{"@context":"http://iiif.io/api/presentation/3/context.json","id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/iiif/zw18k7711m/manifest","type":"Manifest","label":{"en":["Dr. G. Gayle Stephens (1979)"]},"logo":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","metadata":[{"label":{"en":["Rights Statement"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine.  Disclaimer:  The views presented in this broadcast are the speaker’s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice. \u003c/p\u003e"]}},{"label":{"en":["Date"]},"value":{"en":["1979-12 (created)"]}},{"label":{"en":["Agent"]},"value":{"en":["Dr. Lucy Candib (Interviewer)"]}},{"label":{"en":["Format"]},"value":{"en":["video"]}},{"label":{"en":["Keyword"]},"value":{"en":["family physician","Society of Teachers of Family Medicine","family medicine"]}},{"label":{"en":["Language"]},"value":{"en":["English (primary)"]}}],"requiredStatement":{"label":{"en":["Attribution"]},"value":{"en":["\u003cp\u003eThis item is protected by U.S. copyright and related rights. It is being made available by the Center for the History of Family Medicine as its rights-holder for noncommercial use, including sharing and adapting the work. No permission is required for noncommercial use so long as attribution is provided. All other uses require permission from the Center for the History of Family Medicine. \u0026nbsp;Disclaimer: \u0026nbsp;The views presented in this broadcast are the speaker\u0026rsquo;s own and do not represent those of CHFM or the AAFP Foundation. The information presented is for general, educational, or entertainment purposes and should not be considered legal, health, financial, or other advice.\u0026nbsp;\u003c/p\u003e"]}},"provider":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/aboutus","type":"Agent","label":{"en":["Center for the History of Family Medicine"]},"homepage":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/","type":"Text","label":{"en":["Center for the History of Family Medicine"]},"format":"text/html"}],"logo":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/organizations/logo_images/000/000/246/original/CenterForHistoryFamilyMedicine_2c_RGB.png?1773344256","type":"Image"}]}],"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/collection_resource_files/thumbnails/000/277/380/small/GGayleStephensInterview.mp4_1750101183.jpg?1750101184","type":"Image","format":"image/jpeg"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380","type":"Canvas","label":{"en":["Media File 1 of 1 - G_Gayle_Stephens_Interview.mp4"]},"duration":3674.8712,"width":640,"height":360,"thumbnail":[{"id":"https://d9jk7wjtjpu5g.cloudfront.net/collection_resource_files/thumbnails/000/277/380/small/GGayleStephensInterview.mp4_1750101183.jpg?1750101184","type":"Image","format":"image/jpeg"}],"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/content/1","type":"AnnotationPage","items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/content/1/annotation/1","type":"Annotation","motivation":"painting","body":{"id":"https://aviary-p-centerforthehistoryoffamilymedicine.s3.wasabisys.com/collection_resource_files/resource_files/000/277/380/original/G_Gayle_Stephens_Interview.mp4?1750101153","type":"Video","format":"video/mp4","duration":3674.8712,"width":640,"height":360},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380","metadata":[]}]}],"annotations":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/transcript/81091","type":"AnnotationPage","label":{"en":["An Interview with Gayle Stephens, MD [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/transcript/81091/annotation/1","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Family MedicineVol. )(][l, No. 63\n\n\nSpecial Article\n\n\n\nAn Interview With G. Gayle Stephens, M.D.\n\nLucy Candib, M.D.\n\n\n\n\n\n\n\nIn 1979, I was invited to participate in the Dialog Project, an interdisciplinary effort of social scien­ tists, geographers, educators and planners, to re­ cord on videotape interviews with leaders in vari­ ous fields. The goal of the international project was to use the taped interviews in teaching. The project developers made several assumptions: That people become generalists out of a recog­ nition of the failure of a categorical approach to solving problems in their fields (e.g., health care, urban planning, agricultural develop­ ment).\n\nThat students have usually not been exposed lo this process of becoming a generalist.\n\nThat listening to and watching someone who has gone through the process discuss becom­ ing a generalist would be of interest to students and might provoke discussion about personal direction in relation lo developments in their fields.\n\nThat the perspective and contributions of an individual leader may go relatively unrecog­ nized, yet may be useful to students.\n\nThatvideotape would provide a more intimate format than the written word for introducing students to important thinkers in their fields. For my own part, I hoped to merge a long-term interest in personal life histories with an effort to introduce residents to some of the leaders in fam­ ily medicine. In particular, I had participated in several long discussions with Gayle Stephens dur­ ing my residency, and appreciated his thoughtful\n\ncommentary.\n\nIn December 1979, l made a videotape ofan in­ terview with Gayle Stephens for use in work with residents and faculty members. The transcript\n\n\nDr. Candib is medical director of the Family Health and Social Service Center, Worcester, Massachusetts.\n\nwhich follows is an edited and abridged form of that interview.\n\nG. Gayle Stephens, M.D., is professor and chair­ man of the Department of Family Practice at the University of Alabama at Birmingham. A past pres­ ident of the Society of Teachers of Family Medi­ cine, he received the STFM Certificate of Excel­ lence in 1979. He is widely recognized as one of the creative writers and thinkers in family medi­ cine.\n\nDR. CANDIB: Will you start by talking about how you became a family doctor?