{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/xd0qr4qw24/manifest","type":"Manifest","label":{"en":["Dr. Robert Graham (Dan Ostergaard)"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Description"]},"value":{"en":["\u003cp\u003e This is an exceptionally long interview, covering six sessions with two interviewers. It captures Dr. Graham's very successful career(s) with the federal government and the American Academy of Family Physicians (AAFP), as well as the parallel careers of his wife, Dr. Jane Henney.  \u003cbr\u003eDr. Graham attended medical school at the University of Kansas, where he became a student activist, primarily through the American Medical Student Association (AMSA). Upon graduation he joined the Public Health Service in Washington, working at NIH to incorporate behavioral science into the medical school curriculum. It was there that he met his future wife, who had come to Washington as a medical student working with AMSA. \u003cbr\u003e In 1973 he went to work for the AAFP as Assistant Director of the Division of Education. During his time there he served as Interim Administrative Officer for the Society of Teachers of Family Medicine (STFM), a young association for which the AAFP was providing administrative management services. He and Dr. Henney were married in 1975, and they moved to Houston, where she was in an oncology fellowship. While in Houston, he had an appointment at the Baylor College of Medicine, until he was recruited to Washington to serve as Acting Administrator of the Health Resources Administration. Dr. Henney followed him to Washington as the Deputy Director of the National Cancer Institute. Dr. Graham subsequently became Director of the Health Resources Administration. During his time in Washington, he also served for two years on Senator Ted Kennedy's staff. \u003cbr\u003e In 1985 he was recruited as the first physician Executive Director of the AAFP. Since that involved a move back to Kansas City, Dr. Henney secured a position as Associate Vice Chancellor at the University of Kansas School of Medicine .During his 14-year tenure with the AAFP, he described his biggest challenges as externally managing the AAFP policy positions in terms of the President Clinton's health reform,  and internally as realignment of the AAFP staff with performance evaluation and  hiring people with skill sets in finance, publishing,  and human resources, as well as implementing staff development . He implemented regular meetings with all of the AAFP divisions and brought a new level of professionalism to the AAFP. Much of the interviews covered his changes at the AAFP. \u003cbr\u003e  \u003cbr\u003eDuring his tenure at the AAFP, his wife was recruited back to Washington as the Deputy Director of Operations for the FDA. After 2 1/2 years there, Dr. Henney became Vice President for Health Affairs at the University of New Mexico. In 1998 she became the FDA Commissioner, a position that lasted until 2001. She subsequently became Vice President for Health Affairs and Provost at the University of Cincinnati School of Medicine. \u003cbr\u003e In 1999 Dr. Graham stepped down from his AAFP position. He returned to Washington where he was Acting Director of the AHRQ for three years. He then joined his wife in Cincinnati, where he served as the first Endowed Chair in the Department of Family Medicine, where he spent five years. \u003cbr\u003eThere is considerable discussion in these tapes of the developments in medicine, the role of government in medicine, and the AAFP during Dr. Graham's career. It is enriched by his recollections of his wife's career progression. It is an extensive history and one that deserves preservation. \u003cbr\u003eLocation: Kansas \u003c/p\u003e (summary)"]}},{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}},{"label":{"en":["Date"]},"value":{"en":["2009-02-13 (created)","2009-03-19 (other)"]}},{"label":{"en":["Type"]},"value":{"en":["Oral History"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. Dan Ostergaard (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["audio file"]}},{"label":{"en":["Keyword"]},"value":{"en":["family physician","family medicine","American Academy of Family Physicians"]}},{"label":{"en":["Subject"]},"value":{"en":["Robert Graham III, MD (personal name)"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}}],"summary":{"en":["\u003cp\u003e This is an exceptionally long interview, covering six sessions with two interviewers. It captures Dr. Graham's very successful career(s) with the federal government and the American Academy of Family Physicians (AAFP), as well as the parallel careers of his wife, Dr. Jane Henney. \u0026nbsp;\u003cbr /\u003eDr. Graham attended medical school at the University of Kansas, where he became a student activist, primarily through the American Medical Student Association (AMSA). Upon graduation he joined the Public Health Service in Washington, working at NIH to incorporate behavioral science into the medical school curriculum. It was there that he met his future wife, who had come to Washington as a medical student working with AMSA.\u0026nbsp;\u003cbr /\u003e In 1973 he went to work for the AAFP as Assistant Director of the Division of Education. During his time there he served as Interim Administrative Officer for the Society of Teachers of Family Medicine (STFM), a young association for which the AAFP was providing administrative management services. He and Dr. Henney were married in 1975, and they moved to Houston, where she was in an oncology fellowship. While in Houston, he had an appointment at the Baylor College of Medicine, until he was recruited to Washington to serve as Acting Administrator of the Health Resources Administration. Dr. Henney followed him to Washington as the Deputy Director of the National Cancer Institute. Dr. Graham subsequently became Director of the Health Resources Administration. During his time in Washington, he also served for two years on Senator Ted Kennedy's staff.\u0026nbsp;\u003cbr /\u003e In 1985 he was recruited as the first physician Executive Director of the AAFP. Since that involved a move back to Kansas City, Dr. Henney secured a position as Associate Vice Chancellor at the University of Kansas School of Medicine .During his 14-year tenure with the AAFP, he described his biggest challenges as externally managing the AAFP policy positions in terms of the President Clinton's health reform,  and internally as realignment of the AAFP staff with performance evaluation and  hiring people with skill sets in finance, publishing,  and human resources, as well as implementing staff development . He implemented regular meetings with all of the AAFP divisions and brought a new level of professionalism to the AAFP. Much of the interviews covered his changes at the AAFP.\u0026nbsp;\u003cbr /\u003e \u0026nbsp;\u003cbr /\u003eDuring his tenure at the AAFP, his wife was recruited back to Washington as the Deputy Director of Operations for the FDA. After 2 1/2 years there, Dr. Henney became Vice President for Health Affairs at the University of New Mexico. In 1998 she became the FDA Commissioner, a position that lasted until 2001. She subsequently became Vice President for Health Affairs and Provost at the University of Cincinnati School of Medicine.\u0026nbsp;\u003cbr /\u003e In 1999 Dr. Graham stepped down from his AAFP position. He returned to Washington where he was Acting Director of the AHRQ for three years. He then joined his wife in Cincinnati, where he served as the first Endowed Chair in the Department of Family Medicine, where he spent five years.\u0026nbsp;\u003cbr /\u003eThere is considerable discussion in these tapes of the developments in medicine, the role of government in medicine, and the AAFP during Dr. Graham's career. It is enriched by his recollections of his wife's career progression. It is an extensive history and one that deserves preservation.\u0026nbsp;\u003cbr /\u003eLocation: Kansas\u0026nbsp;\u003c/p\u003e"]},"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153004/file/281613","type":"Canvas","label":{"en":["Media File 1 of 3 - Graham_Robert_Pt_5_09_a.wav"]},"duration":2286.99724,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/public/images/audio-default.png","type":"Image","format":"image/png"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153004/file/281613/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153004/file/281613/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/281/613/original/Graham_Robert_Pt_5_09_a.wav?1752076001","type":"Audio","format":"audio/wav","duration":2286.99724,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153004/file/281613","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153004/file/281613/transcript/81602","type":"AnnotationPage","label":{"en":["Dr. Robert Graham interview by Dan Ostergaard transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153004/file/281613/transcript/81602/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"CENTER FOR THE HISTORY OF FAMILY MEDICINE \n\n HISTORY INTERVIEW WITH ROBERT GRAHAM, MD\n\nINTERVIEW CONDUCTED ON FEBRUARY 13, 2009 \n\nBY DANIEL J. OSTERGAARD, MD\n\n\nToday is Friday the 13th of February, 2009. We are here in the archives of family medicine, Dan Ostergaard, the interviewer, and Bob Graham, the interviewee. We are going to spend the next hour or so talking about when Dr. Graham was our EVP and maybe diverging a little bit into some of the more interesting sidelights of his presence with us at the AAFP.\n\nBasically we are going to start by my asking Bob about our initial crossing of our paths here at the AAFP. Bob, when I first came to the AAFP I came because you recruited me out of the Indian Health Service to come to the AAFP. And you were the first Assistant Director of the AAFP Division of Education and I therefore was the second. I came out of the Indian Health Service here to find a legacy which you had left me. But then you left to go to law school. And if remember right, you didn’t last very long in law school. \n\nYour memory is accurate. You wouldn’t remember me being in law school because I never got it. But I know where you’re going with that question. And for the purpose of context to the interview, there is a reason why Dan is interviewing me which goes more than just to the fact that I recruited you to take the position of the Assistant Director because you and I knew each other before. Both of us were active as medical students in the then Student American Medical Association, now AMSA, and the fact that you are four years behind me. I can remember when I was working with the Academy the first time, you and I had some sessions here in Kansas City talking about the Academy, talking about SAMA activities. And, as a matter of fact, because of when you were in SAMA you met my wife Jane before I did because you were both SAMA activists at that same time. You’re the same age. So you guys had an acquaintance before I had ever met Jane. So there’s another set of relationships there which brings us to this conversation.\n\nThat’s a lot of fun, Bob, because actually we are the same age. And I would like to take credit for introducing the two of you, which is probably not true and I can’t take that credit. But I do remember another time when you were living here at the Academy and I came into town for something and borrowed your car and drove around. But back to you, Bob. What about going to Houston? \n\nYes, and you were able to borrow my car because I was off traveling for the Academy, which I did about 80% of the time. Back to Houston. Jane I were married in 1975. My wife is Jane Henney, she is also a physician trained in oncology. We met when I was in the government for the first time. And for anyone with an interest in this, there’s a lot more detail about this period on some tapes that I did with Sandy Panther which are also here in the archives. But after about four or five years of dating, Jane and I got married and was the first time we had to decide who was the trailing spouse. And Jane was just starting her oncology fellowship at M.D. Anderson in Houston and so I decided that I would do what you should do when you’re newly married which is go to live where your wife is. So Jane and I got married in June. And as she points out, because it had some implications for the commuting that we got into later in our relationship, we \n\ngot married and immediately started commuting. I came back to Kansas City and finished off the last six months of my tenure with the Academy and she went to Houston and started her fellowship in July. So I moved to Houston in December of 1975 which is roughly when you joined the Academy. I think you may have come two or three months after I left.\n\nI came here starting January 1st, right after you left. \n\nSo there was pretty close overlap.\n\nBut I forgot that you had been living absent from your spouse even at that early stage of your married life.  \n\nIt didn’t seem unusual to us because we’d been dating for five years and never lived in the same city. I was in Washington when I met her. She was in Indianapolis. I moved to Kansas City. She started her first year of residency in Indianapolis and went to Atlanta. So boarding passes were part of the relationship from day one. So the fact that we extended this when we got married didn’t seem on the face of it really unusual. But I went to Houston and we thought gosh, fellowships take a couple of years. M.D. Anderson is really a great place for cancer, learning to be an oncologist, and figured we would be down there for four or five years. I had a staff position on something that was called the Program for Health Management in Baylor College, the Baylor Medical School. If you looked at it today, it would probably be called an Institute for Health Studies or something like that. And was working on a project which had some carry over from what I’d done in my Academy days which is looking at manpower projections for Texas, specifically the supply of FPs. So that was kind of the job that I had.