{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/w950g3jv0t/manifest","type":"Manifest","label":{"en":["Dr. James Puffer"]},"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":["Format"]},"value":{"en":["video"]}},{"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. 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Puffer MD. That's going to be exciting, it's going to be fun. We'll never get everything Jim has done in such a short interview, but I'd start out by saying where we are. I am Dr. Dan Ostergaard, and that'll be the end of my formality. I'm here in my home office in Olathe, Kansas, close to the AAFP Motherhouse. Dr. Puffer, I believe it's in your own home in El Segundo, right?\n\nDr. Jim Puffer:That's correct.\n\nDr. Dan Ostergaard:LA area, El Segundo, and Natalie is at the office, as she should be, at the AAFP and the AAFP Foundation Center for the History of Family Medicine. That is just a little more introduction of Natalie. I'll be interviewing Dr. Jim Puffer and we'll go casual at this point. Natalie is the manager of the Center for the History of Family Medicine, so she will be checking on us and, when we're all done fixing everything up, so this goes very well. Jim, first of all, early life. You've been an LA guy ever since forever, except when you moved to Lexington, which we'll get to in a little while. Tell us about your beginnings and your entering family medicine and if Marcus Welby, who was in your area of LA, had anything to do with that in his movie show.\n\nDr. Jim Puffer:You're right, Dan. I am a native Southern Californian, born and raised in this little beach community called El Segundo, which is just a little bit south of LA International Airport. It's a community of about 15,000 people with its own school district, and it's a community which is somewhat unique in Southern California in that it's really like a little slice of the Midwest that's just been picked up and transplanted into Southern California. There've been five generations of my family now that have grown up in this community, and that is not unusual. Most of the people that live here, here almost their entire lives, as have their parents and grandparents and their great-grandparents. It's a very unique little community. This great little community had a terrific family physician by the name of …, he was our family's family physician. He trained at the University of Chicago as a general surgeon and moved to California and set up his practice in this little community.\n\nThis is, of course, well before the time when family medicine even existed as a specialty, but he delivered both my father and his sister, delivered myself, my brother, and my sister, and then actually took care... He stopped doing obstetrics, but after our children were born, in addition to take care of my wife and myself, he took care of our children as well until he retired. If we have time, I'll tell you a little bit about the interesting coda that brings this story full circle, if you will, at the end of our presentation, if we have time. It was actually one of the most significant parts of my career.\n\nDr. Dan Ostergaard:Actually, stories are often more fun than facts. If I forget to bring you back to it towards the end, and if we have time, make sure you raise your proverbial hand and let's do it. What about Marcus Welby?\n\nDr. Jim Puffer:… was my Marcus Welby. Marcus Welby wouldn't come on scene until considerably later. Obviously, I think Marcus Welby had a tremendous impact on practice of medicine at the time, because people were yearning for a physician like Marcus Welby. Very few of them existed, we were fortunate to have our own Marcus Welby in … in this little community… was my inspiration for going into medicine. My younger brother was asthmatic and it was not uncommon for me to wake up in the morning and come into the kitchen for breakfast and our family physician would be sitting at the breakfast table with my mom and dad after having breakfast, having spent all night taking care of my brother with his nocturnal asthma attacks. From a very, very early age, he really was an inspiration to me and was my role model. If you ask anybody who knew me, even when I was really, very young, and I'm talking about five, six, seven, eight, I wanted to be a family physician like …\n\nDr. Dan Ostergaard:Let me ask you about that, because I'm very happy that you are a family physician and you have all of the religion of what we have as continuity of care and all. You've been a sports medicine guy since forever. Didn't orthopedics try to attract you away?\n\nDr. Jim Puffer:That's an interesting story in and of itself, Dan. I would graduate from this small little high school in this community and matriculate to UCLA. I was an intercollegiate athlete there and swam and played water polo. We were fortunate to win two NCA championships during my four years there. Actually, the sport didn't become an NCA sport until my sophomore year, so two of my three years we won the championship. In my junior year, we lost in sudden death overtime. I say that simply to set the stage. When I started medical school, of course, my first two years were busy with all of the basic sciences, but as I began my clinical work in my third year, I became attracted to orthopedic surgery, primarily because sports medicine at that time was coming into vogue and the only people that were doing sports medicine at that time were orthopedic surgeons.\n\nDuring my fourth year, I was fortunate to be able to get one of the very coveted sports medicine clerkship spots with Todd Grant and Jerry Finerman, who were the team physicians at UCLA at that time, both orthopedists, both trained at Johns Hopkins. Todd played football at the University of Michigan and then went on and played for the Detroit Lions for a short period of time before going to medical school and then doing his orthopedic surgery residency at Hopkins. Jerry had come to UCLA first and then recruited Todd to come. Todd, during my time there, was primarily the team physician, Jerry helped him out.\n\nMy very first football game on this clerkship, I was a fourth year medical student, and at that time, I was wrestling with career choice. I was just terribly conflicted, I had had this passion of wanting to become a family physician almost my entire life, and now I became very intrigued by glamor, if you will, of sports medicine and realized, at least at that time, that before I started this clerkship, probably the only way I could do that was to become an orthopedic surgeon. At very first game, we had this... I was on the sideline as a fourth-year medical student with Jerry and Todd and had this big tight end who was a really... I won't mention his name, I don't want to violate HIPAA here, but he was really good. He would go on and play in the National Football League for the Chicago Bears, but he had exercise-induced asthma.\n\nVery shortly after the game started, he came off to the sideline, was wheezing, and the trainer took him to the bench and Dr. Grant went over to evaluate him and told the trainer, \"Get the Dexamethasone inhaler out, let's give him a couple of hits off the Dexamethasone inhaler,\" so the trainer got the Dexamethasone inhaler and gave the kid a couple of big hits off of the inhaler. He obviously wasn't getting any better and Dr. Grant says, \"He is a big guy,\" he was a big guy. He says, \"He is a big guy, he is going to take... Just keep giving him a couple hits off of this thing, it'll eventually stop.\" We then go back to the sideline to continue to observe the game, and after about two or three minutes of pregnant silence, Dr. Grant, Todd, turns to me and says, \"I didn't manage that very well, did I?\"\n\nI'm a fourth-year medical student, what am I going to say, \"No, Dr. Grant, you didn't manage that very well at all\"? I was hemming and hawing around. He said, \"Hey, just tell me. What should I have done?\" I said, \"Dr. Grant,\" being politic, I said, \"Dr. Grant, I'm not so sure I would've managed it that way,\" and he said, \"How would you have  managed it?\" At that time, the only inhaled selective beta agonist we had was terbutaline. I said, \"He needs to be on a terbutaline inhaler, he needs to take the terbutaline before the game, and then we need to have terbutaline in the medical kit in case he has an exacerbation and we can use it as a rescue inhaler during the course of the game.\"\n\n\"Puffer, you're in charge of,\" the kid's name, \"For the whole rest of this rotation. The next four weeks, you're in charge of him. You get his asthma fine-tuned, you make sure we have these terbutaline inhalers in the medical kit, I want him ready to play every game.\" He was my project for these four weeks. All of a sudden, the light bulb went on and I realized there's, really, a very important part for primary care people in the management of athletes. You don't need to be an orthopedic surgeon, because athletes have all kinds of problems other than just musculoskeletal problems. I've got this big tight end all spiffed up, and he would go on to become an All-American that year, who'd go on, as I said, have this very successful career in the NFL. Interestingly enough, both Todd and Jerry realized that they needed a primary care guy on the sideline, so they took me...\n\nI covered every single football game, it was the last four weeks of the season when I was on the clerkship. They took me, I was on the team plane, I went to Oregon, I went on both the road trips, I had both of the home games. The season was over and came time to put in your match list, and they both were pressing me very hard to go into... \"You need to go into orthopedic surgery, you're just perfect,\" because during that time, I scrubbed in on every case during that four weeks.\n\nI just was sopping up all of this sports medicine information I could get during this clerkship. They kept pushing me and I said, \"No, I've always wanted to be a family physician and I can see that I can do sports medicine being a family physician, because there's really an important role for primary care people in this field.