\n\nDR. STEPHENS: Paradoxically enough, I wanted to be an internist. I think what I admired most about inter­ nal medicine was the pslerian model. I had known a couple of people like that -  one in medical school and one during my internship - internists whom I admired a great deal because of their skill at diagnostic medicine. I saw that as the most intellectual of the medical disciplines, so I was attracted to it. But it be­ came clear that I was going to have to go to work and earn a living after I was discharged from the Army in 1955.\n\nDuring my first two years in practice, I probably did more hospital work than ever after. I felt the need to do that; I was eager, ambitious, took calls for everybody who was out of town, made lots ofhousecalls, and took call at the emergency room. I really felt I had to dem­ onstrate my competence in organic medicine at the hospital level. I was very interested in surgery and de­ veloped some very nice relationships with three or four surgeons. My surgical training was learned on the\n\njob, arising primarily out of my own practice. But there is a process, r think, by which one becomes transformed from simp'.v doing procedural and epi­ sodic medicine -  as gratifying as that is -  to some\n\nof the harder tasks of taking care ofpatientswho don't need procedures and who don't get well simply by a physician's recognizing their diseases.\n\n4November/December 1981Family Medicine\n\n\n\nDR. CANDIB: Or who don't represent a diagnostic puz­ zle ...\n\nDR. STEPHENS: Yes, and who seem to continue to complain and come back and be uncomfortable in spite of everything. And it's around those issues that I began to think about what else might be done.\n\nQuite frankly, my first approach to many of these problems was a peculiar mix of religion and psycho­ analysis. Analytic theory, as small an amount as it was, was all that I was taught in medical school about psy­ chiatry. So fundamentally I had an analytic model of behavior without very much understanding of any­ thing else about it; but I did have some concept of de­ velopmental stages, and some concept of the impor­ tance of the past, and some concept of the importance of family relationships - quite a bit to get out of psy­ choanalysis. I mixed that all together with religious fundamentalism and large doses of authoritarian ethics, exhortation, and persuasion.And I guess it was out of the failure of that mix ...\n\nDR. CANDIB: Over what period of time did you realize that the mix was not working?\n\nDR. STEPHENS: Over about the first ten years. The other thing that made this of some special significance to me was that I saw a large proportion of religious people as patients. At one time I counted 26 preach­ ers' families in my practice. I had a reputation as a \"Christian doctor,\" whatever that meant. I never did like that very much; I never did like people referring to me on those grounds, as though that modified other things: surgery, penicillin, whatever else I did. Never­ theless, that understanding by my patients character­ ized a lot of my practice. I became disappointed and to some extent cynical about the ways that religious people responded or failed to respond to illness, to life's problems, to stresses; that in spite of the sup­ posed availability of religious resources, they really didn't seem to do any better, or maybe not even do as well, when the chips were down.And so I became a bit cynical about hypocrisy and false claims.\n\nAbout that time I became more aware of philosophy as a discipline. I should say that one of the things I miss the most about private practice is that all during my practice life I had one day off per week, in the mid­ dle of the week- and it was areal dayoff. It was either Wednesday or Thursday and I was free to do whatever I wished, even to go out of town. Often, ifI happened to have an obstetrical patient in labor, I would go ahead and do the delivery, but my partner would have done it if I had been away. That day off really became my study day. I was preoccupied with reading about religion and philosophy - philosophy on a primitive level. Usually the step was from religion to theology to philosophy. Then I began to hear about behavioral sci­ ences as a kind of alternative to this religious-phil­ osophical orientation..So I think over the ten years I made a gradual intellectual evolution from religion to an amalgamation of ideas derived from other sources.\n\nDR. CANDIE: Was this reflected in some kind of aware­ ness of yourself in your practice?\n\nDR. STEPHENS: Yes, I think it was. It was reflected mainly in what I was trying to accomplish with people in counseling. In the early days, I had been trying to deal with issues of guilt and meaninglessness. I tended to see those as religious and ethical issues. \"The reason you have these headaches is because you feel guilty about this or that in your life, and what you really need is some kind of absolution, even the capacity to forgive yourself\"\n\nI would say that I still haven't abandoned all those ideas. There are some religious concepts that are not found, at least in clarity and purity, in behavioral sci­ ences and psychology. One of those is simply the no­ tion of grace, which is a very powerful human exper­ ience. The idea of unmerited favor is a powerful force towards reconciliation; clearly so in families in con­ flict, couples in conflict, and people in conflict with themselves. One of the needs is for reconciliation. How does that come about? Through insight, through understanding, through substitutionary experiences (there are some religious overtones to that), but it can also come about through grace. I don't necessarily mean that in a supernatural category. There is grace of people to each other, you know. If a woman who has an alcoholic husband is going to be reconciled with that husband, even quite apart from the thought that she might, in some way, be a participant in his al­ coholism, there is still pain and suffering on her part that must be borne, must be somehow wiped out, or eliminated as a continuing factor in their relationship. It means that there is no equality in the bearing of pain and suffering; there is no way you can ever equalize it. Whether one is talking about parent-child disappoint­ ments in each other, or spouse disappointments in each other, somebody somewhere along the line has to find a way to deal with an inequitable amount of pain and suffering. Grace is one of the ways to do that; at least for people who can understand that concept, that is one of the ways to deal with it. To me it goes far beyond acceptance as a psychological construct. I can agree to \"accept\" you with all your faults, but there's a little more reservation about that: \"I can accept you but ... \" Grace in its ultimate form says that there is nothing you can do to keep me from feeling a certain way about you.