicine research was a work accomplished and is a shining star for FMA Health. One that got started a little bit later, the health equity one that has to do with trying to help define the social determinants of health and have family medicine kind of take ownership of that and be seen as a leader in that I think is progressing very well. There is a conference out in Portland, Oregon I think this month and Dr. Julie Wood, who followed you at AAFP, just announced a Center for Health Equity at American Academy of Family Physicians. So I think that activity has been catalyzed as an amazing start and go at it. I think the ones around practice and payment and engagement will struggle to have an impact. We’ll have to see. I’m most closely associated with payment and engagement and I think both groups (I didn’t explain how engagement did it) … But both groups had a lot of changes to their work plan from day one to two and a half years into it because of changes in the marketplace. \n\nDr. Young: So they were adaptable in terms of changes in the environment that reality of today is not necessarily the reality of tomorrow?\n\nVince Keenan: Right. My perception of the feeling of those on those tactic teams was that they might have spun their wheels for nine to twelve, fifteen months because of those changes. And because those changes weren’t clear in the direction that they were going, it was hard to say, okay, here’s what we’re going to refocus on. So, for example, on the engagement side, the original intention was to really try to push activity that would have family physician practices have a patient and family advisory board on them. And, again, conceived in the 2013/14 region where we had Pete Corley (?) at the federal level doing a lot of that type of activity. But then as we got more and more changes in the marketplace, it just became unclear as to what type of influence Family Medicine for America’s Health could have in that area. So it backed off and said, gosh, maybe we should do some of this activity around getting our chapters to have a public member on the chapter boards and challenge each of the eight organizations to have a public member on their board.\n\nDr. Young: Can you define engagement?\n\nVince Keenan: Sure. The engagement group was probably the most public facing of all of the tactic teams. Its job was to try to help family medicine engage the public and use it as a part of the team to promote and advocate for family medicine. To use the example of the subspecialist world, a lot of buildings, programs and services … I’ll just take one I’m involved in, Alzheimer’s is built around  neurologists and researchers who do research in the Alzheimer’s area and so funding and activity comes around from people who have been served and helped by that profession with their loved ones who have Alzheimer’s. So the concept was how will we take the collaborative of love of family physicians for their patients and turn this into more than just an enjoyable part of the visit with patients or what makes family physicians feel great about seeing multi-generational families, but turn it into an ongoing activity that can be valued by payers, valued by others along the way instead of just, yeah, that’s the way it’s supposed to be. So it was trying to take a gut cultural level feeling about family medicine practice and the way patients relate to that and then turn it into some type of ongoing measurable, describable activity.\n\n(Pause.)\n\n\nSide 2:  \n\nDr. Young: Would you like to continue with your last point?\n\nVince Keenan: Sure. I was describing the engagement team and trying to say what they were trying to accomplish and the struggles that they had because their work was conceptualized in 2013 and 2014 and then by the time we started to get that group active in 2015, some things had changed along the way. So we were talking about patient and family advisory councils as one of the things that was originally conceptualized as a way for what this group would do. So where the engagement core team ended up is that because of different things going on in the marketplace, they set their goals in different ways than they did in the beginning. So one of the goals was to have patients, the public and community members on boards of family medicine organizations or innovative ways to engage patients in the design and delivery of care. Or developing a set of shared principles for a person(?)-centered, team-based primary care. So a little different than what they had originally conceptualized but they were able to kind of pivot in the marketplace to do that. One of the other specific areas where chapters were likely to be involved and thought that the American Academy of Family Physician chapters should be involved … It should also be noted that the American College of Osteopathic Family Physicians was part of the board of directors and also one of the funding organizations. So there are chapters of the American College of Osteopathic Family Physicians involved in this too. So with regard to my colleagues, I envision someone who is overly optimistic, wakes up everyday cheerful and happy, but generally an annoyance to people because of that. So with my chapter colleagues, I was seen as a good person to come into a changing and moving situation and be a cheerleader for it. So that was a role that I played in the first two years, from June of ’14 through June of ’16, was to go to meetings and describe what was going on with regard from a chapter perspective and how chapters and their leaders and others could get involved. \n\nDr. Young: What sort of questions did you get or reactions from chapter execs when you interacted?