\" I can remember Todd saying, \"You're making the biggest mistake in your life. All you're going to do is take care of runny noses and sore throats, you're not going to be a real doctor.\" He was joking a little bit, but he really wanted me to... He thought I was wasting my career and really wanted to be an orthopedic surgeon. At any rate, I matched into the family medicine program at UCLA and family medicine was a brand new residency program at UCLA. I was in the second group of residents, actually.\n\nTo say we were a stepchildren in this big quartenary academic health center would be an understatement. Nevertheless, I start my residency in June and in July or August, Todd and Jerry come to me and say, \"We would really like you to be on the sideline with us this season. You just added so much to the care of the athletes [inaudible]. You have skills that neither of us have, and we'd really like you to help us take care of the team.\" I said, \"I don't think that's going to be possible. I'm a first-year family medicine resident, I don't know how in the world I could possibly do that with an intern's schedule.\" Todd said, \"How about if I talk to your program director and see if we can't rearrange your schedule, so you can cover the games?\" I said, \"If you can do that, I'm all in, I'll tell you, but I don't think it's going to happen.\"\n\nMary Liz Roth was the program director at that time. Excuse me, Merrill Werblun was the program director at that time. Actually, right before Mary Liz came. Merrill Werblun. Merrill Werblin goes, \"I think this is a great idea.\" They jimmied my schedule around, so that I helped take care of the football team the first year of my residency and every year thereafter, I was part of the medical team that took care of the football team during the course of my residency. They made another run at me after the end of my first year. Todd and Jerry took me out to lunch at Madam Woo's, such a big... At that time, it was a really fine [inaudible] Chinese restaurant in Westwood just adjacent to the university and said, \"We have a second year orthopedic surgery spot for you, it's got your name written all over it.\"\n\nI said, \"No, I'm in the right place. I'm doing what I think I have been called to do. I enjoy the breadth of family medicine, I love delivering babies and taking care of kids. I like taking care of older people, but I like sports medicine, too, and I think there's a real need to develop a niche for family physicians and other generalists who want to do sports medicine.\"\n\nDr. Dan Ostergaard:You did that.\n\nDr. Jim Puffer:Interestingly enough, the next year... Let's see, would've been 1978, I go to... My very first time going to an American College of Sports Medicine meeting, and while I'm there, I meet Doug McKeag, who is the team physician... He's a couple of years older than me. He's the team physician at Michigan State University and we happened to meet just by chance. Fred Alman, who was an orthopedist in Atlanta, and Alan Ryan, who was a physiatrist, who was the team physician at the University of Wisconsin at the time, put together this working group to develop a sports medicine curriculum for medical students.\n\nThis meeting was announced and anybody that wants to come to this can come, so I show up, Doug McKeag's there, and by chance, we end up sitting next to each other. I introduce myself and he introduces himself and he says, \"What do you do?\" I said, \"I'm a second year family medicine resident at UCLA,\" and he says, \"You're interested in sports medicine?\" I said, \"I actually helped take care of the teams as a resident.\" He says, \"You're kidding.\" I said, \"No, no, it's a long story. If you're interested, we can go to lunch. I'll tell you.\" He goes, \"Yeah, I'd love to hear the story.\"\n\nAfter this meeting, we go to lunch and he's doing the same thing I'm doing at UCLA at Michigan State. He said, \"You have to meet my partner who helps me take care of the teams at Michigan State, Dave Howe, who's at this meeting, too,\" and he says, \"There's one other guy who's not here that you have to meet. There's only a couple of us that are doing this, the other one is John Lombardo, who's at the Cleveland Clinic.\" All of us, the four of us, get together and we began to think really seriously about how we could develop opportunities for family physicians and other generalists who are interested in sports medicine. Over the course of four or five years, we come up with the bright idea that we ought to be developing sports medicine fellowships.\n\nShortly after we came up with this idea, I was elected to the then board of the American Board of Family Practice, which would, as you know, subsequently become the American Board of Family Medicine. If you'll recall at that time, Dan, the geriatric CAQ, Certificate of Added Qualifications, had just been approved by ABMS after a lot of controversy early between the academy and the board. The academy, of course, was very much against the creation of certificates of added qualification, and nevertheless, it was approved by the [inaudible]American Board of Medical Specialties and it was the first, if you will, subspecialty certificate that was created in family medicine at the time. At the same time all of this stuff was going on, the family medicine program at UCLA was close to collapsing. I don't know if you recall this.\n\nDr. Dan Ostergaard:Let me stop you right there, because I want to, for the record, make sure that we get into the record that Doug McKeag and John Lombardo are family doctors and they are, as Jim is pointing out, the vanguard of family docs being the head physician for college teams. To the CAQ, I'm going to come back later and ask you about Mo Mellion, because he was pivotal as a sports medicine guy in getting the academy to change its position on the whole certificate of added qualification. We'll do that later, so go ahead.\n\nDr. Jim Puffer:Let me back up just a little bit. I'm getting ready to finish my residency and … the Marcus Welby of El Segundo, said, \"I'd love you to come back and practice with me.\" I said, \"… you have no idea. That's been my dream, to come back and practice in this little community.\" He said, \"I'd like you to come back and practice with me. I'm probably going to practice for no more than five years and I'd love you to come and practice, and I’ll eventually [inaudible] turn over the practice to you.\" I was all ready to go. I was all ready to [inaudible] finish my training at UCLA to come back to El Segundo and set up shop in … office and take care of people in this community along with him. Probably about maybe six months, five, six, seven months before [inaudible] I finish my training, all of the family medicine faculty at UCLA decide they're going to leave.\n\n[inaudible] Andy Hackett, Merrill Werblun, and Bob Martin had already left a couple of years before, actually after my first year of training. Ralph Bergen, who was primarily responsible for the predoctoral program under Bob and Merrill, Merrill was the program director, recruited Bob Bourne and Andy Hackett to come in and be faculty. They weren't happy at UCLA, it was just... They didn't feel that family medicine was valued, they felt that it was very difficult to train family physicians the way they wanted to train family physicians at UCLA, so they up and left and poor Ralph Bergen was left all by his lonesome. He came to myself and to Bill Rodney and to Tim Murphy literally three or four months before we were going to finish and said, \"I need your help.\"\n\nHe said, \"Andy and I are going to be leaving, I can't run this program all by myself. There's no way I could recruit people that would be ready for the new group of residents are going to be coming in July 1st. Would you guys consider staying on and helping me keep the program afloat while I attempt to recruit some additional faculty?\" We said, \"Geez, Ralph, we all have jobs.\" We all had jobs lined up. He said, \"Just for one year, just give me one year.\" I went back to … and said, \"…, the Family Medicine Residency training program at UCLA is really in dire straits, and myself and two other of my third-year residents have been asked if we would stay one year to help stabilize the program.\" He said, \"By all means.\" He said, \"This will always be waiting for you. It's really important that we have training programs in places like UCLA. By all means, go get the program back on its feet, this opportunity will always be here for you.\"\n\nAll three of us signed on for a pittance, I'll tell you. It's just a little bit more than we were making as residents, that's a whole other story I won't go into. It's very interesting in and of itself. We, all of a sudden, become faculty and we help Ralph with the program. Unbeknownst to us, Ralph is getting wooed by Northeastern Ohio University to come and be associate dean there, so by the end of summer, like in August, he drops this bombshell on the three of us. Said, \"Hey, I'm going to be leaving in October,\" and we said, \"What?\" He said, \"I've been offered the associate dean's job at Northeastern Ohio,\" he said, \"It's much closer to family.\"\n\nDr. Dan Ostergaard:Was Mary Liz Roth there yet?\n\nDr. Jim Puffer:Mary Liz had already gone.\n\nDr. Dan Ostergaard:She was there and already gone?\n\nDr. Jim Puffer:Yeah. The three of us got together and we said, \"It looks like it's the three of us. You know what? If we're going to be responsible for running this program, we're going to run it the way we think it ought to be run.\" We literally blew up the entire program and redesigned it the way we thought it would best work [inaudible] in an academic health center. We ended up recruiting a couple of residents [inaudible] from the next... Marty Quan and Rich Johnson from the next group of graduating residents. Then we took the two top residents out of the next group and we developed this core faculty group of people who felt very comfortable in an academic setting, did not feel threatened in the least being up on the wards and going toe to toe with the giants of internal medicine or obstetric and gynecology or pediatrics.