\n\nDR. CANDIB: Grace is also a part of your concept of what a family doctor offers to a patient?\n\nDR. STEPHENS: Yes. Unconditional positive regard. Anything goes. The patient can bring anything to the doctor; nothing's too terrible, nothing's too shameful. It's all OK. That's a very important foundation of what I think family doctoring is all about.\n\nDR. CANDIB: That was clear to you at a point about ten years into practice?\n\nDR. STEPHENS: I would say that was an emerging re-\n\nStephens InterviewNovember/December 19815\n\n\nalization about ten years into the practice. It came about through a number of broken relationships with patients, some of which had gone on for as much as five years. I can remember two or three patients of a certain psychological type with whom I had gotten into a relationship that I now look back on as neurotic\n\nas much on my part as theirs - inwhich I was play­ ing some kind ofan authoritarian, demanding, father­ figure role. Finally, the relationship would reach a stage, usually over some trivial disagreement, when the thing would blow up and I would not understand why. It is those failures with certain kinds of patients in whom you have invested a great deal, with whom you have done your best, where the learning takes place. This says something about training and educa­ tion for family practice. I don't think you can learn to do it until you are engaged with patients at the very extreme of your capacity, and maybe beyond your capacity.\n\nDR. CANDIB: So, the place where your awareness of your own part of the doctor-patient relationship be­ came the most acute was where it wasn't working for you? (DR. STEPHENS: Right.) And initially that was an after-the-fact awareness. Was it then followed by an awareness of yourself, in the process of its not work­ ing?\n\nDR. STEPHENS: I would say that took longer to develop\n\nthe awareness ofmyselfand thewayitwasn'twork­ ing. I had nursed for a long time the feeling that there were some secrets in psychiatry that if I just knew I would be able to do better.\n\nDR. CANDIB: It strikes me that the secrets were not in psychiatry but inside of the place you hadn't yet looked - in yourself.\n\nDR. STEPHENS: Yes. It was shortly after this time that I had what I regard as the great privilege ofmy life, ofbe­ ing in a seminar with Michael Balint in Cincinnati in 1969. I went to that seminar as much of a blank slate about Balint as there could possibly be. I was attracted entirely by the title, The Doctor, His Patient and the Ill­ ness. But I knew nothing about Balint, I knew nothing about his work, I had never read his book�I was simply looking for a continuing education course and that title took my fancy. It turned out to be a truly trans­ forming experience for me because it brought some sense out of the frustrations and failures in my prac­ tice and set me on a new track; it laid open for me the possibility of analyzing the relationships between me and my patients which wasn't possible before except in the crudest way. It also gave me some tools with which to do that analysis; it gave me a new sense ofle­ gitimacy as a family physician, as a general practi­ tioner, being concerned about these psychological­ psychosocial issues in practice.One of the fears is that these issues are too mysterious and too complex - that family physicians shouldn't get mixed up in them. That's for the psychiatrists to do. Balint restored my feeling of confidence and legitimacy that it was good for me to work on this; that I wasn't going to be hurting\n\npeople or damaging people by inquiring into their lives. Also I didn't have to go outside my role as a fam­ ily physician and try to be something else in order to do that.\n\nDR. CANDIB: How did he do that?\n\nDR. STEPHENS: He kept insisting that family physi­ cians have unique opportunities, because of the lon­ gevity of their relationships with patients, to do impor­ tant therapeutic work; and in some ways have more consent to do that without the stigma, from the pa­ tient's perspective, of being labeled psychiatric - and that it was right and proper that we should do it. He gave examples of family physicians he had been work­ ing with in Britain for 15 to 20 years at that time.There was a fantasy in me, as well as in many of my col­ leagues, that people with psychological problems are fragile, and that you shouldn't probe around or you'll break them. That fantasy has some interesting psycho­ logical implications for the doctor - power and killing people, hurting people and all that. But Balint forth­ rightly dispelled that myth; he wouldn't even listen to it, and said in essence: \"You know, you don't lack the time, you don't lack the skills -what you really lack is the nerve, the heart, to want to have this kind of inti­ macy with your patients.\" And he convinced me that that was so. At least that is the way I remember it.\n\nDR. CANDIB: It was more the process of that interaction with him than the group process?