\n\nBut I started a Master’s in Public Health degree. The University of Texas had a School of Public Health. So I was enrolled and started in a Master’s in Public Health degree. And since I thought I was going to be there awhile and my prior experience in Washington caused me to be kind of interested with these policy guys who had both MDs and JDs. So I thought maybe I’ll go to law school. And so I sat for the LSAT and did okay on it and applied to the University of Houston and was admitted. So I was ready to start to law school in September of 1976. But in April, actually when Jane and I were at the STFM meeting in New Orleans, I got a call from a fellow by the name of David Kindig who I had worked with before. David was one of the first directors of the National Health Service Corps. Had also been a SAMA activist. He’s two years older, so I had met him when he was a SAMA president. That would have been probably about 1967 or 1968. David was at that point of the Deputy Director of the Bureau of Health Manpower in Washington which had responsibilities for all of the federal funding for Health Professions Education of which Title VII for family medicine was passed into law and the Bureau was administering those funds. Also did Area Health Education Center student loans and the beginning of the National Health Service for Scholarship program. And David had been the deputy for about three years and had been recruited to be the president of Montefiore in New York. And so he was looking around for somebody to take his place and said this is a perfect place for you because you have been into primary care, this is one of our pushes. You’ve got some federal experience, you know how it works. You’ve been a commissioned officer, you could come back as a commissioned officer. And so that was of interest. We had to figure out exactly what Jane would do. And through a series of conversations the National Cancer Institute said we would be happy to have her continue her fellowship in the  but we just don’t have a position, a slot. Well, the head of the agency in which the Bureau of Health Manpower was located was then called the Health Resources Administration. The head of the agency was a fellow by the name of Ken Endicott. And Ken was a physician administrator, a longtime commissioned officer, US Public Health Service. But interestingly back in his history he had been the Director of the Cancer Institute. Now this was before the war on cancer when the Cancer Institute was just another relatively small institute. And Ken was not an oncologist – it wouldn’t happen today. But he had been the Director of  and he knew the people. And he was a little bit exasperated with them because he knew you could find positions if you wanted to find positions. But he said being the quintessential anti-bureaucrat, he’d been around long enough he could be a good bureaucrat if he wanted to be one and he could just cut through stuff if he wanted to.  He said fine, I’ll float the position. So he put an HRA position in the . Jane occupied that galut for the remainder of her fellowship training. I went and became the Deputy Director of the Bureau of Health Manpower. There is an interesting little coda to the end of that story in that because Jane’s career progressed through the  and she became the special assistant to a fellow named Vince DeVita who was one of the division directors and then DeVita wound up being the Director of the . And so about four years after she interviewed for the position there where they just couldn’t find a slot for her, she was the Deputy Director of the . People treated her a lot better at that point.  \n\nThat’s a fantastic story and it does give me a little bit more peace about the fact that you and Jane did have some time together. Because even as newlyweds you weren’t together. But then when you got the call from Washington things worked out so that she got to join you in Washington. And that’s another part of your career.\n\nBut I would like to take you back to the time you were at the Academy here in Kansas City a little bit before you left and ask you about a couple of things that were really, really important to our specialty and its development. And one of the things that you did when you were here in that initial capacity as Assistant Director of the Division of Education is that you were required to do and you did a great job, of multiple consultations toward the development of our specialty. And part of the currency that you had to know what to do in those consultations is presence with and in fact a lot of influence on the Residency Review Committee for Family Practice. So tell me a little bit about the Residency Review Committee Special Essentials, as we fondly called them in those days. Who put them together? How did it happen? What was the technique? And how did you personally fit into that process? \n\nI can tell you what I can remember. Probably some of this history is imprecise because it wasn’t something I really focused on at that point. I arrived in February of 1973. The Residency Review Committee had been operating since 1969. So there was already a set of Essentials in place. Now my recollection of that history of where they came from is that they were largely written by Lynn Carmichael and Lee Blanchard. Lynn Carmichael, the founding Chair of the Department of Family Medicine at Miami. Lee Blanchard based in Stanford. A general practitioner/family physician with no academic tie-in. And I don’t know the personal histories of Lee and Lynn well enough to explain how they became associated with the AMA in the late 60s. But both of them had a charge from the AMA to move around the country and essentially be looking at what probably were not more than twenty or twenty-five general practice residency programs that had been started in the early 60s. From post-World War II years there was a growing degree of ferment about what do we do about general practice in the United States. And one of the efforts in the early 60s was we need to have more training than just an internship, so we need to have general practice residencies. So these residencies were two-year residencies. But by the time the mid to late 60s came there was a growing set up [?] opinion that that was just a two-year internship, that model was not going to work. That if we really wanted to take general practice to a new level, we had to take it to a level where it did a lot more things that would become family medicine. And Lynn Carmichael and Lee Blanchard were right in the middle of that working with the AMA Council on Medical Education. So my understanding at the time that I got here is Lynn and Lee Blanchard had kind of put together the first set of Essentials that defined what family practice residencies would be: three years, continuity of care responsibility, model family practice unit. All of these things which are very familiar to us now which were major departures from the way graduate education was done. And what was part of the reformulation of general practice into family medicine in 1968 and 1969 with the American Board of Family Practice being formed or incorporated in 1969. So when I got here in ‘73, the Residency Review Committee was already operating. The same three parents that we’ve got today: the Academy, Board [ABFP], AMA. I do not remember who the secretary of the  was. It is possible that it was Lee Blanchard. Now by this time Lynn Carmichael was fully academic in Miami. I just remember from the time I got here – and, of course, this was an unfamiliar structure to me. So that’s why some of the details are a little bit hazy. I didn’t really sit down and study it and try to figure out what was going on and where it came from. I was just right in the middle of it. And part of my responsibilities as the Assistant Director of the Division of Education were to attend all  meetings. And I was there to understand what the concerns were, what the priorities and the policies were of the  because the major part of my job description, as you have noted, was to be available as an Academy resource to go to hospitals and medical schools that wanted to start residency programs or academic departments of family medicine which, of course, was outside the periphery of the , and provide consultation. I had come as the first Assistant Director because the Director of the Division of Education was Tom Johnson. And Tom had been in that position seven or eight years, a long time. Tom was starting to do some of this consultation himself but Tom didn’t fly.  \n\nHe drove a Cadillac.   \n\nHe drove a Cadillac but he mostly took trains. And I just remember the stories of the staff, when I got here, Tom would take off and he’d be gone for six weeks. And he would mail these three-inch wide flexible Dictabelts, which was the technology of the day, back to the office and they would be transcribed. Those were his consultation reports. And I had interviewed with Tom and with Roger Tusken who was the Executive Vice President at the time before I took the job, essentially was hired by Roger with Tom’s support. But for reasons personal to Tom but I don’t think any of us really understood fully, after I was there for four or five months Tom retired just very suddenly, very abruptly. He was just gone. I don’t think it was anything about being frustrated about working with me. So I was an Assistant Director without a Director. And whether or not I would have had that amount of contact with the  if we had had a full-time Director here, I’m not sure. But it was really helpful for me to be able to sit and listen to the people talk. I would have to go back and look at who the  members were at that point. But I suspect if you and I had that roster in front of us right now, we would really recognize a lot of the names as being some of the early movers and formulators of the family medicine movement.  \n\nThe next project that Lee and I took on, which is what makes me think he probably was the Secretary of the  at that point, is a revision of the Essentials. This is I think where your question was going. And at that point I am not clear on whether or not the original Essentials kind of had three tracks or whether Lee and I were trying to create three tracks. I just remember that being an ongoing debate. One of the tracks basically would have been much more a public health orientation towards family medicine rather than just the clinical orientation.\n\nPerhaps community medicine/public health, I remember. \n\nThat’s fair. And whether or not that was in the original Essentials, which I could well imagine that it could have been given Lynn Carmichael’s strong orientation to community medicine. I could imagine that being there. But you already were getting into some of the tensions and cultural differences in terms of what should family practice look like. How clinical should it be. How academic should it be. How community-oriented should it be. Lee and I were working on a revision of the Essentials and I think we probably started that in 1974. And I can remember Lee had a wonderful home in the San Jose area that overlooked San Jose proper. It was on the eastern foothills, a great swimming pool. And he and I spent two long afternoons just out by the pool with yellow sheets and writing and talking about stuff. But I am sure that by the time that I left and you took over the revisions had not been accomplished.\n\nActually that’s another chronology that I’ll add a little bit to because I also remember sitting in Lee Blanchard’s house in early 1977. Lee Blanchard and I and Nick Pisacano and Tom Stern And the four of us sitting down to, I believe it was, and again my memory is a little faulty too…but I believe it was to finalize that second iteration. And now I can’t remember if it was the first or second iteration. But one of them was a two-track system which would allow family practice residencies to either have OB or not have OB. And now we’ve come full circle because right now there’s within all of our academic family medicine organizations basically a consensus almost fully developed that’s not two tracks but is with maternity care to the point of competence in delivering a baby or just exposure to and prenatal care rather than intra-partum care. So it’s kind of come full circle. But both for you and for, when I followed you, the fact that we had that RRC experience and the input into that made us maybe the people who had the most knowledge in the consulting world about what needed to be done to have a family practice residency in those days.\n\nLet me switch gears on you, Bob, a little bit. But still your first time here. We will talk a little bit in a little while or maybe next time to tape about when you were here as our EVP, when you come back. But when you were the first time you were very instrumental in the establishment of the Society of Teachers of Family Medicine. And if I’m remembering correctly, you were the first executive director of the STFM kind of on loan from the AAFP because of your role as Assistant Director of Education. And you’ve invoked the name of Dr. Lynn Carmichael several times and I believe you must reinvoke his name as you tell us a little bit right now about the origin of the STFM, the role of the Academy and your own personal role.\n\nI can take absolutely no responsibility for the establishment of STFM. STFM was established in 1967 or 1968. Was already an ongoing academic body. Lynn Carmichael was a major participant in that. Marian Bishop a major participant in that. A decision had been made before I got here that STFM needed some sort of administrative structure. Up until that point it had been run out of Lynn Carmichael’s garage in Miami. And this was not anything that Tom Johnson or Roger Tusken or I talked about at all. I showed up in February of ‘73 and it was almost an oh, by the way we have another job for you. We just got all of these boxes shipped up here from Miami because the Academy has agreed that they will provide administrative support to the Society for a period of time. The way we did things in those days, I don’t think the period of time was defined or any documents signed. And you’re it. Which turned out to be just a fascinating set of responsibilities. Because of my past activities in the government and even back into med school days, I was relatively comfortable running projects. I felt comfortable in administrative capacities. And so the fact that I’m suddenly supposed to be an administrative officer of an organization that I didn’t know anything about, hadn’t had an administrative officer before was fine. The Board members at that point at least were Gayle Stephens, Marian Bishop and Lynn Carmichael. I don’t remember others. Gayle I believe was the President. Because I can remember driving down to Wichita when he was still there at Wesley to meet him and talk with him as the President. And my responsibility was to kind of figure out what the STFM was doing at that point and try to bring a little bit of administrative structure to it. And I did that for the remainder of my tenure while I was here with the Academy. I remember working on bylaws. I don’t remember whether that was a revision of the bylaws or whether it was the first time that STFM had bylaws. When I got here there was one administrative support person that was assigned to the Society.  \n\nFrom the Academy?   \n\nI don’t know what paycheck she got. And she was hired before I got here, so I have no clear recollection of that. I just remember after about three or four months I came to the conclusion that her skill set was not a good fit for what the Society needed. And I actually switched her out with another employee in the Division of Education that I thought was a much better fit there. And that turned out to be really a very good thing because this person then wound up working for the Society for four or five years, was very creative and had a tremendous capacity for individual activities. Her name was Jean Hawk and was a great person to work with. So at the point that I left the Society I think felt like they had matured enough that they could get their own full-time executive director. And it was at that point that they hired a woman by the name of Pat Phlak. And she was the first Executive Director of the Society. I think Pat stayed for, this would have been your tenure so you’ll remember better than I...maybe three to five years. \n\nThat sounds about right.   \n\nAnd at that point when she went to Minnesota they hired Roger Sherwood.  \n\nAnd Roger was here for twenty-five years or so until this past year.\n\nThat’s right.\n\nWith apologies for skipping around chronologically a bit, I’m going to go back to when you left the Academy the first time, went to Houston and then went to the government. Here’s a question for you: What was it like as a thirty-something to run a billion-dollar enterprise which was the entity in which you found yourself in DC? \n\nAnd you’re referring to HRSA, Health Resources and Services Administration? \n\nYes. \n\nI will come back to your question. But again, just to make sure anybody who chooses to listen to this tracks with it. I didn’t go from the Bureau of Health Manpower into the HRSA job. There were some things that happened. I was the Bureau of Health Manpower for a couple of years. And then I mentioned that it was part of a larger agency, Health Resources Administration. So I moved into the Deputy’s position there for a couple of years. Then was down on the Hill on detail from the Public Health Service on Senator Ted Kennedy’s staff for a year and a half which was a wonderful exposure to the legislative process. And I had responsibility for four or five areas that actually got passed into law during that time period. But it was also during that time that he was challenging President Carter for the primary nomination for the election as the Democratic presidential nominee in 1980. And, of course, Kennedy did not win. But I got wound up in his campaign basically because we always had one of the four physicians on staff with him any time he was out in public and we coordinated our activities with the Secret Service. And most of the time I spent with events in Washington, DC but over the time of the campaign I was on the campaign plane for probably three weeks, which was absolutely an unduplicatable experience to see how a campaign is run, to see how an individual behaves, conducts himself, to come to an understanding of the complexity. Which does lead me back into your HRSA question about how you prepare an individual and how they prepare themselves. And in one day we were in eleven different media markets. Just hopscotching across the country from one state to another state, going east to west. One of those stops was in Fort Wayne, Indiana. An unscheduled stop because Vernon Jordan had been shot, if you remember. There was an attempted assassination and he was seriously wounded, was in the hospital and Kennedy said I’m stopping. You just watch all that complexity and say how do you manage things going on. Every time the door opens you’ve got local press that’s going to ask you local questions. Any time you touch down somebody’s going to ask you what do you think about what the President said this morning at","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153004/file/281613#t=0.0,600.0"},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/153004/file/281613/transcript/81602/annotation/2","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"and you’ve been in the air since 9:30. So even though it was not a successful campaign and Kennedy was not a good campaigner early on...in the latter stages of the campaign he was really excellent. That was an exposure to a whole level of complexity I had just never seen before.  \n\nSo at the end of my detail it’s December of 1980. Reagan had won the election. It’s time for me\n\nto go back into the government. Well, HRA had turned over administrators at that point and there’s a new administration, a political appointee, Karen Davis, who now runs the Commonwealth Fund. Karen and I had a mutual friend and I got a call one day and Karen said you left here as the Deputy. I don’t have the Deputy slot filled right now. I’m going to be here for six weeks and once the inauguration is done I’m going to be gone. Would you be willing to come back and serve as Deputy? Because maybe there’s a possibility that you would be able to transition for a period of time and provide some stability for the organization. And I said I’d be happy to do it but I want to make sure that I don’t show up someplace that the new secretary and everything doesn’t want me. Well, the new secretary was Richard Schweiker. And Schweiker had been the minority on the health subcommittee where Kennedy was a majority. So I had been working with Schweiker and his staff for the last two years. And so I called Schweiker’s chief of staff and said this is what I’ve been asked to do. But I don’t want to be there if you guys really have some different plans for the agency or you don’t want a former Kennedy staff member out there. And he said let me get back to you. And about a day or so later he called back and said it’s okay with us but don’t unpack your bags. And so I went back to HRA as the Deputy. And when Karen left January 20 I became the Acting Administrator of HRA.  \n\nHealth Resources Administration.   \n\nAnd, of course, the Reagan plan for HRA was not a very pretty one. We had three bureaus at that point: Health Planning, Health Manpower and Health Facilities. That handled the old parts of the Hill-Burton program. The Reagan budget for the agency was zero. We had about 1800 staff members in those three bureaus. The first term that Reagan had, there was a Senate majority but the Democrats still controlled the House.  So there was a period of negotiation back and forth. And so the final budget for HRA was Health Planning would be zeroed out. The Bureau of Health Professions, it had changed from Health Manpower by that point, was essentially cut back by about 50% and Health Facilities was cut back by about 50%. And so my job as the acting administrator was to run what’s called a reduction in force, a RIF, which had not been done in the government in anybody’s memory. I had a staff meeting when we first saw what we were going to have to do. And I said okay guys, how do we do this? And the senior staff said we don’t know, we haven’t done it before. So we kind of figured our way through it. And because of a variety of circumstances we wound up reducing our  head count in the agency by 40% but without anybody being involuntarily separated from federal service. And we were able to do that because there were individuals who took voluntary retirement and because we reached an agreement with the Secretary that other positions in the department would be frozen. And our agency and the Health Services Administration was going through something of a similar thing. But basically those staff would have preferential rights to select positions at other places in the government. So between people leaving voluntarily for retirement and taking positions in other parts of the government we were able to get down to our permitted head count in about nine months without having to fire anybody. Which obviously people in the agency had very good feelings about that.  \n\nIn the middle of all this going on one of the authorities that we were responsible for was a loan and grant program for historically black colleges and universities. And Meharry Medical College was a participant in that program and chronically ran into serious problems. And in the spring of ‘81 they ran into one of their problems where it looked like they were going to have to default on the bonds that supported their teaching hospital. And the Meharry Board of Directors typically was made up of individuals from the African American community but they happened to have a Vice Chair of the Board who was a Caucasian radiologist from Houston. And he suddenly became the Chairman of the Board and he’s a good old Texas Republican and he went to the White House. I think Jim Baker was the Chief of Staff at that point and he said Jim, you cannot let this institution go down on President Reagan’s watch. And I’ll tell you what we want, we want half of the Nashville Veterans Administration Hospital and we want all the money that comes with it. Well, of course, the Nashville VA had an exclusive relationship with Vanderbilt. The White House looked at the prospects of trying to divide that and all of the politics that came with it. And they called Dick Schweiker and said take care of this. So Schweiker’s people looked at that and said that’s an HRA responsibility – Bob, take care of this. And so I became the chair of a White House task force on Meharry Medical College. And it’s very interesting to look at it retrospectively in terms of management theory today and matrix organizations. On that task force we had people from the Department of Education, we had people from Treasury, we had people from Justice, we had people from the Veterans Administration. And our job was to find a solution in six weeks. And we came up with one. We figured out a way to alleviate the obligation of that particular set of bonds that stood behind the hospital. Something I had never heard of before, it’s called diffusing bonds. You basically roll one obligation into another but it left the hospital’s mortgage paid off. We initiated a teaching affiliation with Murfreesboro Hospital which is about forty miles away from Nashville that had not been a teaching facility before. The VA looked at that as a win for them because they were delighted to have the Murfreesboro campus upgraded. That was acceptable to Meharry because they had their own VA and the fund flow that came with it. And Vanderbilt was perfectly happy because their turf in terms of their VA wasn’t being encroached upon.  And so people sort of said well gee, that came out okay. So at this point because HRA had gone through a reduction in force, the Health Services Administration which did community health centers and National Health Service Corps and Indian Health Service had gone through a reduction in force. They’d sold off nine public health service hospitals and closed down the hospital side. The decision was made to merge those two agencies. And basically came down to a decision of Ed Brandt who was the Assistant Secretary for Health, also an Academy member, to figure out what the leadership should be. And the acting head of Health Services Administration was a fellow by the name of John Kelso that I had worked with before when I was in the government the first time. Just a wonderful guy. But not somebody who really enjoyed being the No. 1 person. And Brandt just sort of worked it through and I’m sure talked to John before he called me because John was about fifteen or twenty years my senior and offered me the position to be the HRSA head and John is the deputy, which is just a wonderful combination. And we were able to put the agency together I think relatively smoothly. About as smoothly as you can do something like that. You always hear there are no mergers, only acquisitions. This was really a merger. And if you looked at who the senior staff was, with all the office administrator staff, we made sure that there was a balance in terms of whether you came from HRA or HSA. What was it like to do that at thirty-two or whatever it was at that point? I think I was a little bit older than that but not much. It was absolutely fascinating. And it would have been even more fun I think if I had had the experience that I have right now. Because quite honestly, what we were doing for the first year and a half was trying to stabilize an agency with programs that felt like the administration was going to zero them out next year. Or it was common word on the street that HRSA would be in existence for two or three years and then the Reagan Administration would come back and finally be able to zero all of this stuff out, which hasn’t happened. And one of things I’m really pleased about now is if you go to Washington and you talked about HRSA, people really know there is an agency. And that was not true for the first three or four years. But it was an excellent set of experiences both in terms of administrative complexity and to some extent the politically visible leadership of how you positioned an organization with its multiple constituencies. And you spent time in the Indian Health Service, you can understand...you know, you’ve got the Indian Health Service over here as one part of the agency. And, of course, they are no longer part of HRSA. They found the independence that they wanted. And Maternal and Child Health Program and Health Facilities and National Health Service Corps – very, very different activities. So it was just a wonderful learning experience. But some of the stuff that I had been through in Washington before and the fact that my first tour of duty there was on the staff of a guy who was running something called HSMA, Health Services and Mental Administration, which had many of these same components. So to some extent when I wound up at HRSA and looked around the table at who the bureau chiefs were that I was working with, probably three-quarters of them I had known for at least ten years because of my prior time there.