\n\nVince Keenan: I think there were two. One was all of the chapter execs are business people, association executives, and they felt that the public relations activity was interesting but didn’t feel that there was a strong evaluation component to it. So while there was a lot of activity and a lot of … You know, like there’s a band and there’s a march and they’re based on a lot of the activities and splash in the pan types of activities that didn’t warrant involvement, so I did a lot of work trying to recruit the chapters to be part of the city tours in 2015. And then also I helped put together for the tactic team side a review panel of three other chapter execs and myself, helped the tactic team consultants get a feel of where the chapters were coming from. So I think where the health is primary, the public relations side. One of my colleague’s comments was there’s no there, there. How are ever going to know that it worked? And again, there are some measurements that public relations people might say this seems good. But we didn’t, we as the FMA Health board, I don’t think pushed the promotional consultant team hard enough to come up with measurable, full measures that satisfied some of us on the board in terms of this is a make a difference type of activity. And, in fact, the reason we made a pivot at the end of 2015 and didn’t continue on with any of the city tours in 2016 was exactly that – none of the four events, if I count the one in Kansas City, really had a success in the way that any of us at the state chapters felt it would be a success. Plus, the public relations consultants who were doing, it felt like, the amount of effort and time they had put in this was far more than what they were used to. They were used to putting on events not exclusively but pretty much in Washington, DC and they knew how to do it there. But to come outside the beltway and doing that type of activity was a challenge. \n\nVince Keenan: With regard to the tactic teams, I think the chapter exec group was fairly helpful in getting the consultants to understand where we came from, how we did our work and how it was quite different from I guess other types of work, community organizing, what they had done in the past. It did seem to me, as a board member for FMA Health, an ongoing struggle to … Sometimes I felt like I was describing Pluto to people who lived on earth. You know, it was hard to describe how association chapters worked, how our activity was done, how we related to each of these eight funding organizations. I think there was a sense that the Family of Family Medicine was more tightly organized. And part of that, Herb, as you know, is the history of family medicine. Other professional medical societies were started top down and family medicine, as far as I know, is one of the few or only national organizations that kind of started from the bottom up. So there was a lot of states’ rights and culture and feel to family medicine that you wouldn’t necessarily find in say general internal medicine which is a very top down, here’s what we’re going to do says the national, then it’s kind of played out at the state level. So the chapters were skeptical and we tried through a series of meetings and mechanisms to get them involved. Did some kind of workshop type activities that involved not only the chapter staff, the chapter leaders. The problem was that I don’t feel the chapters, they felt like they were providing some input but there wasn’t that kind of cohesive turnaround from the information that was provided at these workshops into activities that could happen at the state level. So I think most chapters came to the conclusion by the end of 2015, mid-2016, that perhaps what they could do was take the public relations components and put them into their newsletters and use them in ongoing activities in their social media enterprise. But that anything more than picking up on that … So, for example, some state chapters had their annual meeting be held as primary, so picked it up in that way. But I think there was a general sense of, whether it is a general sense of disappointment, that it still was very focused on public relations activities. Still very focused on within the beltway. And also that the tactic team activities fairly much didn’t involve or weren’t … I think the engagement activity hoped to be the best activity in the family … And the chapter exec who served on that was fairly disappointed. As I mentioned before, that really wasn’t a stunning example of types of activities we hoped to get done. So I think there was that type of disappointment. So maybe the concept of you have high expectations, you have to re-jigger those expectations, but then the outcomes might even be lower. We didn’t … I think an eye on the board didn’t do such a great job of helping to reshape the expectations --.    \n\n\nVince Keenan: If I could just use one other example: One of the ongoing struggles that state chapters have with the American Academy of Family Physicians is though big changes have been  made on the advocacy side of things, his (?) advocacy efforts are really within the beltway. And so I think since AAFP was the biggest funder, they had the most influence in terms of where activities would go. So when the pivot was made in the fall of 2016 to make savings out of the tactic teams and turn it over to the public relations activity, there was kind of like a last hope by chapters that maybe the communications PR team would at least try to do activities with the leaders of the health committees in the new administration. That they would actually do those activities in the districts rather than in Washington, DC. Now, just from the little bit that I know from the first three months of this year, that really isn’t taking place. So I think there was an ongoing level of disappointment by state chapters around that activity, that we thought there could be more pull-thru. But as I kind of proved in Chicago, we weren’t really sure what we could have done to get the attention of media and others except to do something bizarre to get the media’s attention. \n\nDr. Young: Clarify a little bit. So there’s public relations that is to a broader audience and then there’s that which focuses on say key members of committees of Congress. Are those the same type of activities or are they different?