\n\nDR. STEPHENS: I think it probably was. I have won­ dered since what the group evaluation of me in that seminar might have looked like had it been done at the close of the seminar. Whether anyone else would have thought that something had happened to me in the course of it. I can imagine that several of the group might have not seen anything significant going on with me. But it really was -  it changed my behavior, forever\n\ndifferent from what it used to be. That was a mile­ stone for me in personal development, though it was still mostly around the individual patient, the adult patient.\n\nDR. CANDIB: You are someone who is doing a fair amount of writing and thinking in family practice. I wondered if you could talk some about what it is to be creative in what you do.\n\nDR. STEPHENS: I don't think I am a truly creative per­ son. I think I'm a risk-taker; I think I'm a synthesizer; I'm a great borrower. But I don't believe I can tell you anything that is a unique personal contribution toed­ ucation. I think I may be a popularizer. That's what I would consider to be a secondary creative level, rather than primary. I'm an implementer, a starter-upper of things.\n\nWhat seems to work for me and what I would rec­ ommend to anyone else is to commit yourself to the discipline of writing down what you think. You don't really know what you think until you can see it. I some-\n\n6November/December 1981Family Medicine\n\n\n\nhow started doing that early. Maybe that came out of my public speaking interests, the need to see what parts ofmy thoughts were really formula table in words and what parts were so vague that I couldn't say them. I've come to believe that the things that cannot be said probably don't have much reality to them, at least for me. It is also very important that you keep reading.\n\nSomehow one also has to have ongoing experiences; you have to be engaged in the work which you are do­ ing, actively engaged. You have to be thinking about it, and you have to be reading something that is at some distance away from it, but not entirely unrelated. If I have been able to bring off any kinds of syntheses that have been helpful, it's probably because of that.\n\nDR. CANDIE: When you say \"engaged\" in the work, I take it you mean seeing patients.\n\nDR. STEPHENS: Seeing patients and teaching - that's the work. Everything else is tangential to that. I have never been bored by, or disliked, or dreaded seeing patients. Seeing patients is always a new excitement to me, every day. I think about it every morning when I get up. I never put my hand on the door of the examin­ ing room that I don't feel some kind of a new surge of wonder, perhaps even reverence. There is a sense in which you need to clear your head and purify your thoughts before you go in to see a new patient. That whole experience is multipotentiality. As soon as you open your mouth you limit it in some way; something less is possible as soon as you say \"hello.\" That's why it's reverent. You would like to go in there and not limit the possibility of what could happen. Now it may turn out to be purely routine and mundane, at least the occasion for the visit. But the patient is never routine and mundane. I find it the most exciting human activ­ ity there could possibly be. I would pay to do it.\n\nDR. CANDIB: Many people don't understand the place in me that feels that I have the privilege of working, of seeing patients.\n\nDR. STEPHENS: If we get jaded along that line, it is a small step to contempt, and certainly a very small step from contempt to manipulation and exploitation of a patient. That is one of the things that worries me a good deal about physicians' becoming experts in pro­ cedures and technology. It becomes possible to en­ counter the patient without encountering the won­ der. It is possible to do things to patients without knowing anything about them. You can provide ser­ vices, you can take pictures, inject dyes. But it is also necessary to know the patient in order to help; that is where the wonder comes. The experts run a terrible risk of losing the wonder after a while. After five cardiac catheterizations in a day, it's hard to wonder as much on the fifth one as you do on the first one since there is a competition for time.\n\nDR. CANDIB: When you talk about \"experts\" you're speaking from a shared world view. Would you elab­ orate on it?\n\nDR. STEPHENS: The role of a doctor has undergone a lot of changes in the course of history. Perhaps one of the earliest roles was the role of the medicine man and perhaps the priest, and later on the role of healer and teacher. Only in modern times has the physician become an expert in knowing about protoplasm - how to manipulate protoplasm in the laboratory. The concept of expert comes from the fields of science and technology. An expert is a person who can do a cer­ tain complex task predictably well and repeat it over and over again with minimal risk and maximum re­ producibility. That role has come into medicine in the last 100 years particularly. All physicians have had to take it on to some extent. What Iworry about iswhether that role subsumes all other roles. Physicians begin to think of themselves only as experts who have a prod­ uct to sell or a technique to perform. In so doing, they can actually evade the human dimensions, the agony of suffering. Experts come in and do their thing and leave. That is not what doctors have historically done; in the past, doctors came and stayed.That is a different role from that of an expert. It does come out of a differ­ ent world view about what health is, what sickness is, and what doctors are supposed to do. All I am saying here now is that I don't think being an expert should be 99%of what a doctor does.\n\nDR. CANDIB: It seems to me that the concept of expert is linked to the more reductionist aspect of our work, the part that we as family physicians tend to be further from.