\n\nSo if I can make a value judgement on that, it is because of the success you had in the massive reduction in force as the Deputy and the success you had as the Deputy of HRA to solve the politically very, very volatile Meharry Problem that you became the Director. And that was even though you were in the Reagan Administration and a Kennedy staffer. So this probably couldn’t happen today.\n\nIt would be very difficult. And like many things in Washington, it had to do with relationships. I’ll give you another anecdote. I had very good relationships going through this with Secretary Schweiker and his staff because we worked together on the Hill. And we were the majority, they were minority but was it was no adversarial when we were on the Hill so...then I’m suddenly their minority. We were able to get along. And as you said, a couple of challenges came along and they were handled in such a way it didn’t embarrass the Administration. And in the Meharry circumstance kind of bailed the Administration out. I mean they were very happy to see this one just off the table in terms of something that was going to be a problem for them. But when Brandt and Schweiker decided to make the offer to me, there were members of the Secretary’s staff...as frequently happens in DC, the President appoints a Secretary but then he appoints one of his people to be Deputy Secretary just to make sure there’s a connection to the White House. And we did have that circumstance in the department. And this individual called his contacts in the White House and said you cannot imagine what they are going to do. They want to put a former Kennedy staffer in as an agency head. And so as I am told (I was not there), about 6:30 at night the Secretary’s phone rings on the line that only the White House knows. Secretary Schweiker is not there. His Chief of Staff is in the office, picks up the phone and it is Jim Baker from the White House. Obviously he’s got a long list of things to do and this is No. 7. And says we understand the Secretary is thinking about appointing a Kennedy staffer. Does that make a lot of sense? And so the Chief of Staff said look, he’s been here for eighteen months and he’s done this and it worked out pretty well. And you remember that Meharry problem you had? He was in charge of the thing that kind of got us out of that. And Ed Brandt’s been working with him and has full confidence in him. And really nobody knows what HRSA is anyway. And so the Secretary is comfortable with this. And Baker apparently says okay, that’s good for me and hangs up the phone and goes on to whatever No. 8 is on his list.  \n\nAnd that was it?   \n\nThat was it. But I think we did a lot of things that came out well. But if I hadn’t had that set of relationships with the Schweiker people kind of a sense of trust with them even from the Hill days, it doesn’t work. I don’t go back as the Deputy and they certainly don’t have a level of comfort handing over a hot potato with Meharry that could have caused a lot of problems for the Administration.\n\nSo what was the budget of HRA when you as this young kid were running it? \n\nOf HRA?  \n\nWhen you got to the HRSA stage.   \n\nAt that point, I like to point out to people that we were the biggest public health service agency. We had a little bit more than 15,000 people. Eleven thousand when we were the Indian Health Service. But I wished we were the biggest in terms of budget. I think the largest budget that we had in 1980 dollars was about $1.5 billion. And when you talk about federal budgets, there’s money and there’s money. It’s not like operating a business. You don’t have to have a business plan. You don’t have to go out and develop your business. You do have to argue for the appropriation. You have to make sure that you execute the budget well and the money is spent the way it is. But it’s totally different than running a budget like it was here at the Academy. Although the Academy’s budget was far, far smaller the complexities in terms of getting money to come in the front door are much greater in an organization of this type and size than when you’re running a federal agency.\n\nWell, you’ve just started the segue from your time in the government to your arrival for the second time here at the American Academy of Family Physicians. And we will discuss that in a point. Because you did indeed come here from that last Washington position with the 1-plus billion dollar budget to our budget here. But just for the record, to make sure that the various parts of your chronology are clear, you had made reference in the last few minutes a couple of times to your prior service in the government. Just take a moment, please, to explain what you meant by that, that you were actually in the government before you came to the Academy the first time.  \n\nAnd again, for anyone listening to this or reading the transcript, you will find mentioned in the description of this on the interviews that I did with Sandy Panther. But I did my medical school at Kansas [KU] but I did my undergraduate degree at Earlham College which is a Quaker school in Indiana. And I would have to admit, I probably majored in cross country and minored in pre-med. But the Quaker community is just a wonderful educational community and they really teach you self-reliance, to question authority and maintain a high degree of personal responsibility. And I think those are wonderful lessons for life but they were not good preparations for coming to University of Kansas School of Medicine in 1965 where the attitude was sit down, shut up. If you make it out of here then we’ll listen to you. So I became a student activist, and really without thinking about it. The first thing I did after our first semester where we had anatomy and physiology and biochemistry, the routine stuff, is something we had done routinely at Earlham which was teacher evaluation. And I did have a major in clinical psychology and I knew how to put evaluation instruments together. And so another guy and I put an evaluation together and distributed it to the students and we got about an 85% response rate. We tabulated the results and made it available to the Chairs of the Department and the Dean. And this was viewed as a subversive act. And then, of course, this is 1966, ‘67, ‘68, everything is going on in the campuses. We had the two assassinations in ‘68. We had the Vietnam warfare. And Kansas turned out to be a hotbed of student activism. So I spent as much time as a medical student working on student projects related to reforming medical education and establishing student health centers. Actually, I wound up taking five years in medical school largely to permit me to serve as the Vice President of the International Medical Student Association for the last year. And so at the time that I graduated we were still involved in Vietnam and I had the opportunity to fulfill my draft obligation. I could do an internship and then go into the military. That would have been fine with me. On the Vietnam issues I tended to be more on the hawkish side than the dove. Or I could do an internship and a residency through the Berry Plan. And at that point I had not really liked what I saw of clinical medicine at Kansas. I didn’t like the way patients were treated. I didn’t like the way medical students were treated. And I had these other interests. We had actually gotten a grant of about $250,000 from the Carnegie Foundation and we did a nationwide study of reform in medical education and wound up publishing a small book under SAMA’s auspices for that.  \n\nWhat was the name, because I remember the book?   \n\nHandbook for Change.  \n\nAbsolutely, I still have a copy.\n\nAnd so about the time that I was thinking this through I had a conversation with a gentleman here in Kansas City, E. Grey Dimond, who came to be the founder of the University of Missouri at Kansas City School of Medicine, but I had been involved with him in this Medical Education Reform project. Grey said I’ve got a friend in Washington who is the head of this Health Services Mental Health Administration. Now this guy is Vernon Wilson who has a role in the development of family medicine because Vernon was one of the founding members of the American Board of Family Practice Board. And even though he never did any clinical work at all, I don’t remember if he did an internship or not. I just remember him being the administrator at HSMA. And he decided that it would really be great to get an opportunity for three or four young docs to experience health policy and the government and start bringing new people into the system. And I wound up getting really a tremendous position on his staff. It was a direct report to him, called the Assistant Administrator for Agency Goals. It was a wonderful title and nobody had any idea in the world what you did. Didn’t really have a staff or supervise anybody. But I did special projects for him. I tried to figure out whether or not you could apply the principles of agricultural extension service into innovation and health promotion in the field for health. Had two contracts to look at the future of health care in the year 2000 which, of course, is thirty years away at that point. So that was my first tour in the Public Health Service. Again, giving me some of this administrative background. Being able to watch Vernon Wilson operate. And he and Ed Brandt are the two best physician administrators I have ever seen. And I had the good fortune to work very directly with both of them and just kind of watched the way they did. You know, not only how they handled issues but how they treated people. And both of them were just extraordinarily decent, self-effacing individuals. And because there are a bunch of people around in that orbit who are not, I said that’s what makes them effective. They’re not out there saying me, me, me. They’re saying let’s hear how to get this done. So that’s also where I met Marian Bishop. Vern Wilson had come to his position from Missouri. Marian was on the faculty at Missouri and had a background in sociology. And I understand it, Vern essentially said I’m going to be running this organization for several years and it is a fascinating culture. You need to come and look and see how things function, how things change. You’ll understand how that works. So I was single. Marian was back there and Bob and Win were still in Columbia.  \n\nThat’s the family of Dr. Bishop.   \n\nYes, Dr. Bishop’s husband, Bob Froelich, and son Win Froelich. And so she and I were sort of the odd ones out. Everybody else had spouse and family around. So she and I spent a lot of time talking and just kind of sharing observations about stuff. And it was her at one point, linking back into the first question you asked today, at one point in late 1972 said there’s this organization in Kansas City that’s looking for a young doctor to help promote family medicine. And you’re from Kansas City and I think you might be interested in looking at this. And so she’s the one who made the contact between me and Tom Johnson.\n\nSo you came to the Academy the first time from the government. And you went not directly from the Academy the first time to the government with a little bit of a circuitous route. And you came back to the Academy in about ’83 or ’84 (we’ll clarify that in a moment) from the government. And that creates another series of questions about which I’m going to have a good time probing you in a few minutes. The other thing that I’m going to do in a few minutes is take some of the names about which you’ve just made mention, perhaps add a few other names and ask you for your quick reaction to those names. Such as Marian Bishop, such as Lynn Carmichael. And here’s a couple you haven’t mentioned yet – Tom Stern. And I just mentioned Nick Pisacano but I’m going to ask you about Nick Pisacano and a few others a little bit later. \n\n\n\nCENTER FOR THE HISTORY OF FAMILY MEDICINE  HISTORY INTERVIEW WITH ROBERT GRAHAM, MD \n\nINTERVIEW CONDUCTED ON MARCH 19, 2009 \n\nBY DANIEL J. OSTERGAARD, MD\n\n\nToday is March 19, 2009. We are in lovely Johnson County, Kansas. It’s a beautiful day here in Leawood. We are in Don Ivey’s office in the archives of family medicine. I am Dan Ostergaard and have the privilege of talking with my longtime friend and colleague Bob Graham. And this will be part two of the taping we have done to get some of Bob’s thoughts into posterity.\n\nBob, we had a good visit a few weeks ago and got some things down on tape and now we’re going to do another one. One of the things we talked about doing when you were here before was for me to give you the names of a few of our early leaders in family medicine and for you to give an instant reaction. Not a treatise on their accomplishments or their personalities but just your reaction – when I say the name, what do you think of? First of all, somebody who is the boss of both of us, Tom Stern.\n\nCurmudgeon, dedicated, stubborn. Enjoyed a second career in Kansas City working with the Academy which was a type of responsibility I think he never imagined he would do. \n\nLet me just probe you one more thing about Tom. He did lots of things. What are the things he did in terms of family medicine that stand out?\n\nWell, he was an early family medicine educator. In fact, he was Director of the Santa Monica FP program. And I don’t remember whether he actually took that in the transition from the GP program to the FP program. But in these little centers that there were around the country in Ohio and California and Illinois that were starting to move general practice into family medicine, Tom was involved in that. So that’s one career that I think of for him. And then, of course, the other that he was enormously proud of and made a lot of difference to the specialty at the time, he was the medical director to the Marcus Welby show. He developed a very close relationship with Robert Young who was the star, the Dr. Marcus Welby. And that was a time where family medicine was just kind of establishing an identity and Welby in his show clearly associated himself as being a family physician. Used the Academy’s logo or allowed the Academy’s logo to be visible in his office. I think just all of the energy and the inside Hollywood stuff, I think Tom really enjoyed that. I don’t think he ever saw himself as working in a large organization and doing stuff on a national scale. But he had some real talents.  \n\nAnd many of his documents from the old Marcus Welby show are right here in the room in which we are having this conversation.\n\nAnother name, Nick Pisacano.\n\nStarting to sound redundant. Curmudgeon, energetic. Nick came out of a very different stream of family medicine leadership. He had a passion for family medicine but he had a passion for family medicine to be legitimate. And so his association with the American Board as a founding director of the American Board, he was one of the drivers behind the concept that family medicine needed to be different from the other specialties. It needed to distinguish itself and be committed to intellectual rigor. And that’s where we got the 100% required recertification on a seven-year cycle which was before any other specialty did it. I think Nick was always attracted to kind of mainstream – he always wanted family medicine to be respected by the Harvards, the Yales, the Secretaries of HEW. And I think it was always frustrating to him that they didn’t give him and didn’t give the specialty that respect.  \n\nThe next name I’m going to throw out to you, Bob, is a name that both you and I know but a lot of people in the history of family medicine probably don’t know because he wasn’t technically one of ours, Dr. Bill Ruhe.\n\nC.H. William Ruhe. At one point I probably knew what the initials stood for. Do you remember?  \n\nNo, I don’t remember.\n\n“C” is probably Charles or something like that. I don’t know what his title would have been, AMA, Director of their Division of Education, a Vice President for Education. Again, back in the late 60s, early 70s, as you noted not a family physician, not always a full supporter of family medicine. But he was involved in I believe the Willard Report. Of the three reports, Willard, Folsom and Millis, that provided the advocacy and intellectual basis for family medicine, with the establishment of the Residency Review Committee for Family Medicine – I think Bill may have been the first staffer. Certainly had the responsibility for organizing the Residency Review Committee. I think we sometimes lost a little patience with him because he was supportive but not passionate about family medicine. I think he saw that family medicine had a role in the U.S. healthcare system. I think he saw the positives of the movement. But he wasn’t necessarily willing to use the leverage that we may have perceived that he had within the accreditation process within the AMA to become an advocate of the cultural revolution that we might have been thinking of. So I think we saw him as maybe part of the William R. camp but not fully. A gentleman though who had a personal and ethical tone which was exceptional. He always wanted to do the right thing. A very measured, very even person. And in medical education politics at that time, not everybody was quite that way. Where Nick and Tom were capable of periods of irascibility, you just never see Ruhe respond that way.  \n\nThat’s a very good contrast actually from Dr. Ruhe to Tom Stern and Nick Pisacano. I remember having dinner one night at Tom Stern’s house with all of those people, all that we’ve mentioned so far, and again, those personalities do show up a little bit differently in that kind of context.\n\nThe next name is your clinical mentor, Dr. Jack Stelmach.  \n\nI was going to say there’s somebody out there who wants to deny that statement. But you’re right, from the history that we talked about before, directly into medical school, from medical school into the Public Health Service. Didn’t do an internship. When I came back here to Kansas City as the Assistant Division Director and was substantially involved in consulting with hospitals and med schools about starting family medicine, one of the programs I consulted with was Jack Stelmach over at Baptist Hospital. And I don’t remember exactly how we got to the point but as Jack was moving ahead with getting the program accredited – and it was a good program. They had a lot of resources and a lot of support from the hospital and the community. I decided at that point that family medicine was a discipline that I really was comfortable with. I wasn’t happy with medicine as I saw it in medical school – and one of the reasons that I went into the government. But I really liked family medicine. I liked the way people were taken care of and I liked the culture of it. And so it worked out an arrangement where I would be half-time in Jack’s initiating family residency class and half-time with the Academy. So I would do a month of clinical work and when I’d get done at the hospital at night I would come over to the Academy building and do all of my correspondence and everything else. And then I would be off for a month and go do all of my travel. And obviously Jane and I were not married at that point. That was about the only way that that life was possible. And that was a very useful experience for me. I will never represent myself as a clinician. I did enough of it that I did get qualified and got a license. I finished one full year. Although Jane and I about halfway into the first year, I thought I was going to do this half-time for six years – Jane and I decided we were going to get married and that involved a move to Houston, so I just finished off the one-year equivalent. The other thing that actually turned out to be a very useful management principle that I backed into is that the class that Jack put together was four first-year residents, and so I was the fifth. So they loved me. Every time I showed up their call schedule went down because I was an extra. And I realized later if it had been four and I was one of the four, they would have hated me because I would have been gone when I was supposed to be there. So I was somebody the other first-year residents...I’m sure they thought I was kind of a little bit of a weird duck because I’d been out of med school for four or five years and I was doing catchup on a lot of stuff. But at least when I was around they didn’t have to take as much call and they thought that was really nice.\n\nThat’s wonderful insight about you can either be very, very popular or very, very unpopular with your colleagues. And speaking of your colleagues, just in case we may want to check back with them in case some of them are in this area still, do you remember the names of the other people in your class? \n\nCarl Myers is one name I remember. And I believe Carl is still practicing north of the river. Larry Anderson who was later a Board member for the Academy and is still practicing down in the Wichita area. I was always enormously impressed with Larry because Larry is a veterinarian and he knew how to do things. I would just sort of stand in awe – how in the world did you know how to do that suture in that place at that time? And I can see one other face and the name does not come back to mind. But Carl and Larry I do remember.  \n\nAnd they are both in practice, that’s good.\n\nThey were exactly the sort of family docs that you want the program to turn out. They’ve gone someplace, they practice at taking care of the community. Carl I think was active in the Missouri Academy. And Larry put time and effort into the national level.  \n\nThree more names. Let me do the third one first. We haven’t mentioned his name, I don’t think: Gayle Stephens.\n\nGayle to me is still the intellectual articulator of modern family practice. And the phrase that he used in the late 60s of family medicine as a counter-culture in medicine I think had enormous resonance within the specialty at that point. And growing up as a student activist and as a member of the “counter-culture” generation, it made a lot of sense to me because what he described was a conflict between cultures. It wasn’t a different way of doing things. It was a way of doing different things in terms of what was important and what medicine’s responsibility to society was and where the imbalances were. I met Gayle for the first time as he was the incoming president of the Society of Teachers of Family Medicine. He was still at Wesley in Wichita at that point. He had not moved down to Alabama as the dean at Huntsville yet. And I was the executive officer of the Society of Teachers of Family Medicine. But just as Jack Stelmach and the residents I trained with taught me so much about the pragmatics of what it means to be a real family physician day in and day out and the scope of what they could do and how they knew their patients, Gayle was this different person with his ability to conceptualize and use appropriate references from history and theology describing the clash of cultures. And it was a wonderful time. One day you would be in one camp, one day you would be in the other camp and the next day you would be on an airplane going out to a hospital trying to interpret all of this for people trying to figure out how to start a family practice residency.  \n\nThat is a very, very good summation of Gayle Stephens and how he related to the procedure lists or whatever. And he wrote the book The Intellectual Basis of Family Practice.\n\nYes.  \n\nTwo names that we have mentioned in this conversation but I didn’t ask you for a quick reaction. So a quick reaction: Lynn Carmichael.\n\nWest coast [?]. Lynn started the program in Miami and more than even the Montefiore program in New York which called itself social medicine, that was Lynn’s commitment. And the program is still operating. It’s got close to a forty-year history now. And you look at the types of residents that it has turned out, they’re good family docs. Many of them have been successful in academic medicine. And they all have a degree of social commitment and involvement. They’re looking at the interface between what the residency and the training can do for the community. And I remember one of the clinics that they maintain in Miami was in Bimini. You get on the boat and you go bouncing across the water for forty minutes and that’s where your neighborhood health center is. And, of course, Lynn was one of the founders of the Society of Teachers that bequeathed his records to Kansas City.\n\nAnother major, major leader in the Society of Teachers whom we lost a few years ago, Marian Bishop.\n\nMarian we have talked about before because of my connections with her in Washington. A very interesting leader in family medicine and in some ways I think it reflects the best of both her abilities and family medicine because she’s a sociologist. A close affiliation with Vern Wilson who was not really a family physician although he wound up being one of the founding board members of the American Board of Family Practice. And Marian was drawn into this discipline of family medicine in Columbia and then with Gayle Stephens down in Alabama. And then went on to become department chair herself in two departments. So very bright, very articulate, effective leader. A major force in the Society of Teachers of Family Medicine. But this specialty which is this counter-culture new specialty, when you go around to the medical schools and you look at the chairs and they’re all old white guys, there’s Marian as the Chair of Family Medicine. And just other specialties would not have provided that opportunity for someone with her background. She wasn’t even a doctor. Family medicine had a place for her.  \n\nThere would have been those of us who might have said she wasn’t a real doctor because she had a PhD.\n\nYes.  \n\nBut she was a real doctor from the sense of being a true academic.\n\nIt occurs to me, I got tied up in the residency, I didn’t talk about Jack Stelmach.  \n\nYou really didn’t talk about Jack himself, so go back to that.\n\nJack is just the consummate human being. Now he had a practice in suburban Kansas City, affluent suburban-urban Kansas City. Maintained that practice for twenty-five years or more. Turned it into the teaching practice of the residency. Was a leader in family medicine, a President of the Academy. But Jack never met a person that he didn’t care for and nobody ever knew Jack that didn’t care for him. You tried to describe him as my clinical mentor and I really think we need to be fair to him and say he admitted me into his program. But other than that, I think he bears no culpability. But just because of the size of the program and the irregularity of my schedule, I spent a lot of clinical time with Jack watching the way he dealt with patients, watching the way he treated patients. And many of his patients, like many family physicians he’s known for years and years and years. And that really put the flesh on the bones of the model of family practice for me because more than any of the other family docs, Nick and Tom I knew in administrative roles and I knew a lot of family docs who did a bunch of things. But Jack I knew when I saw him in his clinical role. And when Jane and I moved back to Kansas City when I became the CEO here, Jack was our family doctor. And Jane’s a classically-trained internist, oncologist. Neither one of us had a regular physician until that point. We were in our early 40s and figured it was time. She loved Jack. We’ve been happy with our doctors after that, but every time we go to a new city she says “I miss Jack.”   \n\nThat’s Jack Stelmach.\n\nLet’s talk a little bit about you and your time here. And the first question of two or three in this regard would be, given the fact that you were the first physician CEO of the AAFP and you followed two previous CEOs which we called Executive Directors, I guess, at that time – what was it like? What were the issues with which you dealt as a physician taking on the job which had always been held by non-physicians in the past? \n\nI think there were two which I was aware of coming in, there weren’t any surprises. And I’m sure the levels that they played out on I’m not fully aware of. From the staff side, even though I had been here on staff before and I knew some folks and I wasn’t a totally unfamiliar person, I think there was some uneasiness as to whether or not this is going to be a doctor. Whether I would see my role and identity as being a classical physician. I know the right way to do things, we’re going to do them my way. This is a physician’s organization. And somehow physicians were more important in the organization on the staff side than the rest of the staff. And that there would be kind of a rebalancing in terms of values because at that point, I guess when I came back, you were on staff as a physician.  \n\nI think I might have been the only one.\n\nI think there were only two of us. So one of the feedback that I got early on from the vice presidents and the division directors was whether or not vacancies are going to start being filled by physicians. We were going to see a physician acquisition of the Academy. And I think in part because people were watching that go on at the AMA with docs taking positions that maybe they were not well-prepared for in terms of their training and background but just because the AMA board felt that it was just too important to not have a doctor in charge. I think we worked through that fairly successfully. During the time that I was here we certainly added more physicians on staff but not in a way that I think people felt that other values were not being observed. And by the time I’d been here ten years, if you looked at the direct reports that I had, there were only two docs: yourself at that point and Norm Kahn in Education. The Deputy was a lawyer, Mike Miller who had been here for twenty-five plus years and whom everybody in the organization just had a huge amount of trust and respect for. No matter who said anything, Mike would speak his piece. Rosie Sweeney with a background in public administration. Mickey Schaefer and Bill Myers in Membership. And Clayton Hasser in terms of publishing. And so after about ten years people looked and said well yeah, the organization may work a little bit different but people are being hired at the skill positions based upon their training and their competency rather than the fact that they have an MD behind them. So I think that level of tension and concern on the part of the Academy went down.   \n\nI think the other thing that happened is partially just because of my good fortune and who was available for task at what particular time, we became really unusual in the profile of gender balance in senior management. Now the Academy has always had a strong proportion of women on its staff in the clerical and the support areas. But when we looked at the division and assistant division directors in the mid-90s, we were about evenly balanced in terms of male and female. And at that point in terms of the vice presidents, particularly if you count Sandy Panther as the head of the Foundation, we actually had more female direct reports to me than we had male. And there just weren’t many associations at that point that looked like that. So I think on the staff side that was a transition where people may have had some concerns in the first year or so when I arrived about what my values would be and what that would mean in terms of who could succeed in the Academy and who would have responsibility. But I think we made a reasonably easy transition. On the member side I think there was some ambivalence. When I interviewed with the search committee they wanted somebody who had run large organizations before. They wanted somebody that they felt could raise the level of visibility of the Academy within the Washington corridors. And they had come to a policy decision that they wanted a physician. And I happened to meet those three criteria reasonably decently. I don’t know how much conversation that Board had. And, of course, because of the dynamics of the Academy electoral process, boards change very rapidly. Every year of those seventeen votes around the table, you usually have at least five or six new people. And so after you’ve been here a couple of years there’s practically nobody that was there that was on the search committee when I got selected. And so how much they walked through what is the impact on physician president leaders, member-elected leaders of having a physician executive leader. I know that this has been a point of stress in other organizations and I think occasionally it played out a little bit in the Academy. In some of the early years I would have conversations during a specific decision or during the annual performance review about well, what should be the EVP’s visibility versus the visibility of the elected members? I would have to say as I got to the last five or six years of being here, either because of a generational and value change of the Board or just because people were more comfortable with me and what my style was, this really didn’t come up too much. But I think early on there were some flash points as to what...should Bob give that testimony or should the President give that testimony? Fortunately, I’ve always been much more interested in how you make an organization run smoothly over time and not terribly preoccupied with having the opportunity to get in front of the camera. And the only times that I would really take a position with the Board Chair in terms of a particular presentation would be on testimony. It’s before a committee where I know people on a first name basis. It is a fairly technical set of issues and we are likely going to have to be at this over a period of time rather than a one-time, high profile presentation. And in those circumstances I would suggest to them that the Academy’s position was probably strengthened by having me be the witness rather than with the President.  \n\nAnd in my observation of you and the Board and that dynamic over that time, you were able to find that balance very, very well. And there was a minority of times where it was most important that you do that particular function – and I think they largely received that well. And besides, you’re basically an introvert and introverts are comfortable not being in the camera.\n\nThat is true. Although the political nature of the Academy is such that I know from time-to-time Board members get beat up on by members and the Congress of Delegates as to why you let the EVP have too much visibility.  \n\nThat’s true. What, of all the time you were here, do you consider to have been your biggest challenge? And I’m going to follow that with your biggest success. And then if you’ll permit me I’ll follow that with your biggest defeat, assuming there was one. There may have been no defeat.\n\nFirst of all, your biggest challenge at the AAFP? \n\nLet me identify two – one external and one internal. The external was managing the Academy’s public position in terms of the Clinton health reform. The Academy had established a year or so before Clinton came to office a relatively, I thought, enlightened position in terms of health reform,  obviously had increasing primary care in the role of family physicians at the heart of it. But unequivocally said that every American should have healthcare coverage. Everybody should be included. Now the Academy’s plan today doesn’t look like that plan then but that’s as much because of the evolution of the policy debate rather than the Academy making a fundamental change from values and opinion. That provided us with an opportunity for enhanced access to the early stages of the Clinton debate and conversation because we were perceived by the Clinton people and by the folks on the Hill who were pro-reform as good guys. We had white hats on. At that point, for a period of time so did the AMA, so did the American College of Physicians. Then the Clinton reform process itself started really going very badly and it was not being handled well by the White House. There were alternative positions being staked out on the Hill. And it started becoming acrimonious. And one-by-one some of the supporters started peeling off and becoming non-supporters or becoming agnostic. So at a point in time we were really the only major medical association that continued to say that although we didn’t agree with all of the provisions of the Clinton proposal, we thought that it was a basis from which we could start the discussion. We had a certain number of our members that were not happy about that. We had a very diverse membership politically and geographically. And this was pre-email days and there was a period of time, probably two or three months, where I would get five or ten letters a week from members who were really very angry, that we walked away from them. And I know the Board members got phone calls from their political constituency from the Congress of Delegates. And we had at least one special Board session about whether or not we should maintain our position. And we talked through the pros and the cons and what the politics were and what our core values were in what we were trying to accomplish. And by and large the Board came out of that and said we’re going to stand for what we stand for. But for the Board, and there never any finger pointing, which I thought was one of the better things out of that experience. And for at least one of those associations, the Board and the EVP got crosswise with one another and the EVP left around that set of issues. But within the Academy there was never any sense that the Board was unhappy with me or that they felt like staff had positioned them wrong. I think they were really trying to figure out how to better communicate to the members why this was the right position for family practice to take at that time. \n\nThe internal challenge that I would identify is when I came in the Academy had a staff makeup of people who were dedicated to the Academy, dedicated to the members but may not have had always the right skill set to move where we needed to go. And so part of what I felt we needed to do and we did over four or five or six years of time...I’ve been the person who believed in coming into an organization and saying I’ve got to have my people. I can’t operate this thing my way if I don’t have my people. So both at HRSA and here I never came in and fired anybody. But I did try to move us to a set of expectations about behavior, about performance. Regularize the performance evaluation system so people really were getting feedback and we could deal with issues if things weren’t going the way they were supposed to. And then as opportunities presented themselves try to put people in positions where I felt they really had the skills that we may not have had before. So we didn’t have a human resources director at the time that I came and we hired a person who was a professional HR manager and she became a tremendous asset to the Academy. We had an individual who had been with us for twenty-some years who was a comptroller. And when he retired we went to the Chief Financial Officer model. There was nothing wrong with the technical quality of what the comptroller did but his job was more to tell us where the money was and I wanted to see it flow to tell us where the money should be or where we should be going. I think I mentioned in our earlier conversation, one of the immediate challenges was I came on and the publisher of the journal [AFP] had a brain tumor. That was a very technical field and the journal was very important to the Academy not only for  but also for revenues. So for a year or so I wound up being the publisher which was a wonderful learning experience for me. But it gave us an opportunity to hire somebody who was a real professional publisher and knew the industry. And what she built over the ten or twelve years that she was here in terms of the scope of our activities in publishing the profitability for it we never had before. That was not something that was a real apparent challenge. I don’t think there was a lot of friction. I think with maybe only a couple of exceptions, the people that left the Academy did so feeling that their contributions had been valued and it was simply time. They looked forward to retirement and doing something else. And so we never had to have a purge. But if you came back and looked at the people that are around the Vice President’s table in 1995 versus 1985, there was a very different set of people with a very different set of backgrounds and expertise. And that went down to the organization because we started in the late 80s doing regular staff development. Started doing those things to train people the behaviors and the values that were necessary for an organization to function effectively at a high level of competence over a period of time. You don’t do that in just one, one-day retreat. So we did it two or three times a year and we did it over seven or eight years. And I think they’re still doing something like that now. That’s the way you create a high performance organization and you maintain it. So that was a challenge just to get done but it played out over a large number of years.\n\nAs you talk, it’s interesting for me because I feel like I’d like to say yes or I’d like to react. But that’s not appropriate to this conversation. \n\nI’m going to move you on to your biggest success. And if there are multiple successes that’s okay.