\n\nVince Keenan: They’re almost the same type of activities. I think the basic component, and we’re seeing it now come out in some of the social media activities that Health Is Primary is doing is a lot of the stories they collected from 2015 from the city tours are now being re-pathed into short stories that are used to promote an understanding of family medicine. So I’ll just take, for example, one of the people who spoke in Chicago was a family physician who’s now chair of her medical school family medicine department, which she had kind of invented behavioral health integration, a type of marriage of primary care services or behavioral health services for her clinic that she was involved with. So that’s what she spoke to at the conference. And there was probably forty minutes of material on that. So that material could be used for activities within the district of a health committee leader. So it can be used that way. I’m just not hearing that from my colleagues. Texas, for example, has many of the chairs of the health committees located there this year and I’m not hearing from them that there’s a pull-thru of trying to tell the family medicine story in the district. Because if you tell those stories in the districts, then you’ll get the attention of the senator or representative. Whereas when it’s done in DC, you’re likely getting the attention of the health staff, what we call the health --, the health legislative. So I think it’s just a difference of perspective on what’s successful.\n\nDr. Young: And I was wondering if it was … Because I’m not familiar at all with the Academy’s assistance at the chapter level in terms of advocacy with federal legislators, whether that’s uncommon or hasn’t been done and this was an opportunity to do it.\n\nVince Keenan: The Academy has strong advocacy. Again, it’s mostly done within the beltway. Not as much strong activity in the districts. The Academy also has a political action committee. So the coordination of trying to do path (?) donations in the district as well as doing activities within the district hasn’t been a priority for AAFP. Most of its activities have been at the DC level. So while there’s good work with the chapters on those activities, it’s mostly come join us, what we’re doing inside the beltway, not so much how can we build a more powerful grassroots. I mean we’re starting to get there, it’s changed over the years, like the personnel changes that have helped that along. But for many years there was a state government relations staff located in Washington, DC for AAFP. But any time there was a federal level activity, their state government relations activities were put on the back burner and they got involved in federal activity. So I think there will be a little less of that now but it’s still an ongoing resource struggle, I think.\n\nDr. Young: Take the long view and the big picture. How has this project done and would you do it differently from what you’ve learned now were this to happen again after this project closes I guess as we’ve gone through the Future of Family Medicine and then into this one and I suspect there will be yet another?\n\nYeah, I think this concept of every ten years moving the profession forward, reviewing where it’s been at and kind of re-jiggering where it might go is a great idea. So I really applaud the folks who had the foresights – folks like you at AAFP around the turn of the millennium who said we need to redo this activity that had been done earlier in the late ‘70s and early ‘80s. So I think applause to AAFP and ABFM for taking leadership and seeing that there is a future down the road there and they need to at least collaborate if not coordinate their activities. So I tend to be a very hopeful person. I’m always optimistic. So, yes, I think the FMAHealth when the final story is being written, it will have some really great acceptance. I just think the research, the future for family medicine has just terrifically been enhanced by FMAHealth and I don’t think it could have happened any other way. I was able to get my computer restarted so I can look at all the different --. But I think the group with regard to technology, they’ve done a very good job. I forgot to mention that. That actually got back over to AAFP. I think it was the first one that was turned back over. And AAFP with Dr. Steve Waldren as the kind of lead physician now in regard to the technology -- has always done a good job in providing some real leadership for family medicine and primary care. So the technology team I think has done a good job of pushing ahead the needs of solo, small group family physicians. That’s been the focus of their activity. And also all the new applications that come up in family physician. So I think they’ve done a very good job of pushing that activity along. The health disparities team, which I think I’ve called ten other different names, health equity and things like that, over the course of this interview, what’s called the health disparities team, I think that activity with the possibility of giving