The original interview with Dr Zervanos took place in July, 2010. Its posting is the first of a series of “Lifetimes in Community-Oriented Primary Care” interviews of important figures in the evolution of primary health care access in the United States. The interview was conducted by William H. Burnett of the Coastal Research Group.
WHB: Nik, what influenced you to choose the profession of medicine?
NJZ: I grew up in a Greek immigrant home in Reading, Pennsylvania. We lived on a very narrow street, called Pearl Street with only 25 homes on the block where I lived, half of which were inhabited by Greek immigrant families. Within several blocks from our home there were two general practitioners, both of whom made house calls, and not infrequently I would witness their visits into our neighborhood. They were highly respected and among the most honored people in our community, and that made quite an impression on me.
My father’s brother, Hippocrates, was a physician and practiced in the Island of Kos in Greece, where both my parents grew up. This is also the birth place of the 5th century BC Hippocrates. Four of my father’s first cousins, all born in Kos, were physicians and practiced in Kos, Athens, Rhodes and Kavalla. I also have many second cousins in Greece primarily on the island of Kos and in Athens who are physicians, and even one in Thessaloniki.
In 1865, my grandfather had completed one year of medical school at the University of Athens, but then switched to the school of Philologia (Letters/Humanities), and went on to teach in the Greek grammar schools in Alexandria, Egypt. In the mid-nineteenth century the Turks, who still occupied the Dodecanese Islands allowed the locals to re-establish their own school system. They invited my grandfather back to the island to oversee its development.
When I entered college, I majored and excelled in chemistry, and many of my peers were in the premed program. I was encouraged by one of my classmates to consider medicine as a career. It was only because I did not think it was financially possible to go to medical school, that this was not considered in the first place. But when I began talking about it within my family circle, I was advised by a relative to approach a Greek-American state legislator, to explore state assistance.
The legislator in fact told me that if I could get accepted into any one of the three Pennsylvania state supported schools, he would obtain a senatorial scholarship for me. I was accepted into all three and chose to go to the University of Pennsylvania, and for the next four years my tuition was taken care of. Once I decided on medicine as a career, I read a good many books on the history of medicine, and one book by Taylor Caldwell, entitled, “Dear and Glorious Physician,” a historical fictional account on the life St. Luke, made a great impression on me. So did everything I read about Sir William Osler.
WHB: Why did you choose Family Medicine?
NJZ: I wanted to be like those general practitioners who I got to see in our Pearl Street neighborhood. These doctors had made a huge positive difference in the lives of so many people from the youngest to the oldest and especially on these families, or at least so it seemed.
I also assumed that if one sought to become a physician, it would be either like these two general practitioners or a surgeon. When I entered the halls of my medical school, and got to know my classmates during that first year, I wasn’t surprised that nearly half of my freshman classmates wanted to become family doctors.
However, the socialization process of our medical education system took its toll on my classmates so that by the time I graduated there were no more than five of us that wished to pursue “general practice.”
Yet, the fundamental character of becoming a physician never changed regardless of specialty choice. After all, all of our role models were specialists and people many of us wished to emulate. They were simply impressively good physicians.
But it was also evident that the GP was not held in high esteem by our mentors, or at least so it seemed. By the 1950’s it was the general internist who was now viewed as the new primary care practitioner. It was no wonder that more of my classmates chose internal medicine as a career choice than any other specialty.
One of the most important political issues of the day while I was in medical school was what the policy makers in Washington and elsewhere were calling, “a crisis in the health care delivery system.” Indeed we medical students would often find ourselves gathered together to discuss the medical politics of the late fifties. The biggest issue was the doctor shortage, but it was also the declining number of general practitioners.
Many considered the GP the backbone of the health care system, especially in rural America. Moreover, there was also concern about the growing number of elderly who were also facing the issue of both access and availability. At the same time, another more pressing and perhaps even more critical issue was the rising cost of medical care, and that health care was no longer affordable by the vast majority of Americans, and especially among the elderly.
Although universal and even national health insurance was a pressing political issue following the war, it was strongly resisted by organized medicine, and during my medical school days it still was. The Democrats were again in power, and the rhetoric was growing. The AMA took what seemed an increasingly unpopular position to resist any kind of government health insurance or universal health care insurance.
I remember the confrontation of President Kennedy with the president of the AMA, which provoked much discussion among of all. The compromise seemed to center around insurance for the elderly (Medicare) and federal/state insurance programs (Medicaid) for the medically disadvantaged poor. What was also surfacing was a strong argument for a new kind of holistic-oriented specialist that would provide and coordinate comprehensive health care on a continuing basis.
The difference between the general practitioner and what was being advocated is the formation of a “discipline,” which both elevated the status of this kind of physician, and also assured that this physician would acquire the needed competency skills. I for one never deviated from that goal. What was now needed is the endorsement and support of the academic medical community.
WHB: Who were your mentors during the time you were deciding upon your career?
NJZ: In medical school it was our chief of medicine at Penn, Dr. Francis Wood. He embodied all that was good about being a physician. He embodied “professionalism.” He was gracious and loved us as students as much as he displayed his love for the practice of medicine.
He had that wonderful magic that attracted people to him, whether it was with patients, colleagues, residents, or students. He was our Sir William Osler, who by the way also graced the halls of my medical school in the late1880’s. He also had invited our class to his home early in our clinical years, and we were also very impressed with his wife, who I considered another role model for Diana and us married folk.
After medical school and while an intern at Lancaster General Hospital, I was strongly influenced by Dr Edward Kowaleski, a Lancaster County rural-based general practitioner who was then president of the Pennsylvania Academy of General Practitioners. He talked about the looming crisis being caused by the decline in the general practitioner.