\n\nI think the thing that I probably feel best about, one is very tangible and one is much more intangible. I did a lot of analysis and preparation for the Board because they would identify an issue at a meeting and they would ask me to come back with a memorandum for them at the next meeting with pros and cons and some background, and that was part of my role. It was relatively unusual that I would take a proposal to them without any background or discussion with them at all. And in 1990 I did this – I gave them a proposal about how to change the membership and leadership makeup of the Academy over a five- to seven-year period. Because I had watched other organizations go through the inevitable change of gender participation and race and ethnicity. And so many of these organizations held the reigns of control very tightly with what was the prior leadership, largely white males. And until they got to a point of friction and then it just became very divisive in the organization because you had an out group and an in group and they battled. And I think partially based upon my experience of working with Jim Price when I was here as the Assistant Division Director, where Jim had wanted to pull residents and students into Academy governing structure – he wanted them during his presidential year to have delegate positions and positions on the Board and that was one of my tasks. And I really learned a lot from that because in the 70s and 80s medical students knew that there was one medical association that was really friendly to them and that was family practice. And that helped us a lot in building a specialty and building all of our Family Medicine Interest Groups. And so I proposed to the Board that we create delegate positions for women, new physicians and minorities in the Congress of Delegates. That they be time-limited and they be reexamined after, and I forget what the original proposal was, five years or more based upon whether or not we were seeing movement of those individuals into leadership positions from the chapters. That we begin having an annual conference for leadership development for the same three groups. And that we create positions on the Board of Directors for those same three groups. Because I felt that if the Academy could be proactive in reaching out the same we had to students and residents to this demographic that was changing in our membership already. I mean we could see it in our residency programs. It didn’t have a thing to do with what Academy policy was; it had to be with what was the mix of people coming out of medical schools and going into family practice residencies. They were going to be our leadership in the next ten to fifteen years. I wanted them to feel welcomed into leadership rather than they had to battle their way in to do it. And by and large, and this took some negotiating with the Congress of Delegates, we did it. We got the delegate positions there. And by plan the women’s positions sunsetted. And I think it sunsetted after eight or nine years rather than four or five. I think the new physician and minority delegates are still in place. We got the annual meeting for special constituencies which gave the chapters incentives to identify people within their membership that otherwise wouldn’t be rising through their leadership ranks yet because they weren’t senior enough. Gave them an opportunity to come to Kansas City and get exposed to the national Academy, go back to the chapters and become active. Most of the chapters really liked that. A few of the chapters felt like we were getting into their business. We weren’t able to successfully make the argument to change the board governance structure. And it was only sometime in the early 2000s that there was finally agreement to have a new physician member on the Board. But I don’t believe that there are Board positions where minority or women on the Board. And I am very happy with the way that played out. Although the special constituency conference never got quite as large as I thought it might, the number of individuals who have come to Board leadership and presidential leadership and the number who now participate in the Congress in their chapters, as I was leaving the Academy and the last year that I was in contact with the members I was very touched with the number of individuals from those three groups who took the time to tell me that they really felt that that had made a difference to them in terms of their participation in the Academy and their ability to play a role in the Academy that they otherwise did not think would have been possible.   \n\nThat’s a good one. It endures today, Bob. \n\nNow you probably didn’t have any defeats. But if you had one that was even modest what would it be?\n\nThere was one thing I advocated for that was voted down. And I just mentioned that and that was the new physician on the Board.  \n\nBut that happened eventually.   \n\nIt happened eventually. And fortunately our current EVP, Dr. Henley, was on the Board at that time and was on my side. And so he has taken great pleasure in being able to accomplish something during his tenure that we weren’t able to get done when he was the Board...I don’t think he was Board Chair that year, but I remember he and I talking and it just wasn’t going to work out. You sometimes can see in clearest detail what didn’t work out when you get a little bit of a vantage point on it. There was something I was really involved in that I thought was a good idea at the time. And I still think it was a good idea at the time, that had an unintended consequence, and that was the movement to the relative value scale and the establishment of a sustainable growth rate. As frustrated as people are now with the sustainable growth rate, at least in the primary care community, I think many do not remember how bad things were when we were arguing for the RVS pay schedule because the pay schedule before that was usual and customary and reasonable. And when we did make the switch to RVS there was an increase in family physician and primary care fees in Medicare billings of about 15% over the first two or three years. So there was a demonstrable increase in income to family physicians as a result to that new calculation of what fees were. So in that short term we accomplished our policy objectives. What was not apparent to any of us at the time, and whether or not if we’d been smart to figure it out we could have had the leverage to change the legislation, I don’t know. I sort of doubt it because I think at that point the AMA would have peeled out. The sustainable growth rate was put in by the Congress because they were afraid as they changed this fee schedule and did better by primary care and cut back on subspecialty that the sub-specialists would start doing more things so that they could maintain their payment level, and they were right. So they put the sustainable growth rate in that basically would not allow total reimbursements to grow at more than 2% above medical inflation costs. None of us anticipated the volume by which intensity and frequency of services would go up in the subspecialty community and that is what has driven the problems with the sustainable growth rate and the necessity every year to propose that fees across-the-board will go down by 5% or 10%. If we had been able to politically accomplish a split of the  into primary care and non-primary care, the primary care  never would have triggered. So looking back on it that is a policy problem that the current set of leadership has and is directly involved in the policy which has created that problem. And if you would have asked me the day after the law passed to anticipate what the problems were I would not have anticipated how bad the  position would have been. It has also been made worse by the way the RUC, the Relative Value Update Committee which was contracted to the AMA by  because the government didn’t want to be in the process of deciding between doctors who got more money. And so they very, very intelligently gave that to the doctors. Well, the AMA being subspecialty-dominated has put together a RUC committee which consistently favors the creation of new codes or higher values for subspecialty over primary care. That wasn’t even explicit into law.  \n\nWell, what you have just described is so complex and has been vexing in so many different sort of sub-areas, like you just started to talk about the RUC, that I would not characterize that as a defeat. I would characterize that as a good policy which ran amok when others beyond our control did things which were not anticipated. So I’ll have to say no defeats, Bob. \n\nLet me just ask you a couple more questions about the specialty. Not Bob now, not the Academy, but the specialty. And it may end up being a Bob question or an Academy questions. But looking back what should the specialty have done differently – such as one that pops up from people who know history a little bit, we didn’t incorporate emergency medicine into family medicine which was an opportunity for us thirty, forty years ago and which did occur in Canada. But I don’t know if that would be the one you would pick, but what should the specialty have done differently in your mind? \n\nIf we had only listened more carefully to Gayle Stephens. That’s the beauty of Gayle’s formulation to me, to look at what we are trying to do embedded within the dominant American medical culture which is fragmented subspecialty economically driven. Family medicine is holistic, trying to pull things together, and it really has the patient as the focus. If in our movement we could have adhered more successfully to the strategic value of inclusiveness rather than control certainly there could have been some other partners there for us. Emergency medicine is one of them. And maybe that’s the only one that we could have captured in its entirety. But if you think of it, in the American medical system all of the specialists have figured out a way that they can legitimately look a patient in the eye and say I’m not responsible for what you have. See my shingle? It says my practice is limited to obstetrics and gynecology so don’t bring your broken bone to me. And within our system that’s legal. Everybody understands okay, you can do that. There’s only two specialties that a patient can present to and the doctor says what you have is my responsibility – that’s family medicine and emergency medicine. Now we practice in very different orientations. We have different scope in terms of continuity and comprehensiveness. I think EDs would look very different today if they were staffed by family physicians. You would have to move way upstream and this would be very counter-culture to the American system, but the ability in Canada for one organization to be responsible not only for member interest but certification I think is a tremendous power. Now that is consistent with the Canadian system. That is the way the other specialties do it. We would have been an outlier. I’m not even sure it would have been found to be legal or acceptable in the United States. But if somebody were to say what challenge would you give family medicine today, for the next ten years to try to accomplish to really move forward, I would say go sit down with the people in Lexington and see whether or not it’s possible within our government structure and within the structure of American medicine to take another look at whether or not the interest and the objectives in public service of the Academy as a member service and advocacy organization cannot be seen as consistent with the interest in public service of the Board in terms of certification and quality of practicing physicians. Because if you could ever put those together you would have such a much greater degree of alignment in terms of what an organization is doing for their members and for the public than they have right now.  \n\nThat could be called by some enlightenment and by others heresy. And it is indeed similar, if not almost identical, to that which we found with our colleagues in Canada.\n\nYou just sort of jumped to one of my last questions and I’m going to come back to it. But before we get to that one, what should we have done differently, and again, the specialty, and maybe Bob elements or Academy elements, what should we have done differently to better crack the academic ivory tower? \n\nHaving spent a lot of my time working the academia during my federal sector and having a very inside view of it because of Jane’s tenure at being the vice president at two institutions, I can’t put much of the blame on family medicine. Academic medicine is dominated by subspecialty interests, dominated by a culture that is research and reductionist. And it determines not only the culture but the fund flow in many instances. And so if you look at the business plans of schools of medicine or academic health centers, they are focused on maximizing revenue from patient care and services in the subspecialty high volume, high reimbursement areas and on research from the NIH. There’s nothing that family medicine brings to that table with the exception of maybe a referral stream for primary care that some of them figure out. I think that that is an area where we need to be committed to being an ongoing, uncompromising counter-culture. The health of the American public will be improved more by expanding the primary care base and making sure that people have access to the type of services that family physicians can provide than by more investment in buying medical research. If you look at the differences between where we stand today in our competitor countries in western Europe, they get just as good of technologic medicine as we do. What they get better is primary care. The med schools and academic centers, as long as they have the economic incentives that they have and the subspecialty-dominated cultures are never going to welcome us in. We are just going to have to be the counter-culture people that carve our own area out. We have been more or less successful in some areas. We at least have ninety-some departments of family medicine. But there are still sixteen or more schools where somebody can get an LCME-accredited medical education and never meet a family physician. I don’t think that should happen.  \n\nGood advice to those who will follow us into the future. What advice would you have for them in that regard, how to make a bigger impact in those academic settings? \n\nI think given the current reimbursement mechanism, it’s very difficult to do simply because they’re focused on the fund flow of subspecialty medicine in NIH. The only thing that I see changing a very large institution like that is something that happens, either an institution basis or because of the change in national policy that brings us to a point of global budgeting. So that if you ever give an academic health center a global budget to do everything that it does and take care of a defined population, they will discover family medicine tomorrow morning. Now maybe some of that can happen if we have healthcare reform that entitles everybody to health services and there’s more pressure for family medicine. That to me almost is a parallel channel rather than actually changing the culture of health sciences centers. I don’t see any way to change that culture until you change the economic incentives. And the economic incentive under global budget is 180 degrees different than it is when you’re trying to maximize your revenues from patient care and NIH research.  \n\nSo if I may just summarize what I think that meant is that we can’t win playing the game of the subspecialists in that environment because of the funding mechanisms all support that other group of people. But we must stick to our principles, our philosophies and patient-centeredness of doctors who can take care of undifferentiated diseases in people.\n\nAnd try to grow and expand that market niche. And I think that’s one of the reasons that I’m really enthusiastic about the conceptual potential of the Patient-Centered Medical Home. Yes, it would create a somewhat different fund flow for family medicine practices that might make them more competitive and more attractive. Short term that’s really good and that’s the way we’ll get some of the practices interested in doing it. But long term if you look at the processes that change and the way the teamwork changes and the way you change communication with patients over time, we’re going to start having an income on the outcomes of care, which we have not paid as much attention to. Like most American medicine, we’re very focused on processes and not as much on outcomes.\n\nWe will be more and more focused on outcomes. There’s no doubt. \n\nBob, a few minutes ago you gave some advice for those would who develop and craft our future, one piece of which was to perhaps the specialty society and the certifying board should talk again about whether their goals and processes and outcomes can be combined. A very interesting possibility to which I said there would be those who would consider it heresy and those would consider it enlightenment. What other examples might you have, or maybe just one example, of what people should do as they try to plan the next twenty or thirty years of family medicine in this country? \n\nI guess what comes to mind is internal rather than external. Having more to do with the Academy than it does with a large public policy thing. We’ll see if something else occurs to me while I’m talking. But one of the things that I reflected on as I left the Academy and had a little bit of time to kind of look back over the years is the challenge and the difficulty of maintaining a balance of interests in the organization. One of the things I’ve been working on more recently that has its roots in the Academy, my experience in the Academy, is defining and describing high performance organizations. Organizations that succeed over time. Which really is the greatest challenge an organization has. You can describe a variety of different fields – sports or business or otherwise. You know, some organization is really super for this year, a couple of years. Then you come back five or ten years and they’re just not there anymore. Somebody wins the World Series this year and then they’re not in the playoffs next year. How do you build an organization that succeeds over time? And I think it’s really critical when you look at a membership advocacy organization because so much of what we will be able to do to meet the interests of practicing family physicians and people graduating going into family practice and their patients are only going to be done if the Academy is effective as an advocate and as a member service organization. And if you have fluctuations in the Academy’s effectiveness over a period of time then those things aren’t going to get done. And because of what we were talking about just five or ten minutes ago in terms of the dominant culture of American medicine, if we’re not doing a good job looking out for family medicine and primary care in the United States nobody else is because nobody else has that as their only business plan. Other people try to dabble in it but that is what we are about. And in that context thinking about the balances and the stresses that the Academy has to manage successfully is member-staff and staff-member. I remember occasionally in Board discussions that we would get into an issue and somebody would say well, is this a member-driven organization or is this a staff-driven organization? And my response was always it better be. There’s a certain vitality and legitimacy which comes from the member side because that’s why the organization exists. These are the people out in the trenches practicing family medicine. They have the perspective. They’re volunteering their time and their leadership. And they define the priorities of the organization. The staff we hope is here over a period of time building a set of competence and connections. We would look at the Board and say if the Board doesn’t turn over every three years, we’ve got a problem. If we look at the staff and said the staff turns over every three years, we would say we’ve got a problem. So there are very different contributions that come to that. And so part of my response to the Board was okay, you’ve got a V8 engine. Which four cylinders are the most important? You’ve got to maintain the balance there. And that’s hard for organizations from time to time and it takes a tolerance from both perspectives to understand and respect the unique value and contribution that their counterpart brings. Staff should never get in a position where they think they ought to be calling the shots and setting the priorities of the organization. Because you do that, you’re going to run the organization into the ground very rapidly because staff does not understand what the practice of family medicine is like. And it does change every two or three years and that’s why you need new Board members. Board members are not in a position to understand what it takes to maintain an effective organization over time. And to some extent the nature of the political process brings folks to the Board in their active phase of Board representation with a degree of impatience which may be dangerous to the organization. That somebody says I’ve only got three years on the Board or I’ve only got three years as President and we better get it done now. Where sometimes that leadership is absolutely critical and that’s what moves you forward. And if you didn’t have that advocacy you wouldn’t be an organization who is at the cutting edge. And sometimes it is really dangerous. And that’s where you’ve got to have the respectful interplay of your Board leadership and your senior staff leadership about when is it time to go fast, when is it time to look carefully and look critically and make sure that we’ve got a strong organization five and ten years from now. I’ve never encountered a Board member who would take the position let’s spend all the reserves this year on my priority because everybody understands that’s absolutely absurd. You need to have something in the bank. You don’t just throw it all away in one year. But you sometimes get into positions and advocacy for doing things that starts getting pretty close to that and spending a lot of your resources, either your financial resources or your human resources on something which is short term, not long term. So No. 1 advice is you’ve got to find a balance of member-staff to maintain an organization that can be successful and vital over time with stability and innovation.  \n\nThe second one is staff-member. During the time that I was here I felt very fortunate that we had excellent staff leadership and the relationship between the Board and the staff was very positive. I really felt like the Board respected the staff. One of the things that I always enjoyed was Board meetings because we sat around the Board table and there were seventeen votes and there were twenty-five people. And almost without exception the Board Chair would call on the hands and the hands went up. It wasn’t Board member, Board member, Board member then staff. If you wanted to speak...if Mike Miller ever raised his hand he got called on out of order because Mike almost never said anything. And when you’re a member service organization in any sort of field, any business where you interface with customers and you provide service, if your staff and your customer service people are not happy, if they do not feel respected, if they do not feel that their job is rewarding to them, not just financially but intellectually and personally, they’re not going to give good customer service. And so another balance that’s really important is looking at how you maintain the culture and the environment within the staff side of the organization so that they don’t just say member service is No. 1. I’m told to serve the member but I’m not going to respect the member unless I feel like I’m respected. And so finding a way that you can maintain a culture where people come into the organization and say I love this place. And I do because I like the people I work with, because I feel respected and it’s comfortable and it’s challenging and I really look forward to interacting with the members, I really look forward to that phone call. Versus how many organizations do we run into where the person that answers the phone, you’re interrupting me. You walk into a store and there’s three clerks there and they haven’t got time to talk to you because they’re too busy doing something else. But to be a successful organization over time in the business that the Academy is in...the members don’t have a lot of contact with the organization. A lot of them pay their membership dues once a year and the contact is through the mail and increasingly it’s electronic. But when they have a real-time contact with the organization and they finish the email or they hang up the phone, what do they think? And if they say those are really nice people, that’s a member who’s going to sign their check again next year. That’s a member that’s going to feel much more positive when the state Academy calls and says would you be willing to serve on our Commission on Hospitals? They will be much more willing to get involved. For some of the reasons that we’ve talked about before I think the next five or six or ten years are going to be a continuing period of a lot of cultural conflict between the interest of primary care where there may be lots of people outside of medicine now trying to kind of lean our direction and say that we are underweighted in that sector. We need more what you folks are doing. We want to reward you a little bit better. We want to support you better. That’s going to get pushbacks from the rest of the medical care sector particularly if it looks like that’s going to come about in a zero-sum game. We’re in the down part of an economic cycle right now and maybe people are going to want to do a bunch of good things for primary care but at the expense of the procedural subspecialists. That’s going to take an organization that is really strong, has got its priorities organized in a way that the member interest and the policy interest are well-integrated and that the members continue to feel that this is their organization. The only way you get there is by the staff feeling this is their organization.\n\nWell, that’s our goal. Hopefully we can make that work. \n\nLast question. You’ve had many lives, many professional careers. But the one at the Academy, the one we’re talking about here, in your Academy time for what would you like to be most remembered? \n\nI think I made a fairly clear statement when I left here that the individual does not define their legacy. I can tell you what has made me feel best about my time here and that is when I come back into the building. Although there is an increasing number of faces I don’t recognize, the faces that I do recognize come up and say it’s nice to see you again, it’s nice that you’re back here. And I think when you serve fifteen years with an organization you do so many things and you touch people in so many different ways. You’re never going to have done things that everybody agrees with all the time. We didn’t pick the right side of the building or we made the wrong decision on travel policy or what-have-you. And once you’re gone you don’t control what people think of you. You know, they think of you what they think of you. And what’s even perhaps more touching is people that didn’t work here when you were here. I think the best legacy that somebody can hope for is probably not they did this thing or that thing but that you come back after a period of time and you give somebody an open-ended test and they say well, Bob was really a nice person. He seemed like an effective CEO and I really enjoyed working here while he was here. That would be a legacy that I aspire to.  \n\nI think that legacy is very, very secure. And I say that from both the perspectives that you just mentioned, from the people whom you do know, the faces you do recognize here from when you were here who do give you that reaction, and also from those folks who have heard about this person, this legend, this Bob Graham and say oh, that’s Bob Graham. And then after a little chat say you know, he is a pretty nice guy. I bet he did do good things as I’ve been told he did. So I do think if that is the way in which you wish to be most remembered I see absolutely only a positive reaction to you and your epitaph at some point. \n\nAnd with that I would like to thank you for now making two or three treks here to Kansas City to see us and to be interviewed and to put a little bit about your time with us and your time in the specialty in a context of the tape. You know, we’re still young, Bob, and it may be that we want to add another chapter to this at some time in the not-too-distant future. \n\nAnd I don’t know whether interviewees get the opportunity of the last word. But it is wonderful to be interviewed by someone that you’ve known so long. And I can’t remember how much we got into this at the beginning of the tape, but I would make it clear for the listeners who may not know this relationship that my wife Jane and I have known Dan and his wife Ruth forever. And that indeed Dan and Ruth knew Jane before I did because they are four years younger than I and Dan and Jane were activists in SAMA, now AMSA, at the same time and actually were at meetings and made their acquaintance before Jane and I did and started dating. So having that wonderful relationship, the friendship as a couple over the years, sometimes working together, sometimes not working together, watching your kids grow up and keeping track on what they’re doing, who could better be an interviewer? Now some people may say why didn’t you get somebody who was a little bit more critical but we can do that interview on another tape.\n\nYou did get the last word Bob. 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