\n\nIt was a very exciting time. We literally rebuilt that program from the ground up. Warren Heffron and Bob Avant were asked to come and do a departmental assessment by the dean, Sherm Mellinkoff at the time. They came thinking that they were going to... They had heard the whole story from all of our predecessors who had been there and who had bailed out, who said, \"UCLA is just the worst possible place, there shouldn't be a family medicine training program here. They don't appreciate what we do,\" blah, blah, blah, blah, blah. They came, and here are these now five young guys who are running this program.\n\nDr. Jim Puffer:Five young guys who are running this program, and they were flabbergasted. They said, \"We've never seen anything like this. We've never seen a program like this in a place like this. How did you guys do this?\" We said, \"Well, we blew the thing up.\" Having all of us trained here, and I was a medical student there, I knew the institution very well. And I made a lot of really good contacts during my time, both as a student and as a resident.\n\nAnd so they said, \"This is absolutely remarkable. We came here thinking we're going to rip this thing apart.\" And they went back to Sherman and said, \"Whatever you do, do not lose these five guys. What they're doing is unlike anything that is being done anywhere at an academic health center in the United States at the present time.\" And Sherman said, [inaudible]-\n\nDr. Dan Ostergaard:And that was the story. It was unbelievable. So Dr. Mellinkoff wasn't a denier totally. Was he? He was just the dean.\n\nDr. Jim Puffer:He was the dean. And one of the important decisions that Sherman made relatively early on was that family medicine was not in the position to be a standalone department. It needed to be a division within the Department of Medicine. And that served an important [inaudiblepurpose, because obviously the Department of Internal Medicine at UCLA really pretty much ran the place. I mean, a lot of power, a lot of money, a lot of influence. And Dave Solomon, who was the chair when we started running the program, and then Ken Shine after him, were very, very supportive. And Ken actually-\n\nDr. Dan Ostergaard:Let me get a time check on you there. I know I recall very well nationally that family practice people in academics were gnashing their teeth because UCLA only had a division within internal medicine and not a department of family medicine, but at some point, not too much later than that, it became a full department. When was that?\n\nDr. Jim Puffer:So Ken Shine would subsequently became the dean of the medical school. He would... Sher Mellinkoff retired. Ken, after a very extensive search, was appointed as the new dean. And Ken and I were very close. Ken was incredibly supportive of family medicine, as was Ray Schultze, who was the hospital director at the time, and who was incredibly supportive of us in more ways than one. I could use all of our two hours talking about how Ray Schultze helped family medicine prosper in UCLA.\n\nDr. Jim Puffer:Yeah. So let me condense this very quickly and simply say, when Sherman retired, Ken became the dean, Ken said, \"I want to make family medicine an independent division. All your academic stuff will continue to go through the Department of Medicine, but you're going to answer to me as dean rather than to Alan Fogelman,\" who took his place as chair. And that was our first step towards departmental status.\n\nAnd very shortly, not very shortly, but probably five or six years after that, [inaudible]. We became an independent division. Ken made me the division chief. And my major goal over the course of the next five years was to do all of the legwork that would need to be done to make family medicine a department at UCLA. And that finally happened in 1995, '96, right around there.\n\nDr. Dan Ostergaard:Wow. Long time. Well, good. Congratulations on that among many other things. Let's move on to a little bit more of national academics. For example, one of my goals in interviewing you is to give some visibility to the sports medicine organizations. You mentioned one that was multi-specialty, but you also were the founder of the American Medical Society of Sports Medicine. And wasn't that mostly family docs?\n\nDr. Jim Puffer:So it was. So-\n\nDr. Dan Ostergaard:Or am I getting confused with other sports medicine groups?\n\nDr. Jim Puffer:Oh no, not at all, Dan. So that original group of people, John Lombardo, myself, Doug McKeag, Dave Howe, we added Brian Halpern, who was another family physician on the East Coast practicing in New Jersey. Pardon me. He would subsequently go onto the hospital, excuse me, for special surgery and really plant the flag there for primary care sports medicine.\n\nWe came together and said, okay, we've created the subspecialty certificate, created the CAQ and sports medicine, which as you've said, Mo Mellion was critical in helping us politically make happen on the academy side. And Nick Pisacano and Don Kettlecamp, who was the executive at the American Board of Orthopedic Surgery, was critical in helping us push this through ABMS at the time. And then we immediately went and began designing the curriculum for fellowship programs that was reviewed by the Family Medicine Review Committee and adopted as the program requirements. And that group of five guys sat down, and we reviewed and approved the first 12 sports medicine fellowships in the United States at that time.\n\nSo after we had done all of that work, we said, \"Well, we need to create a specialty society specifically for family physicians, pediatricians, internists, emergency medicine folks who are doing sports medicine. We need our own home.\" And that's how we birthed the American Medical Society for Sports Medicine. So again, that came to be around '95 and '96, somewhere right in there. And that's now grown into... Again, I could spend another hour talking about the birthing of the American Medical Society for Sports Medicine in our [inaudible].\n\nFirst meeting, Brian Halpern took out a second mortgage on his home as collateral for the meeting space and the meeting. But needless to say, starting off with an initial membership of 250, this organization now has got over 5,000 members and is the largest sports medicine physician group in the United States.\n\nDr. Dan Ostergaard:What percentage are family physicians?\n\nDr. Jim Puffer:About 75%, 76%. Yeah.\n\nDr. Dan Ostergaard:Great. But there are other sports medicine organizations too. You said earlier, I think you were talking about the American College of Sports Medicine. Is there another one too?\n\nDr. Jim Puffer:So those are the two big ones in the United States. American Medical Society for Sports Medicine, which is the primary home for primary care sports medicine physicians. American College of Sports Medicine is a multidisciplinary organization that includes basic scientists in exercise physiology and allied health people who were involved in developing exercise programs, rehabilitation programs. And then a smaller component, there's a clinical arm that is made up of primary care folks, orthopedists, physiatrists, cardiologists [inaudible] is... A lot of people wondered, why don't you just make your home in ACSM? And ACSM was just too big. We wanted to create our own unique home for primary care sports medicine folks, which is what the primary impetus for was for developing the AMSSM.\n\nAnd then on the orthopedic side, Dan, we have the American Orthopedic Society for Sports Medicine, which is comprised obviously of orthopedists. But very early on the AMSSM and the AOSSM, the AOSSM acted really like a very protective big brother. We did a lot of educational stuff together. Actually, our first several meetings were joint meetings with the opportunity for the orthopedist to attend part of our meeting and we had the opportunity to attend part of their meeting. We did that for probably the first four years of the existence of AMSSM. And that-\n\nDr. Dan Ostergaard:So Jim, was that the American Academy of Orthopedic Surgery?\n\nDr. Jim Puffer:No, this was the American... This was the AOSSM, American Orthopedic Society for Sports Medicine, which is separate from-\n\nDr. Jim Puffer:Yeah. Very separate from American Academy of Orthopedic Surgery.\n\nDr. Dan Ostergaard:Okay, let's move on to some really fun stuff. You are probably the most name recognized sports medicine physician in the whole country, partly because of your work with the Olympics. And I'd like you to talk a little bit about some, maybe not all, the Olympics for which you were the head physician for the United States Olympic team. But I can see it in my mind right now. Seoul Summer Games, I think it was 1988, and our diver, Greg Louganis, went up on the board, came down too close, hit his head on the board, got a big gash, and there you were. I can't remember now if you out on the board or if you were on the side, but you were sewing this guy. I don't know how much later we realized that Greg Louganis was HIV positive. And this was in the very, very early days of HIV. Please recall that. It is indelible in my memory. Recall that and tell me if I'm remembering it right or have I embellished it?\n\nDr. Jim Puffer:No, you're remembering it correctly. Let me back up just a little bit though and tell you a little bit about... You probably have gathered so far, Dan, that up until this juncture in our discussion of my career, you probably recognized a recurring theme, which is that I just happened to be in the right place at the right time. You know? It was so serendipitous. It was just... You couldn't script this.\n\nWell, the same thing happened with respect to my involvement with the US Olympic Committee. So I spent this whole third year of my residency on the sideline. And of course a lot of UCLA games are televised. And people are seeing me on the sidelines of the UCLA football games. And after the disastrous performance of the US Olympic team in the '76 games in Montreal, the US Olympic Committee decides to develop this program called Operation Gold.