family medicine the lead in the social determinants of how this -- overall is really as important as the research activity is. Payment – who knows? I think the activity in that group has been fantastic. They are actually coming out with position papers that are going to go to the health plans to tell them here’s where the future is headed. You guys live quarter to quarter. But if you want to be involved in health payment for the future, here’s what it looks like. The second activity out of that, the calculator should be available by summer that will help the owners of practices and the leaders of employed situations to kind of guesstimate the future of what’s going on. The practice team as well as the workforce team are more inside teams. I really haven’t felt that workforce education is really the ongoing struggle of how to get U.S. medical students to choose family medicine and how to move that along. And I don’t know that we came up with anything new there. And then there’s one more team called Pathways to Transformation Development – and I don’t recall their activities. So I think when the history is written on this on the core team or the practice team side, I think there will be some very good news and some, oh, well, we’ll try again. On the public relations side, gosh, there’s lots of good photos. Can do a good photo book history of this to show all the activities. I think last summer when the public relations team engaged a family physician who does songs on video, his name is ZDogg to put together a video song for the National Conference was brilliant. That thing went viral. That was kind of a real breakthrough, so that will certainly be a remembered activity. But I think buttons and other things. But I think there’s a different way to do public relations or a different way for it to be measured in the future. If it were to be done again, I think there would need to be a really … If the family medicine organizations are going to put millions or tens of millions of dollars into it, I think we need some stronger evaluation on that activity. And I also think we’d probably try to move more to grassroots. All the social media and communication technologies are moving us towards the ability to work in a globally and locally at the same time. I don’t think we really accomplished that this time around. So I don’t think I’d do this any different because it certainly is very hard to pull together these eight organizations. So I think that’s another win for Family Medicine for America’s Health is really to pull together all those organizations. So this is only my perception because I’ve never been to a Working Party meeting before, but my perception from those who now agenda and some people who have attended over time is that this Family Medicine for America’s Health project, the focus keeps the Working Party talking about where to go and what to do and seems to have raised up the level of participation. We actually, FMAHealth, I think one of the recommendations to the Working Party is that they actually become an organization with responsibilities. Because right now it’s a collaborative activity whose responsibility for hosting it shifts by organization year to year and that organization makes up the agenda. So it was kind of fairly loosely done. I think I’ve been all around the block on that question.\n\nLet me just return to two other things: One is you mentioned that the city tour in Kansas City that was related to the National Conference of Residents and Students was different than the others and you just gave the example of ZDogg doing a song. Were there any other aspects of that particular city tour that …\n\nI think what made that different, we tried it in Chicago. We actually got it on a student activity QR student tour day, so we held a daytime meeting at the Merchandise Mart, the company Matter. And then in the evening we held a resident and student activity. And I think there were attempts in other cities to do those types of things. But what makes National Conference such a great venue is that’s the future for family medicine. So if students and residents can get as excited about and as enthused about family medicine as they did in 2015, ’16, and from what I hear it’s going to be another very interesting presentation in 2017, I think that provides a sense, a feeling among students who like family medicine or are leaning towards family medicine that this is pretty cool, they do interesting things, they’re cutting-edge, it’s not same old, same old. So I think the evaluation or measurement of that is in terms of the public relations, money spent experience, gain, and the fact that it is a different one than social media, ads on buses and ads in malls and things like that, that occurred within --. That was more of a general … Not a general population, but it was more of a wider range of public relations activities. This very focused on students who are family medicine leaders and residents who are family medicine leaders I think has a lot of long-term potential. I know many of our generation talk back to several meetings when you as students or residents attended early meetings of what’s now National Conference or another meeting we had called National Conference of Physicians and Leaders, what we used to call NC with a minority of new physicians – that those were kind of make a difference memories for those groups. So I think that has a different feel to it, that most of the activities were around --.