\n\nDR. STEPHENS: The more purely analytic parts, yes; and the hard thing is trying to get a perspective on the science without appearing to be against it, without appearing to be anti-expert or anti-technology, when that's not what is wanted at all. It is really a different perspective - making the technology serve the larger human purposes, rather than making the people fit the needs, the schedules and the requirements of technology.\n\nDR. CANDIB: Given the time it takes for each of us to understand that perspective in our own exposure and interaction with science and with technology, what do you see as an effective way to teach that to people?\n\nDR. STEPHENS: The only people I see who learn it are those who are willing to do what we talked about be­ fore: those who become engaged in knowing their pa­ tients; engaged in trying to understand their patients; and in coming to see and feel their own limitations. I don't think you'll ever abandon ... anyone will ever abandon ... theexpert role as long as it seems to solve all problems. Physicians are susceptible to being de­ luded about that.\n\nREFERENCES\n\n1. Balint M. The doctor, his patient and the illness. New York, International Universities Press, 1957.","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380#t=0.0,3674.8712"}]},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/transcript/82535","type":"AnnotationPage","label":{"en":["Dr. Stephens interview transcript [Transcript]"]},"items":[{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/transcript/82535/annotation/2","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"Lucy Candib, MD: As we talked about before, I thought I'd ask you some questions about how you came about becoming a family doctor.\n\nG. Gayle Stephens, MD: Well, paradoxically enough, I wanted to be an internist. And I had too many kids when I got out of medical school. And I was drafted after my internship. So I went into the army. And I think the military experience certainly constituted the time in my life when I might have been taking a residency. And I was able to manipulate my military experience enough to do some things that turned out to be more important for family practice later on than I realized at the time.\n\nI'm not trying to say that two years in the army is a family practice residency. But for instance, the army sent me to a preventive medicine course of six weeks duration in Fort Sam, Houston, Texas. During my first year, I had a preventive medicine military occupational specialty number. I didn't function in that capacity cause the chief medical officer on my post didn't want a functional preventative medicine officer. But I had the six weeks of training, and I must say that I thought it was good and I was stimulated to study hard and work at it. It was a good six weeks. San Antonio in the spring. It's good.\n\nThe army also sent me to LA for a whole week on venereal disease with some very imminent teachers. And that was more instruction in VD than I've had in my entire life concentrated in the one week. I volunteered to deliver babies in the army. I didn't have to take night call obstetrics, but I did.\n\nLucy Candib, MD: Why?\n\nG. Gayle Stephens, MD: Because I wanted to learn how to do saddle blocks. And I took night call every third night for a year and delivered 105 babies. Did a saddle blocks on each one of them. Well actually, saddle blocks and caudal blocks. And it was a nice experience from the perspective that it was not a busy service and you were usually alone. I was the only physician. The physician, the patient, and one nurse for the labor and the delivery. And I really liked that. And I didn't resent having to get up at night to go do that because I thought, by that time that, I was preparing myself for practice. Now, I had had a rather large delivery experience as an intern. \n\nLucy Candib, MD: So in the course this time, you were really saying to yourself, \"What skills do I need and how can I set about getting them?\"\n\nG. Gayle Stephens, MD: Right. Because I'd already decided that I was not going to be able to do [inaudible","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380#t=0.0,226.0"},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/transcript/82535/annotation/3","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"] and signature medicine. I think what I admired about internal medicine was the Oslerian model. And I had known a couple of people like that, one in medical school and one during my internship, internists whom I admired a great deal cause of their skill in diagnostic medicine. And I saw that as the most intellectual of the medical disciplines. And so I was attracted to that.\n\nBut it became clear that, for personal reasons, I was going to have to go to work and earn a living. Interesting thing in preparing for practice, which turned out to be in Wichita, Kansas, there's a two person partnership. And this was not the custom at the time. This was not the style at the time. I'm speaking of 1955. We put on our letterheads and on our nameplate out in the front, \"Family physicians and surgeons.\" And I think now that was preaching. And I don't know why we did it, but we did. And went into a neighborhood, suburban neighborhood in Wichita where I practiced and reared my family for actually some 18 years altogether.\n\nNow, I guess that doesn't tell you about the internal parts of becoming a family physician or becoming transformed from a general practitioner to a family physician cause I think that is the process that happens. My first two years in practice, I probably did more hospital work than ever after.\n\nFirst of all, I felt the need to do that and I was eager and ambitious. I took call for everybody who was out of town. We made lots of house calls. We took calls at the emergency room. And I really felt the need to demonstrate my competence in organic medicine at the hospital level. I was very interested in surgery. I wanted to do tonsillectomies and appendectomies and herniorrhaphies and hemorrhoidectomies and all of that. And I scrubbed on all my referred patients that needed a surgeon and developed some very nice relationships with three or four surgeons, which, I guess I'd have to say that my surgical training was learned on the job primarily arising out of my own practice. But there is a process, I think, by which one becomes transformed from simply doing procedural episodic medicine, as gratifying as that is, there is some gratification that.