\n\nOperation Gold was an opportunity for some of the lesser known Olympic sports. Track and field, swimming, they were all doing fine. But the US Olympic Committee really wanted to bolster the performance of some of the less well-resourced national governing bodies, national governing bodies are the organizations in the United States that oversee those Olympic sports.\n\nSo Burt Shaw, who was at that time, the head of national governing body for water polo, calls me and says, \"Look it. We're going to apply for one of these Operation Gold grants, but to get one [inaudible] these grants, you have to have a sports medicine section. Would you put together the sports medicine section of this grant for us?\" And I said, \"Burt, I'm like a first year resident at UCLA. I've just graduated from medical school. I'm not even licensed to practice.\" He says, \"I don't care. Everybody sees you on the sidelines. Everybody knows you. You're the most recognizable water polo person that is doing sports medicine.\"\n\nSo I said, \"Well, okay. Well, how big do you want me?\" He says, \"You make this whatever. You just do whatever you think is going to create the best sports medicine program for United States water polo.\" So I talked with my mentors, Jerry and Todd, and tell all about this. And they give me some ideas. And so I put this whole grant proposal together, the sports medicine section together for this grant proposal. And I got a budget of $250,000 a year. It includes money to take the team every year to the training center at Squaw Valley. This was before Colorado Springs existed. It includes money for a trainer and a team physician to go on every single international trip that water polo takes. It includes physiologic and biomechanical evaluation of Olympic water polo players.\n\nAnd this whole thing gets funded, Dan. The whole thing gets funded. So now all of a sudden I am the director of sports medicine for US water polo. And our very first deal, as I'd outlined in this budget, we take all of the US national water polo team up to Squaw Valley before the competitive season starts to do pre-participation evaluations, physiologic, biomechanical assessment. And I take my buddy, Todd Grant, who was the team physician at UCLA. I said, \"Todd, would you come to Squaw Valley with me and help me do this pre-participation evaluation for all these water polo? He goes, \"Yeah, sure, I'll come.\"\n\nSo we get on the plane, we go to Lake Tahoe. Tahoe Olympic Training Center was, I don't want to say primitive, but it wasn't as well resourced as the center is now in Colorado Springs. So we have the staff from Squaw Valley come and pick us up at the airport in Truckee. And Todd and I get stuck in the back of this Jeep on top of all of this luggage. And he's just big. You know? Here's a guy that played center for the University of Michigan and the Detroit lines. We're cramped in the back of this thing. And I can see him, he's scowling, he's looking at you. I said, \"What's the matter?\" And he said, \"Well, I bet you Bob Kerlan didn't get his start this way.\" And I said, \"Probably not.\"\n\nBut at any rate, we doing this five days at the training center in Squaw Valley. And I meet all of these people that are in charge of US Olympic  Sports Medicine, primarily Bob Beaton, who was the program manager at that time. And that started my involvement with the US Olympic Committee because shortly after that I get picked to go to the World University [inaudible] Games in Italy. And then I end up going and being the head physician at the first United States Sports Festival in Indianapolis. And then I get selected to the Olympic Games staff for the winter Olympic team that competed in Sarajevo. And then I get selected to the board of directors that oversees the sports medicine program for the USOC. And then I get picked as the head physician for the Seoul Summer Olympic Games in 1988.\n\nAnd again, all of this happened simply because Burt Shaw came to me and said, when I was a first year resident at UCLA, \"Would you put together this sports medicine program for this Operation Gold grant?\" And that started my whole involvement with the US Olympic Committee and led to the pinnacle of my involvement with the USOC, which was being the head physician in Seoul.\n\nAnd you recount what happened precisely in Seoul. This was a very sort of routine dive for Greg. It's what he's done hundreds and hundreds of times. But interestingly enough, he... And I'm the [inaudible] physician that's covering diving at the event. So I'm at the side of the pool with the rest of the US diving team and the coaches. And Greg is up on the three-meter springboard and he looks to try to get the attention of his coach [Ron O’Brien]. And Ron is, he's chitchatting with other coaches. And Greg gets kind of frustrated because he can't get Ron's attention, but he's got to... Once you get up there, you only have so much time and you've got to dive. And he realizes, \"My time's running out. I got to dive.\"\n\nSo he goes, and he does this dive, as I said, he's done a hundred times before off the three-meter springboard. It's a reverse three and a half somersault with two and a half twists. And he hits the back of his head on the springboard coming down, coming out of one of the somersaults, and opens up this gash right on the crown of his head. And so I immediately grabbed my kit. And there was a fellow,[inaudible]. It was one of the Korean officials who was involved at the diving venue who went up to try to stop the bleeding with his hand. And I didn't think much of it at the time, but I thought it was kind of odd because Greg kept trying to push his hand away from his head. And then Greg put his hand on his head to stop the bleeding.\n\nSo we took him back to this area where I could evaluate him. And I did a quick neurologic exam, made sure he wasn't concussed. And I said, \"We don't have much time if you're going to...\" Because if he doesn't go back and dive, this was now like the... There's 10 rounds in the preliminaries. This is the preliminaries. This is like the seventh or eighth round. He's got like two dives left. He has got the ninth and 10th round. This was the eighth dive. And if he doesn't go and do the ninth and 10th round, he's not going to qualify for the finals. You know? Even though he's leading at that time, without these last two dives, he's not going to make the cut.\n\nAnd so I said, \"If you're going to do these last two dives...\" He goes, \"Well, can I do it?\" I said, \"Yeah, you can do it, but I'm just going to put a big figure-of-eight suture in this thing and close this wound up.\" And then I said, \"When you get done diving, we'll go back to the village and close this up properly [inaudible].\" And his coach look and says, \"Is he okay to dive?\" I said, \"Yeah, he's not concussed, he's going to be fine.\" And so I went into my kit, and I'm looking, I can't find my gloves. I can't find my gloves. And I know I have gloves in my kit. So I start rummaging around and the clock's ticking. I know I've got to put this big figure-of-eight suture in his wound to get him back up on the board for his ninth dive. And finally I said, \"Screw it.\"\n\nDr. Dan Ostergaard:You did it. You did it.\n\nDr. Jim Puffer:Yeah. I said, screw it. And one of the South Korean physicians who was at the venue said, \"I'll run and get you gloves. I'll run and get you gloves.\" And I waited a couple and he was taking forever. Finally, I just said, \"Screw this.\" So I throw this big suture of eight into the wound and close it up. And-\n\nDr. Dan Ostergaard:Without gloves?\n\nDr. Jim Puffer:Without gloves.\n\nDr. Dan Ostergaard:Without gloves.\n\nDr. Jim Puffer:And it's all over television. You see the... Somehow the TV cameras insinuated themselves into... Well, they were filming through the glass window that looked into this area where we were. And I kept trying to tell people, \"Hey look, don't let the TV cameras... They don't need to be seeing this stuff.\" But the TV cameras, they're filming this whole thing. You can see me sewing this, putting this big figure-of-eight in his head. And so I get this closed up, I said, \"You're good to go.\" I said, \"When you're done, we're going to go. You're not going to go back on the team bus.\" I said, \"I have a driver. We'll get in the car with my driver and Ron, your coach, and we'll go back to the village and we'll clean this wound out and do a nice layered closure so you'll be able to dive in the finals.\"\n\nAnd so Ron says, \"We need to go.\" He needed to kind of recenter Greg, if you will. So they went downstairs in this area which was kind of private. And Greg would relate to me later. He goes, \"I think we should...\" Because nobody knew that he was HIV positive, but the only person that knew was his coach. And they wisely made the decision to keep this between themselves because, more likely than not, if this would've come out, he would've never been allowed into Seoul to compete. And so Greg says, \"Ron, I really think we should tell Dr. Puffer that he has blood over his hands.\" And Ron says, \"We can't.\"\n\nAnd it wasn't as if I didn't know Greg. I had known Greg for quite some time. Greg as a 17-year-old, was completed in the World University games in Edmonton. And I had taken care of him there. I took care of him at the World Aquatic Championships in Berlin. So we had kind of a long history of knowing each other from the standpoint of athlete and team physician. But we also knew each other socially because his cousin was a resident in our family medicine residency training program. And we would have social events and she would bring him to these parties. And my wife loved to dance with him. He was a hell of a dancer. She kicked me to the curb. She wanted to dance with Greg. So we knew each other really, really well. And he would subsequently reveal to me that he was HIV positive many, many years later.\n\nDr. Dan Ostergaard:Many years later?\n\nDr. Jim Puffer:Many years later.