\n\nThe other question I had, and you mentioned it in part, on the payment core key: Were the large integrated healthcare systems part of the audience for any of the work, any of the output, any of the input in terms of this? You know, the Kaisers, for example – or I’m sure you can name many more than I can. \n\nRight. And so I didn’t do a very fair representation for practice. The practice core team, --  team really worked on two different things. One was a best practices project. So it looked for what are acceptable best practices and what have they done. And so that responds exactly to what you were talking about. As you might recall, within the last several years there’s been a lot of pilot projects that have come out of the Affordable Care Act and I think that’s separately from the Affordable Care Act around Patient-Centered Medical Home, Comprehensive Primary Care and the like. And the practice core team really tried to identify what those are and set those up as examples and then come up with a physician practice readiness project. So a way to assess your practice. You know, where you are at on the continuum of Patient-Centered Medical Home and what changes would you need to make to get there. So those did involve not the top-level people within health systems like Kaiser or Intermountain Health or Geisinger in Pennsylvania or the Advocate here in Illinois but they did involve family physicians working within those systems. So I think we picked out rock star family docs to do the Bright Spots project around, then we used physicians who were in different systems as a way to build a tool, the Physician Readiness project, to be able to do that. And I’ve forgotten your other …\n\nYou got it on both the inputs and the outputs. Obviously you gave great examples of the input part and I’m assuming that whatever those products are out of the practice core team will be things that will become known to …\n\nYeah, they’re all coming out this year. \n\nAnything else, sir, that you would like to share?\n\nI want to say it was, I think, a big -- on the part of AAFP. I think it was really Doug Henley’s insistence that there be a chapter person on the board. So I thought that was an interesting proposition for FMAHealth. So that recruitment activity, I think I was among several people. And it might becbecause of my length of service and knowing a lot of people that I would reach out, that I was chosen. But it was such a thrill to be involved at that level. Being involved   with all those family docs on the board was just so much fun. We worked well together. Glen Stream as a Past President of the Academy, taking on the job as, I think, half-time of his 300% effort life as the Executive Director and President was just the right thing. He still knew enough about AAFP, was still connected in it enough to know how to work through the politics and all that. But at the same time, since he was no longer the volunteer leader there, he could stand firm and take the position of FMAHealth. So Glen was like the right choice, the right place for that. A couple of things that would be interesting when this all comes out … I think one of the ongoing changes we need to look to is there’s an ongoing, not so silent battle between American Board of Family Medicine and AAFP. And I think for the betterment of the profession we need to move past that. It might be because of the current staff leaders in both those areas that have worked together, apart, against for many years now. And I know the American Board of Family Medicine CEO is retiring next summer, I believe, so there will be somebody new. And I’m not trying to push Dr. Henley out the door, but certainly in the next five or so years there will be somebody new there. But I think for the betterment of the profession, we kind of need to get beyond that. The dominant feature of the board wrestling matches were the play-out between the American Board of Family Medicine and AAFP. Both organizations put in – gosh, I would want to say 85% of the funds. So it was their right as top shareholders to make a difference there. But at times it’s … Being the youngest of five kids, Herb, it kind of felt like my two oldest brothers battling over something that seemed to be nonsensical at times. But I was always the youngest brother, so my whole job in life was to entertain, so that’s how I made my way through. So that’s kind of how I made my way through on the board there too. I just kind of made light of those situations and tried to help move us past that. But I think for the betterment of the profession, if this comes around to ’22, ’23, ’24 and we’re doing Future of Family of Medicine 3.0, I’m hoping that at least the collaborative activities between AAFP and ABFM are much stronger than they are now and perhaps a little less contentious.\n\nVince Keenan, chapter executive for the Illinois Academy of Family Physicians, thank you so much for doing this oral history.\n\nYou’re welcome Herb. And thank you very much. It’s been a thrill. I look forward to the next time we get to be together. I’ve always enjoyed working with you and I wish you well on this project.\n\nThank you.","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162445/file/295871#t=0.0,3292.5933"}]}]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162445/file/295870","type":"Canvas","label":{"en":["Media File 2 of 2 - KeenanVincent_02_Access.mp3"]},"duration":2047.284,"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/3491/collection_resources/162445/file/295870/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162445/file/295870/content/2/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/295/870/original/KeenanVincent_02_Access.mp3?1761144305","type":"Audio","format":"audio/mpeg","duration":2047.284,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/3491/collection_resources/162445/file/295870","metadata":[]}]}],"annotations":[]}]}