\n\nLucy Candib, MD: Oh, yes.\n\nG. Gayle Stephens, MD: To some of the hard places in taking care of patients who don't need procedures and who don't get well with the recognition of their disease.\n\nLucy Candib, MD: And who don't represent a diagnostic puzzle.\n\nG. Gayle Stephens, MD: Yes. Yes. And who seemed to continue to complain and come back and be uncomfortable in spite of everything. And it's around those issues that I think I began to think about what else might be done. Quite frankly, my first approach to many of these problems was a kind of peculiar mix of religion and psychoanalysis. Analytic theory in as small an amount as it, was is all I was taught in medical school in psychiatry.\n\nSo fundamentally, I had an analytic model of behavior without very much understanding of anything else about it. But I did have some concept of developmental stages, had some concept of the importance of the past, and I think some concept of the importance of family relationships, which is quite a bit to get out of psychoanalysis. And I sort of mixed that all together with religious fundamentalism and rather big doses of authoritarian ethics and exhortation, persuasion. And I guess it was out of the failure of that mix, although I never had a Sallman's Head of Christ in my waiting room.\n\nLucy Candib, MD: A what?\n\nG. Gayle Stephens, MD: A Sallman's Head of Christ in my waiting room. It's a picture, the photograph of the blue-eyed, white Jesus with wavy hair. I never went that far. Okay?\n\nLucy Candib, MD: Over what period of the time did you realize that that wasn't working?\n\nG. Gayle Stephens, MD: Well, I think over about the first 10 years. And the other thing that made this of some special significance to me was the fact that I saw a rather large proportion of religious people as patients. At one time in my practice, I counted 26 preacher's families in my practice because I had a reputation as a quote Christian doctor, whatever that meant. Never did like that very much. I never did like people referring to me on that ground as though that modified other things, surgery, penicillin, whatever else I did. But nevertheless, that characterized a lot of my practice.\n\nAnd I became disappointed and, to some extent, cynical about the way that religious people responded or failed to respond to illness, to life problems, to stresses that, in spite of the supposed availability of religious resources, they didn't really seem to do any better or maybe even do as well when the chips were down. And so I became a bit cynical about hypocrisy and false claims, that that sort of thing wasn't working.\n\nAbout that time, I became more aware of philosophy as a discipline. I should say that one of the things I miss the most about practice is that, all during my practice life, I had one day off per week in the middle of the week. And it was a real day off. It was either Wednesday or Thursday, and I was free to do whatever I wished. To go out of town. Often I would, if I happened to have an obstetrical patient in labor, I would go ahead and do the delivery, but my partner would've done it if I hadn't done it.\n\nWell, that day a week really became my study day. And I was preoccupied with reading about religion and philosophy, philosophy on a very preliminary level. Usually, the step was from religion to theology to philosophy. And then I began to hear about behavioral sciences as a kind of alternative to this religious philosophical orientation. So I think that over the 10 years, I made some gradual intellectual evolution from religion to some amalgamation.\n\nLucy Candib, MD: Was this reflected in some kind of awareness of yourself in your practice?\n\nG. Gayle Stephens, MD: Yes. I think it was. And reflected itself mainly in what I was trying to accomplish with people in counseling primarily. Because I think in the early days, I was trying to deal with issues of guilt, meaninglessness, and I tended to see those as religious and ethical issues. The reason you have these headaches is because you feel guilty about this or that in your life and what you need this with some kinds of absolution, even the capacity to forgive yourself.\n\nAnd I guess I would say that I still haven't abandoned all those ideas. The Russian religious concepts that are not found, at least in their clarity and purity, in behavioral sciences and psychology. One of those is simply the notion of grace, which is a very powerful human experience. The idea of unmerited favor is a pretty powerful force towards reconciliation. And clearly, in families in conflict and couples in conflict and people in conflict with themselves, one of the needs is for reconciliation. And how does that come about? Well, through insight, through understanding, through substitution experiences, and there's some religious overtones to that. But it can also come about through grace. And I don't necessarily mean that in a supernatural category, but grace of people to each other. If a woman who has an alcoholic husband is going to be reconciled with that husband, even quite apart from the thought that she might some way be a participant in his alcoholism, there is still pain and suffering on her part that must be born, must be somehow wiped out or eliminated as a continuing factor in the relationship if they're going to be reconciled.