\n\nDr. Dan Ostergaard:Well…\n\nDr. Jim Puffer:So '88 is when this happened in Seoul. And it was probably '93 maybe.\n\nDr. Dan Ostergaard:Well, that's when it was all over the press too, that he was HIV positive at that time.\n\nDr. Jim Puffer:Yeah. And the reason why it was in the press everywhere was because his book was coming out. And the day before he's going to go on this big book tour and be on television and tell his story about his life story, which is kind of a sad story, and eventually that he's HIV positive, he calls me. I'm in my office. My secretary buzzes in at UCLA and says, \"Greg Louganis is on the phone.\" I said, \"Oh, put him through. Greg, how are you doing?\" He goes, \"Oh, I'm doing great.\" He goes, \"How are you doing?\" And I said, \"I'm doing great. What are you up to?\" And he goes, \"Well, my book's coming out tomorrow. And I'm going to be going on this big book tour promoting my book.\"\n\nAnd then out of the clear blue sky, he says, \"Have you ever been tested for HIV before?\" And I started laughing and I said, \"Well, why do you ask that, Greg?\" I said, \"I've never had a reason to be tested for HIV before.\" He says, \"Well, I'm HIV positive. And you remember you sewed me up in Seoul without any gloves on? And I've consternated about this whole thing ever since then.\" And he tells me how he asked Ron whether he should tell me at the time [inaudible]. I think to myself, \"Well, it's a good thing you're telling me like five years later.\"\n\nDr. Dan Ostergaard:Yeah, you'd be sick right now.\n\nDr. Jim Puffer:Yeah.\n\nDr. Dan Ostergaard:All right, we got to move on to... Let's take a quick break, and then come back to the real meat, which is your time at American Board of Family Practice, then the American Board of Family Medicine, and then you and other of our colleagues at the American Board of Medical Specialties. We'll be right back.\n\nOkay, Jim. We want to talk a lot about the American Board of Family Medicine and your many, many years there. But before we go to that, you were involved in so many other family medicine organizations. You were obviously involved in many of the AAFP and you were president of the Association of Departments of Family Medicine at one point. And actually, I remember that, but I didn't look at it at your CV. Roughly when was that and where was that in the trajectory of your academic career?\n\nDr. Jim Puffer:Well, again, going back to this visit...\n\nDr. Jim Puffer:... visit by Warren Heffron and Bob Avant. Bob was the head of Family Medicine at Mayo at that time, and Warren was in New Mexico. By default, between Tim Murphy and Bill Rodney and myself, Bill said, \"I want to be the residency program director.\" And Tim said, \"I want to do pre-doctoral education. And Puffer, you're the most politic of the three of us. You're going to interact with the Dean's office and Dave Solomon in the Department of Medicine,\" and so on and so forth.\n\nSo I was the defacto division chief by default. And that visit by Warren and Bob, Bob says, \"You know, you should really become involved in the Association of Departments of Family Medicine that we...\" I said, \"Well, we're not a department, we're a division in the Department of Medicine.\" He says, \"I know, but I think it would be helpful for you to meet a lot of the other department chairs around the country and it would help you with what you're trying to do at UCLA.\"\n\nSo I go to my very first ADFM meeting. Bob kindly introduces me to a lot of the other department chairs. Bob is the President-elect at my first meeting, so he was relatively well-connected with the group. And of course, I know Paul Young very well because I had just started my tenure on the American Board of then Family Practice as a new board member in the fall of 1988, 1989.\n\nTwo years later, all of a sudden Bob finishes his term, Larry Green is nominated and elected as the President-Elect. And Bob and Paul and Tom Nicholas come to me and say, \"We think you should run for President-elect.\" I said-\n\nDr. Dan Ostergaard:Three years?\n\nDr. Jim Puffer:Yeah. I said, \"Look, I just joined this group. I said, \"We're not even a department, we're a division.\" They said, \"It doesn't make any difference. We think you're perfect for a leadership position in this organization. We're going to put your name up if you'll let us.\" And I said, \"Well, I don't do this, but if you want to do it, I'm happy to go along with it.\" And I got elected as the president-elect, following behind Larry, and served obviously as then the president and then immediate past president. So I had a run of almost four years on the executive committee as I was working up the ladder, so to speak.\n\nMy major thrust was actually a continuation of Larry's very aggressive agenda to try to improve the academic stature of family medicine, particularly in academic health centers across the United States. And to do that, we felt it really critical that the specialty really needed to develop a very strong and well-funded research enterprise. And that was the major thrust, actually, of Larry's term, my term, and actually Chris Ramsey's term after mine. So my term as president was 1990, '91, were the years I served as president of the organization.\n\nDr. Dan Ostergaard:Well, that focus was perfect following Larry Green because of the relationship also that you guys at ADFM had with the North American Primary Care Research Group, which still goes on today. So that was a great focus. Okay, let's move to the American Board. And for the record, the Center for the History of Family Medicine does have oral histories of all of the CEOs. There was different terms used over the years, executive director... The senior staff guy, starting with late Dr. Nick Pisacano and then to late Dr. Paul Young. And we just did Bob Avant recently and now Jim Puffer, and if I am able long enough, I hope to do Warren Newton. And did I forget any CEOs?\n\nDr. Dan Ostergaard:Bob Avant and you and now Warren. Yeah. So first of all, what is the, I used the word trajectory before, but really the chronology of the American, and don't go into too much detail because it's all written down in lots of places, the American Board of Family Practice to the American Board of Family Medicine? And then we'll get to some of the controversies. We talked a little bit about the CAQs, the certificates of added qualification, but we certainly want to touch on MOC, maintenance of certification. So let's hear what that chronology is.\n\nDr. Jim Puffer:So I think it's important to note, two major forces were shaping the agenda of the board when I came on as, at that time, the executive director. So Nick Pisacano was the founding executive director then and Paul Young after him and then Bob Avant. I would become the fourth executive director.\n\nAnd the two major forces that were really going to shape the then American Board of Family Practice's agenda was number one, on the board specialty side, the American Board of Medical Specialties had just passed a resolution moving boards from a variety of different ways of re-certifying, and there were some boards that weren't even re-certifying, to this new paradigm called maintenance of certification. And at the same time, the very same time, our specialty was in the process of going through this self-examination, which was called The Future of Family Medicine Project. And those two, as I came onto transition with Bob beginning in June of 2002, two things were first and foremost on my mind in terms of developing the strategy for how we were going to move the board forward.\n\nAnd part of the future of Family Medicine Project entailed a very strong statement about the importance of changing the name of the specialty from family practice to family medicine. And when the final set of recommendations were adopted by the future of Family Medicine Steering Committee, that Jim Martin very capably shared, I was now well into my first year, almost into my second year of my term as the executive at ABFP. And the only way that a name change could occur would be for the then ABFP to submit a request to the American Board of Medical Specialties that would need to be approved by each of the other 23 specialty boards, allowing the ABFP to change their name from the American Board of Family Practice to the American Board of Family Medicine. And I told the steering group at that time, \"Listen, I'll do everything that I can to push this through ABMS, but you need to understand this is not in my hands. This is going to be totally in the hand of the other specialty boards, but I will do everything in my power to try to move this through.\"\n\nSo in fact, we submitted a request for the name change. It ends up being approved unanimously by the ABMS. And when we incurred the name change, we also underwent a necessary revision of the bylaws, changing the name to family medicine. But from the governance standpoint, we also changed a lot of the nomenclature. So instead of being the executive director, I then became the President and Chief Executive Officer, and the head of the board of directors was the board chair, which prior to that time, the president of ABFP had been the elected head of the board of directors. So that's how the name change came into being. And that's how the title of the executive changed from Executive Director to Chief Executive Officer and President.\n\nDr. Dan Ostergaard:And now you are actually the President and Chief Executive Officer Emeritus, correct?\n\nDr. Jim Puffer:Correct.\n\nDr. Dan Ostergaard:Is Bob Avant holding that title too, or was that at a different stage?\n\nDr. Jim Puffer:No, so when I came on, I came from an academic background where Emeriti faculty members had very robust participation in the shared governance of both the university and most importantly the department. So I felt very strongly that we needed to create Emeriti positions for Bob and for Paul. And so they became Executive Director Emeriti when I came on board. And they were intimately involved in terms of advising me on a lot of the initiatives that I began to undertake as we began to implement the mandate from ABMS to move from our recertification paradigm to maintenance of certification.\n\nWhich by the way was not difficult because we'd already done all of the heavy lifting with the recertification process. It was just a matter of some... All of the four elements of maintenance of certification existed in our then recertification paradigm in terms of professionalism requirements, continuing medical education, self-assessment, lifelong learning, obviously the high stakes examination. And then we were actually well ahead of our time when Nick developed a computerized office record review, which in and of itself was a form of quality improvement, although somewhat rudimentary. And we simply modified that as our initial foray into developing improvement component of maintenance certification.\n\nSo for the most part, our diplomates were used to doing to these four elements as a part of the old recertification paradigm. So it really didn't require a lot of heavy lifting in that regard. Most of the heavy lifting was required in terms of totally revamping the operational infrastructure of the ABFM, which was really inadequate and insufficient to be able to interact with our diplomates in a way that we would need to do so to fully and successfully implement maintenance certification. It required a total overhaul of our IT infrastructure and expansion of a lot of our existing operational departments. And that was the heavy lift.\n\nDr. Dan Ostergaard:Well, a couple more calendar points. So Bob Avant was in the senior role at the beginning of MOC and you picked it up and ran with it, am I right?\n\nDr. Jim Puffer:No, Bob left MOC all to me.\n\nDr. Dan Ostergaard:Oh, he did? That was a dirty trick. [inaudible]\n\nDr. Jim Puffer:And I don't mean that in a pejorative sense. It is simply the timing. There was a transition period where boards were going to be allowed to transition into this new paradigm, and it just made sense, me and to Bob, to allow me to undertake moving the organization ahead with the way in which I thought it best needed to implement MOC. So he rightfully and graciously left the implementation of MOC up to me, even though he was very involved with ABMS in terms of seeing this new paradigm through the entire legislative process in ABMS.\n\nDr. Dan Ostergaard:Going way back to the beginning, I mean the heavy lift, and this predates my involvement, but I've read all the history and talked to all the people involved. The very heavy lifting was the creation of the American Board of Family Practice in the first place, which the AAFP or the AAGP absolutely fought against for a long time. But then finally came around, and at the time that the ABFP, again, for the record, was founded, it was the first and only board, even though it was a new board, which required a time limited certificate. And that was just huge for our credibility in all of medicine that we didn't let the grandfathers just slip and slide along. We had to have a time limited certificate and get our credential again.\n\nDr. Jim Puffer:That's correct. And you can attribute that [inaudible] to Nick and the founders in terms of realizing the importance of creating this time-limited certificate and mandating that family physicians be required to re-certify and demonstrate their continuing competence in order to continue to be a diplomate of the board.\n\nDr. Dan Ostergaard:Very wise, very wise. Jim, I'm aware of the huge database, which the board has, partly or maybe wholly, because this was after I was around, from the next Future of Family Medicine project. You have this huge database. Tell us about it. And is it for the research purposes of our academics, our diplomates, other specialties? Who has access to that database?\n\nDr. Jim Puffer:So one of the amazing things to me when I arrived, there were a lot of amazing things that I learned when I arrived, but one of the most amazing things was, first couple of weeks there, I'm individually meeting with all of the staff, learning... This was during my transition when Bob was still the exec. And I asked him if I could individually meet with every employee in the organization, learn a little bit about what they were doing and how they were doing it. And to my amazement, I go down and meet with Gary Jackson down in the basement. This is when we were still in that old building on Young Drive, which used to be the Jockey Club.\n\nAnd he takes me into this room with all of these tapes. They had these old tape to tape drives, back in the old days. And I said, what is on all of these tapes? And he says, \"Oh, that's information on every single person who's ever been a diplomate at the American Board of Family Practice. It includes where they practice, it describes their practices, it describes how long they practiced. It describes whether they were involved in teaching full-time or part-time. I mean, he just starts naming off all of the stuff that are on these tape drives. And I said, \"Does anybody know these exist?\" And he said, \"Well, yeah, I do.\" I said, \"No, other than you, does anybody know these exist?\" He goes, \"Well, I don't know. I suspect Bob and Paul know they exist.\" I said, \"Has anybody ever decided to digitalize all of this stuff? This is an incredible database.\"\n\nAnd so one of my really, very, very important initiatives as I began to implement, as the board began to implement MOC, was my very strong feeling that we needed to be evaluating rigorously everything that we were doing, each of the components of our maintenance certification process to determine whether it was doing what it was supposed to be doing, whether it was effective in doing what we wanted it to do, and most importantly, to learn how we could improve it. If we're going to be asking all of our diplomates to go undergo this continuous quality improvement process, should we be doing the same thing?\n\nSo we began to digitalize all of this data, and then every time somebody would apply for the recertification examination, you'll recall this, Dan, you had these scan bubble sheets that you had to bubble and you had to put down all the information about your practice. Well, those would come back to the office and they would be scanned in a Scantron and onto these tape drives. And I said, \"Do they even make these Scantron things anymore?\" \"Oh, no, no, no, no. If this thing goes down, we're toast.\"\n\nExam applications came. We had a guy by the name of Ronnie Bright, bless his soul, and Ronnie would sit by this Scantron, and his job was to make sure that all of these scan sheets went smoothly through the Scantron and none of them ended up jamming the thing, because if it jammed, we're toast. And I said, \"We can't operate like this.\" I said, \"We got to come into the 21st century.\" So we totally overhauled. You'll probably recall very shortly thereafter, I came on board, we moved from this old paper and pencil application process to a online application process.\n\nWhen these applications would come in, the old process, the mail trucks would come and back up to the office with these huge bins of all these applications, and they'd go straight down into the basement and every person in the office would come down into the basement, Dan, and they would open up these applications and they'd start sorting out all of these scan sheets. And then Ronnie Bright would be standing and running these things through the Scantron. And that was only the first half. And then if you remember, after you did your initial thing and you picked what you wanted to do for your office record review, you got another bunch of bubble sheets to do your computerized office record review.\n\nDr. Dan Ostergaard:What was the end result?\n\nDr. Jim Puffer:When we turned on the online application... So this would take two months. The application process, Dan would literally take months. Months. So the year we finally went to the online application process and we saved a hundred thousand dollars in mailing costs, a hundred thousand dollars in mailing costs, we turn it on, the first person comes in and what used to take months, you know how long it took the first person in to register online? 10 minutes. 10 minutes, and the staff goes, \"Oh my gosh. Oh my gosh, I can't believe this. You mean we all don’t have to all go down in the basement when all of this stuff comes through?\" And that project, probably more than anything else, is what I think really allowed me to gain some degree of cachet with the staff. Like, \"Well, this guy really does know what he's doing. This young guy, he really does know what he's going to do.\"\n\nAnd after that, we had all these strategic initiatives in terms of improving the business side of the organization, in terms of being more efficient, being more responsive to our diplomates. The staff totally, totally bought into this, totally bought into it. And a lot of them didn't have the necessary skills to do what we were going to need to do. And I said, \"Look...\" And some of them were afraid that I was going to let them go. They were going to lose their... I said, \"Nobody's losing their job. Everybody is going to have a job. If you don't have the skills to do what I'm going to ask you to do, we're going to provide the opportunity for you to train. There may be some of you that say, 'Look, I've been here for 25 years. I don't want to learn new things.' And if you want to go, you're more than welcome to go, but nobody's going to lose their job. You can go on your own volition, but nobody's going to lose their job.\"\n\nAnd that was the beginning of one of the biggest transformations of the organization from…. and I don’t mean this in a pejorative sense. But we literally moved from a mom and pop operation into a digitalized organization. And then we took the next step after that in terms of using data and evidence to really drive what we did. We became a data-driven organization. And that led to the creation of this huge, as you've alluded to, this huge data warehouse where we had all of this information about every single family physician who'd ever been certified with the American Board of Family Medicine. And once we began to collect this data, it was important for us to begin to publish this data.