\n\nSo it means that there is no equality in the bearing of pain and suffer. There's no way you can ever equalize it. Whether one's talking about parent-child disappointments in each other or spouse disappointments in each other, somebody somewhere along the line has to find a way to deal with an inequitable amount of pain and suffering. And grace is one of the ways you do that, at least for people who can understand that concept. That's one of the ways you can deal with it. Goes far beyond acceptance as a psychological thought to me. I can agree to accept you with all your faults, but there's a little more democratic reservation about that that, I can accept you but. And grace, in it's ultimate form, probably say, \"There's nothing you can do to keep me from feeling a certain way about you.\"\n\nLucy Candib, MD: Grace was also that part of your concept of what a family doctor-\n\nG. Gayle Stephens, MD: Yes.\n\nLucy Candib, MD: Offered to a patient.\n\nG. Gayle Stephens, MD: Yes, yes. Unconditioned positive regard.\n\nLucy Candib, MD: Unconditional.\n\nG. Gayle Stephens, MD: Unconditional. And well, yes. Unconditional positive regard that anything goes. The patient can bring anything to the doctor. Nothing is too terrible. Nothing is too shameful. And it's all okay. So I think that's a very important foundation of one of the things that I think family doctoring is all about.\n\nLucy Candib, MD: That was clear to you at that point. We're talking about 10 years into-\n\nG. Gayle Stephens, MD: I would say that's an emerging realization about 10 years into the practice. And this came about through a number of broken relationships with patients, some of which had gone on for as much as five years. I can remember two or three patients of certain psychological type that I had gotten into a relationship that I would now look back on as neurotic, as much on my part as their part, in which I was playing some kind of an authoritarian, demanding father figure role until this would reach a stage, usually over some trivial disagreement, and the thing would blow up. And I would not understand why. So I think it's those failures with certain kind of patients in whom you have invested a great deal, in whom you have done your best. And I think this has something to say about training and education for family practice. I don't think you can learn to do it until you are engaged with patients at the very extreme of your capacity and maybe beyond your capacity.\n\nLucy Candib, MD: So the place where you became aware, where the awareness of yourself was the most acute, was the place where it wasn't working for you?\n\nG. Gayle Stephens, MD: That's right.\n\nLucy Candib, MD: And that was, at least initially, an after the fact awareness. I assume that was then followed by an awareness of it was of yourself in the process of it not working?\n\nG. Gayle Stephens, MD: Yeah, I would say that took longer to develop the awareness of myself and why it wasn't working. Now, I had nursed for a long time the feeling that there were some secrets in psychiatry that if I just knew-\n\nLucy Candib, MD: Yeah.\n\nG. Gayle Stephens, MD: I would be able to do better. And long about the 10th year out, I began to think of going and taking a psychiatry residency. And a matter of fact, I applied for a one-year fellowship in quote psychosomatic medicine, unquote to Menninger School of Psychiatry in Topeka, Kansas. Went up and was interviewed and did all the processing and then the funding didn't come through for that. So I didn't go, but I was recognizing, or at least I was feeling that there were secrets in psychiatry that I didn't know about. And if I could get close to the source of those secrets, that I could find out.\n\nLucy Candib, MD: It strikes me that the secrets were not in psychiatry, but inside of the places you hadn't yet looked in yourself.\n\nG. Gayle Stephens, MD: Yeah. Yeah. Well, it was shortly after this time that I had what I regard as the great privilege of my life of being in a seminar with Michael Balint at Cincinnati in 1969, which was only two years after I had become director of the residency at Wesley. And I went to that seminar as much of a blank slate about Balint as you could possibly be. I was attracted entirely by the title, The Doctor, His Patient, and the Illness. But I knew nothing about Balint. I knew nothing of his work. I had not read his book. I was looking for a continuing education course and that struck my fancy. And it turned out to be, I think, a truly a transforming experience for me because it brought some sense out of the frustrations and failures in my practice and set me on a new track.\n\nI think what it really did, it laid open for me the possibility of analyzing the relationships between me and my patients, which wasn't possible before accepting the [inaudible","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380#t=226.0,1485.0"},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/transcript/82535/annotation/4","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"] way. And it also gave me some tools with which to do that. Analysis. It also gave me a new sense of legitimacy as a family physician, as a general practitioner being concerned about these psychological, psychosocial issues in practice. Because one of the fears, I think, is that these are too mysterious and too complex and family physicians shouldn't get mixed up in them. That that's what the psychiatrist to do. And Balint restored my feeling of confidence and legitimacy that it was good for me to work on this and I wasn't going to be hurting people or damaging people by inquiring into life. And also, that I didn't have to go outside my role as a family physician and try to be something else in order to do that.\n\nLucy Candib, MD: How did he do that?\n\nG. Gayle Stephens, MD: Well, he kept insisting that family physicians had unique opportunities because of the longevity of their relationships with the patients to do important therapeutic work. And in some ways, had more consent to do that without the stigma from the patient's perspective of being labeled as psychiatric. And that it was right and proper that we should do it. And he gave the examples of the family physicians that he'd been working with in Britain for, gosh, I guess it was 15 to 20 years at that time. There was a fantasy in me as well as many of my colleagues, that people with psychological problems are fragile and that you shouldn't probe around or you'll break them. Now, that has some interesting psychological implications for the doctor, power and killing people and hurting people and all of that. But Balint just forthrightly dispelled that myth. He wouldn't even listen to it. And said in essence, \"You don't lack the time. You don't lack the skill. What you really lack is the nerve, the heart to want to have this kind of intimacy with the patients.