\n\nSo I recruited Lars Peterson pretty much right out of his residency to serve as our initial research director, and gave him free rein to develop a first-rate research team that began to mine all of this data and began to produce really, really good evidence that, number one, what we were doing was effective, number two, that it was improving the quality of care that family physicians were providing. But also, we did a lot of other really important work around burnout and in terms of the trends, in terms of what family physicians were doing in their practices with regard to OB care and the care of children. Really major pieces of work that really described where the specialty was heading. And it was all due to this huge, huge database that the board is sitting on.\n\nDr. Dan Ostergaard:Bob Phillips and Andrew Bazemore are always publishing things about our colleagues' work with children and all, the latter being scary about how we are not taking care of kids like we used to. And they were doing that though before they became part of the American Board. So do people outside the board have access to that for their own research?\n\nDr. Jim Puffer:Yeah, so that's really a good point, Dan. I'm glad that you brought that up because my first attempt at trying to bring on a research director was unsuccessful. Nobody wanted to come. Specialty boards don't do research. \"You want me to leave this tenured position I have at the university to come and do research on board? No.\" I hit a dead end.\n\nAnd so I asked Doug Henley at the time whether he would be willing to create a relationship between the board and the Robert Graham Policy Center, at that time. Bob Phillips was, at that time, the director of the Graham Center and was there working with him. And actually, it was very opportune because as you'll probably recall about the time that we developed this relationship between the board and the Graham Center, the academy was in financial straits. They were having budgetary problems. And there was actually concern that the Graham Center may lose some of its funding or maybe not even exist at all.\n\nAnd so we said, \"Hey, look, we have all the data. We'll pay for the Graham Center to do all of the analysis, to help us with the publishing.\" And it was a very, very fruitful, I think, relationship, both for the academy and for us in terms of beginning to develop this very important research relationship, begin to publish information about the specialty, but at the same time to allow us to help support the Graham Center at this time when the academy's financial situation was somewhat in difficult straits.\n\nDr. Dan Ostergaard:Yeah, that...\n\nDr. Dan Ostergaard:Yeah, that synergism between the American Board and the Graham Center was great. And the stuff I see coming out of both the Graham Center and now those two guys I mentioned, Bob and Andrew out of the American Board is really, really helpful information.\n\nJim, we're running out of time. I want to point out to the audience that there is a Puffer Fellowship as a fellowship of the American Board of Family Medicine and what used to be the Institute of Medicine, now the National Academy of Medicine and the other academies. Tell us about the Puffer Fellowship. And I think I'm right, it's been around about 10, maybe 10 or 15 years. What is it? It's in your name. It's a good thing.\n\nDr. Jim Puffer:It's a great thing. And I just feel very honored that they saw a fit to name this fellowship after me. Around the time that Larry Green was the board chair, actually he was the chair elect. Craig Czarsty was actually the board chair. We had begun to develop a strategy for cultivating further leadership within the specialty. And this was part of the continuation of the Future of Family Medicine project. You'll remember the health is primary,\n\nDr. Dan Ostergaard:You're close. Health is primary.\n\nDr. Jim Puffer:Yeah. Yeah. Health is primary, which was sort of an extension of the second go around of the Future of Family Medicine. And we felt that we had ways in which we could contribute to leadership development within the specialty, but specifically around policy development at the national level. And of course Larry was a member of the National Academy Institute of Medicine at that time, as was Bob Phillips, who I had hired to come on. I'd attracted Bob from the Graham Center to come and oversee our research enterprises that began diverging and further expanded our research section.\n\nAnd Larry felt it really important that we have a greater presence at the National Academies, then the Institute of Medicine. And the Institute of Medicine at that time was celebrating its 40th anniversary. And Harvey Fineberg, who was the president of the IOM at that time, developed this set of anniversary fellowships which would provide an opportunity for early to mid-career physicians to come and immerse themselves within the Institute of Medicine and watch how policy was developed and implemented at the Institute of Medicine.\n\nAnd our board of directors decided that we would endow a fellowship for an early mid-career family physician, no more than 10 years out , from their training. It was embraced fully by the board of directors. It passed unanimously without any dissent and I can remember this like it's yesterday. We're in New Mexico I believe, and getting ready, Sheridan and I are good. For those that don't know, Sheridan is my wife. Dan knows her very, very well. But Sheridan and I are getting ready for, at the end of the board of directors meeting, we have a very nice sort of farewell dinner the night before the final half-day of meeting. And Craig Czarsky calls and said, can I come up to your room and chat with you for a few minutes? And I said, sure, yeah, come on up. I mean, I had no idea what he, he's going to talk about. So he comes up and he said, we went into executive session today. I said, I know. And he said, and the executive session primarily because we were talking about naming this fellowship after you.\n\nAnd I said, well, I said, you can talk all you want about naming this fellowship after me. But I said, it's not appropriate to be. This fellowship is funded by the board. This fellowship should be in the name of the board, shouldn't have my name attached with it. He said \"No, we feel very strongly that this should be the James C Puffer MD/ABFM Fellowship at the IOM\". And I said, I'm not going to agree to this Craig. And he looked at me and he said, well, you can agree to it or not, but it's going to happen. So you can either complain about it or you can just sit back and enjoy it because we're going to name this thing after you and I just didn't want you to be surprised-\n\nDr. Dan Ostergaard:I can see Craig Czarsky saying that to you right now. That's pretty cool. But you won in that it is, if I remember right, the James C Puffer MD/ABFM Fellowship, right?\n\nDr. Jim Puffer:That's correct. That's correct.\n\nDr. Dan Ostergaard:So it's all good.\n\nDr. Jim Puffer:Yeah. What's even better is that I was able to negotiate after we had our first fellow. Sean David was our first fellow and at the selection meeting, we had a great group of candidates. It was very hard to pick between. I mean, there was a great group of people and Marie said- Marie Michnick, who ran the program at the IOM said, you know we could probably pick a second person and you wouldn't have to endow this, but if you provided the cost of what it costs us to post a fellow over two years, I have a second fellow. And I said, well, how much is that? She said, $86,000. And I said, it's done.\n\nDr. Dan Ostergaard:Yeah, that's wonderful.\n\nDr. Jim Puffer:It's done. Let's do it. So we ended up picking two fellows. The first one was Sean David. Jenn [DeVoe], I'm blanking on her name. It'll come to me in a minute. So we ended up picking two fellows and then every year we would pick two fellows and they would be staggered. So at any one point in time, there'd be a first year fellow and a second year fellow at the National- now National Academies.\n\nAnd then just recently, shortly after our 10th anniversary, we get our first 10 fellows through. And Warren decides, this is such a great program. I mean out of the first 10 fellows, we get three people elected to the National Academies. Dan out of the first 10 fellows, three get elected. And Warren goes, this is a great program. We have to expand this. And he doubles, he endows yet another fellow and then goes and said, can we do the same deal where we endow another fellow and then we pay the cost of a second fellow who would be staggered? So now we have, at any given point in time, four Puffer fellows at the National Academies, two first years and two second years. And it's amazing.\n\nSo take Jenn DeVoe, whose name is now finally bubbled up. You take Jenn DeVoe, who's our second fellow, elected to the National Academies. And then you've got Cameron Matthews several years later. We have Kendall Campbell and now this past year we have the fourth Puffer fellow elected to the National Academy , Gerardo Moreno, who's the current board chair of the board, and who's the department chair at UCLA.\n\nSo now in the first, this is going to be the 14th year of the fellowship. We've had four former fellows over the course of the 14 years elected to the National Academy. And I can't even begin to tell you the impact these people have had on the work of the Academies. It's absolutely -people were saying, how come we haven't had people like this before, these people bring like a whole different perspective on our work. And I'm talking now about the fellows. So you have Lars Peterson who was a recent fellow who's done incredible research and is incredibly knowledgeable about the work that family physicians are doing in a rural America. I mean, he just knocked their socks off. They go like, where have you been? How come we didn't have this expertise? I mean, this thing has paid huge dividends for the specialty. Just huge dividends.\n\nDr. Dan Ostergaard:Well, congratulations. That's a wonderful thing. And the American Board did a great thing. I want to switch to a couple of things I gleaned from your file at the Center for the History of Family Medicine, and some of it relates to water polo. And as I've told you before, you're the only person I ever knew who was a collegiate varsity water polo champion, and now the team physician for UCLA Water Polo. But what I didn't know is that you received the Duke Kahanamoku Award for World Water Polo, and I can see Duke's statue right on the beach at Waikiki as we're speaking. So tell me about that. That is the most curious honor I've ever heard any of our colleagues ever get. Duke Kahanamoku.\n\nDr. Jim Puffer:Yep. I was incredibly honored. This was a special award that was created now, my gosh, almost 20 years ago now, probably. United States Water Polo, which is the national governing body for water polo and it's awarded to people who have distinguished themselves not only as water polo players, but more importantly in the contributions that they've made in their careers after they've stopped playing water polo. And I just felt incredibly honored to be the recipient of this award. It's been a while since I received it, but it was a very special moment.\n\nDr. Dan Ostergaard:Well, yeah, it is special. When I found it in the file, I said, I got to get this into the interview. And for those who don't know who's Duke, he is a Hawaiian who is the world surfboard champion and also was an Olympic water polo player and I think Champion and his statue is right on Waikiki Beach. It's pretty cool. I have another thing that didn't come from anything except current news, and I want to run this by you knowing that you have done work in the sudden cardiac death of athletes and the sudden cardiac arrest of athletes. So I mention Damar Hamlin and Bronny James, both of whom are wonderful athletes and both of whom had cardiac arrest on the playing field or on the court and both survived. Comment on that please.\n\nDr. Jim Puffer:Well, this is, I think, become a critically important aspect of the work we do. When I say we, I'm talking about physicians that take care of athletes as well as certified athletic trainers. So probably for the last 15 to 20 years there's, which I've not totally agreed with, there's been this emphasis on attempting to use the EKG to screen athletes during pre-participation evaluations to reduce the risk of sudden cardiac death during participation in sports. And despite the, I think the good intent of this initiative, it's never been shown to reduce sudden cardiac death.\n\nIf you take a look at the sudden cardiac death literature, Dan, it's very interesting. So appreciate that there's been this huge emphasis on attempting to identify people at risk for sudden cardiac death over the course of the last 10, 15 years at least. And despite this tremendous effort to try to identify these people, for the most part, it's not prevented sudden cardiac death.\n\nBut if you take a look at a terrific paper that was just published just a couple months ago, actually, it comes out of France and it takes a look at over a fifteen-year period of time. It takes a look at the sudden cardiac death rate during participation in physical activity and survival rates. And if you look at the data, you see this dramatic reduction in sudden cardiac death. Actually, the reduction is not in terms of the number of sudden cardiac death events. The reduction is in survival after suffering, sudden cardiac death during participation.\n\nAnd then take a look at the use of bystander CPR. And most importantly use of AEDs, automated external defibrillators. [inaudible]It clear is that there is a direct correlation between the advent of the use of AEDs in the resuscitation process and people who've died suddenly.\n\nAnd this was played out, I mean, time and time again, when you take a look at sudden cardiac death and major events across the United States, and the two that you've mentioned are probably two of the most visible ones. Kid at USC actually before Bronny James, who likewise suffered sudden cardiac arrest in practice on the basketball court at USC and was successfully resuscitated and is now back in playing basketball at USC as well. And it is all attributed to number one, the development of emergency action plans, what we call EAPs, in which there is a very well understood protocol. It immediately goes into action when an athlete goes down and everybody knows what they're supposed to do, they know where the AED is located, they know how to do CPR, they have a telephone or a cell phone to initiate EMS services.\n\nAnd in each of these instances, both the Bronny James situation at USC. Appreciate they'd already been through the fire drill once with this kid the year before. So they were very well versed, but on national television in front of everybody else, that the well coordinated effort that took place on the field in Cincinnati when Damar Hamlin went down after being struck in the chest is a tribute to I think, the evolution of modern sports medicine into discipline now that has profound effect on athlete safety and wellbeing. So those are just two of many, many, many examples.\n\nDr. Dan Ostergaard:That is absolutely incredibly good that there is a protocol which everybody now knows in the sports medicine world, and probably in the coaching world, they don't want to lose their athletes either. But those two guys, because they've just been in the last 18 months or 12 months, are examples which really are a tribute to what you guys, you, Jim, and all of your colleagues have been doing for the last 50 years. It's wonderful. So we're going to close, but I certainly want to have you make any other comments, observations that you would like to make because I'd love to hear them.\n\nDr. Jim Puffer:So Dan, I'm going to close with probably the most poignant story in my career. I alluded to it a little bit earlier today, was talking about my family physician that I grew up with. And fast forward now, I'm now a professor at UCLA, just happened to be attending on our family medicine inpatient service. And what I failed to tell you when I was telling you about … is that my brother ended up marrying his daughter. I mentioned that only because I receive a call from her one evening and she says, I'm really worried about my father. He's become kind of stuporous and he's kind of incoherent. And I said, Mary Lou, get him in the car, bring him to UCLA. I'll meet you in the emergency department, and I happen to be on service this month and I'll take care of him.\n\nShe brings him up, we admit him to the emergency department. He is in fact stuporous and somewhat incoherent [inaudible ]. His initial labs come back. He's got a serum calcium of like 16 or 17 or something. And so we started hydrating him and started the Lasix and started his bisphosphonates, and we were able to bring down his serum calcium. And he starts to come to, and making a long story short, he eventually gets back to baseline. And I said, …, we really need to work up why your calcium was so high. He says, well, actually, I've been going down, nobody in my family knows this, but I've been going down to Scripps for the last month or so, and I've got multiple myeloma. I said, well, do you want to continue your care at Scripps or, I'm more than happy. We've got great people up here. And he said, no, I think I feel comfortable with these people that I've started this relationship with them at Scripps.\n\nAnd so I said, well, I would like to see you one more time and follow up in the office before I totally discharge you from my care. And he says, well, I'd like that. And I said, well, I'd like that too. So maybe like a week after he leaves the hospital, I said I should get your blood drawn before I see you so I can make sure your calcium is still okay. So I have a medical student with me. I have a medical student with me in the office that day and the medical student enters the room, and introduce him to … And I said, this was my family physician growing up. He delivered me, he delivered my brother delivered my sister, and I'm honored to be able to take care of him when he was in the hospital last week. And so they shake hands and I sit down.\n\nSo I sort of say, well, how are you doing, …? And we'd sort of chit chat for a while and we'd talk about medicine. We talk about a bunch of other things, and he stops and he turns to the medical student. He says, do you see what he's doing? And the medical student says, \"no, I don't know what you mean\". He says, do you see what he's doing? What do you think he's doing? And the student turns red, and it's just the most important thing that you can learn as a medical student, and that is how to be able to develop a relationship with your patient and by starting off the visit, not talking so much about medicine, but talking about other things and developing that really important personal relationship that allows your patient to trust you.\n\nThe student just got like dumbfounded and I turned to the student. I said, do you know who taught me how to do that? He says, I suspect it was him. I said, you're right. I get emotional. Just remembering it was because shortly, he would not live much longer after that. But it was one of my greatest privileges in my career, was taking care of him at the end of his life, obviously, after he had brought me into life.\n\nDr. Dan Ostergaard:Wow. That is a fantastic story. Wow. Yeah. I'm getting emotional too, so you certainly should. That's good. Well, that's the family physician in you, and you learned it from your mentor then your patient. Thanks for doing this interview, Jim. This is really, really good. This is Dr. James C. Puffer, CEO, and President Emeritus of the American Board of Family Medicine and current teacher, again at UCLA Med School in Sports Medicine. Thanks, Jim.\n\nDr. Jim Puffer:Thank you, Dan. It's been a pleasure. I've really enjoyed it.\n\nDr. Dan Ostergaard:Likewise.","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/130531/file/244128#t=0.0,6999.95733"}]}]}]}