\" And at least he convinced me that that was ... So.\n\nLucy Candib, MD: It was more the process of that interaction with him than the group process?\n\nG. Gayle Stephens, MD: Yeah, I think it probably was. I've wondered since what a group evaluation of me in that seminar might have looked like if it had been done at the close of the seminar. Whether anyone else would've thought that something had happened to me in the course of that. And I can imagine that several of the group might have not seen anything significantly going on with me, but it really was. It changed my behavior forever. Just different now than it used to be. So I think that was a milestone for me in personal development. That was still, though, pretty much around the individual, the individual patient.\n\nLucy Candib, MD: But-\n\nG. Gayle Stephens, MD: Pretty much around the adult patient.\n\nLucy Candib, MD: By this time, you had already moved into a more educational role than a practice role?\n\nG. Gayle Stephens, MD: Yes. Yeah, but I still had my old practice. Had residents from 1967. One thing that may be of interest, when I was organizing the residency, and going strictly by the seat of my pants and not knowing what to do or how to do it, it was very presumptuous and brash to have taken that on. But I stumbled quite by accident onto a series of articles on the behavioral sciences and medical education by a guy named Robert Strauss. I've forgotten what his name is. Robert Strauss at the University of Kentucky, who, at that time, had the first department of behavioral sciences that I know about. Now, this is around 1967. And I wrote to him just out of the clear blue and told him about this residency and asked if he would come to Wichita to consult.\n\nWell, I shall always be grateful to him. He said he couldn't come, but he suggested somebody else, a member of his department. And he sent me their teaching book, their departmental teaching book, which was a thick document containing the course outlines and reading references. Just a gold mine of information for me at that time. And he suggested a guy named Gene Gallagher who was a medical sociologist. And he came and spent two days and we talked over the plans and what we wanted to do with behavioral sciences, recognizing the ambiguity of the term behavioral science, then as well as now.\n\nAt the end of two days, he said, \"Look, you don't want a behavioral scientist of the sort I am. What you really need a psychiatrist in this program.\" And I've thought about that many times, of how perceptive and un-self-serving he was in his council. so then I tried to convince the Menninger School of Psychiatry in Topeka that they should do the psychiatric teaching in the department. And I went up there and spent a week and talked to people, seemed to be interested but, when the chips were down, they said, \"Topeka is too far away. It's 120 miles and we just can't do that. But one of our graduates, one of our recent graduates, is coming to Wichita and he's interested in community [inaudible","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380#t=1485.0,1949.0"},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/transcript/82535/annotation/5","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"]. He's [inaudible","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380#t=1949.0,1953.0"},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/transcript/82535/annotation/6","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"] mental health plan. Why don't you talk to him?\"\n\nSo that turned out to be the proper contact. His name is Gary Porter. He's still involved in the Wesley program. And that same year, another new psychiatrist came to town. His name was Dale [Gulich","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380#t=1953.0,1977.0"},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/transcript/82535/annotation/7","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"] who's now at the Cleveland Clinic, and he represented what I think would now be called [liaison","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380#t=1977.0,1984.0"},{"id":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380/transcript/82535/annotation/8","type":"Annotation","motivation":"transcribing","body":{"type":"TextualBody","value":"] psychiatry. He had had partial training as an internist and then went into psychiatry. So as luck would have it or whatever, we had a psychiatrist with a community psychiatry orientation and a psychiatrist with a liaison orientation. And that's the way we got the job done.\n\nLucy Candib, MD: It strikes me that you were solving the systems problem, the body mind dilemma, fairly quickly after having come to some resolution about, how do you solve it? Or more or less at the same time as you were trying to solve it in the practice, in personal realm.\n\nG. Gayle Stephens, MD: You mean by getting involved in an educational program fairly shortly after trying to deal with that myself.\n\nLucy Candib, MD: No, by the way you were trying to bring it into the educational program, that it wasn't something that you could wait 10 years to bring into your educational program.\n\nG. Gayle Stephens, MD: Right.\n\nLucy Candib, MD: 10 years that it took you to figure out the solution.\n\nG. Gayle Stephens, MD: It had to be done now.","format":"text/plain"},"target":"https://centerforthehistoryoffamilymedicine.aviaryplatform.com/collections/2195/collection_resources/150494/file/277380#t=1984.0,3674.8712"}]}]}]}