Within a few years he was president-elect of the American Academy of General Practitioners and later after his tenure as Chairman of the board of the AAFP, was to become the Chair of the Department of Family Medicine at the University of Maryland. He was a dynamic, charismatic individual, with a powerful persuasive melodramatic voice. He was one impressive person who could make things happen. My interest in the medical politics of family medicine was ignited, if I wasn’t already feeling the flames.
During my internship I was drafted into the United States Army. A fellow intern and I got the idea that if we went to the U. S. Army’s assignment branch for the medical corps in Washington, D.C., we might be able to influence our assignment. It turns out that the only reason why the army even granted us an interview was that the medical corps was trying to recruit physicians to volunteer for the Green Berets with deployment to Vietnam.
Fortunately the colonel took a liking to us and was willing to accommodate my desire for the only US army medical corps slot in Greece and my friend who wanted to go to Germany. While in the army my commanding officer and his wife were also my patients. He was not a physician, but liked what and how I was conducting my “family practice” for him and his family and the troops.
When I commented about my concerns about what was happening back home regarding the above issues, he encouraged me to do something about it. I wrote to my medical school dean at Penn, and although Penn was not doing much regarding the issues relating to the creation of a new specialty, he was aware of what was happening at Harvard.
In 1964, even though I was in Greece, I stayed up to date with the editorials on the issues, which were well covered in the editorials of the AGP (American General Practice), JAMA, the NEJM and other ready available publications.
My dean was supportive regarding my expressed concerns and seemed glad that I had written to him. He encouraged me to write directly to Dr. Joel Alpert, the then new chief of the Family Health Care Program at Harvard Medical School. They had developed a new fellowship for general practitioners, graduates of internal medicine, and pediatric residency programs, who were contemplating an academic position of sorts in the newly proposed specialty of family medicine.
Joel Alpert was to become a key figure in my maturation as an academician and had a profound influence on my ultimate decision to become a young program director, after completing my fellowship.
Once in Lancaster, it was Dr. Thomas Hart, the new program director at York, who quickly became a close friend and wonderful mentor. He had a wonderful sense of humor with a Groucho Marx like mustache and very quick mind. He not helped guide me through those very first difficult years, but many others and would often find himself telling new program directors, “tell me what your problems are, and I will tell you where you are in your development.” And some other times, “tell me where you are in your program’s development, and I will tell you what you can anticipate.”
Another very important mentor was Dr. Ward O’Donnell, the chief of pathology at Lancaster General and the president-elect of the hospital when I was hired. We did not have a chief of staff at the time, but he served in that role during his tenure as president. Ward was convinced that the best way for the hospital to advance as a major medical force in the community was to develop a strong academic medical program.
Recognizing the hospital’s history as a highly respected community hospital with a rotating internship dating back more than fifty years, he was convinced that a residency program in the new specialty of family medicine made a great deal of sense. He knew LGH could do it well. LGH’s strengths included fiscally sound well run hospital under the able leadership of Paul G. Wedel, an established rotating internship, a general practice residency, and a new young breed of academically oriented physicians.
With Ward O’Donnell as a driving force, I received a call from our new Director of Medical Education, Dr. John Esbenshade, to determine if I might be interested. The other major players in bringing this about also included Dr. Ian Hodge, chief of urology, and the then president of the medical staff as well Mr. Wedel. Without Paul enthusiastically behind the idea, it would never have come to fruition. They all served as my mentors in those early years.
Once in my new role as Director, I also counted on a growing support system that included Dr. Tom Leaman, the new chair of family medicine at Penn State University at Hershey, Dr. Ed Kowaleski who was now president of the AAFP, but still practicing in Lancaster County, and a growing number of academicians at Temple University, which was to become our major medical school affiliate, but also people at my alma mater, and the rising luminary at Jefferson, Dr. Paul Brucker.
One of my most important mentors was the Associate Dean for Continuing Medical Education at Temple University, Dr. Albert J. Finestone. In 1975 we began a national CME course in family medicine here in Lancaster, called the Temple University/LG Hospital Family Practice Review. I am still directing this course, now in its 37th year. It is conducted in the spring and fall and continues to attract more than 700 physicians a year.
Another very important mentor was my first associate, Dr. Henry Wentz. He was a general practitioner from the town of Strasburg just south of the city and several miles north of Quarryville. He was my attending on our so-called “ward service,” early on in my internship. He was smart, attentive, clinically astute, and a good and honest family doctor who I could look up to with admiration and pride.
He had us as guests in his home, and I was impressed with his wife Mary, who also helped him in his office practice, which by the way adjoined their lovely home. He and Mary raised two wonderful children and were involved in their little town and their church community. They made an indelible impression on Diana and me. We would have liked to emulate his practice, their life style, and community and hospital participation. I also thought what an added joy it would be to practice in Lancaster and here at LGH, be involved in teaching young interns, and serve to enhance the hospital’s medical education program.
When we began thinking of developing both a hospital practice and a rural practice, he was one member of our department who came forth and expressed his strong endorsement of the residency program and also suggested a practice location for a “model family practice unit” in Quarryville.
Of course, when I began to think of a director of such a center, I could not think of anyone better than Henry to help us achieve such an objective. Moreover, he was so highly respected by the members of the medical staff, that he could help sell the merits of the idea. He also happened to be the vice chair of our department.
When discussions took place regarding a center in the southern end of the county, it was Henry who first convinced Dr. Bare of its merits, and soon Dr. Bare became a strong advocate to establish the center in his town. Moreover, I was certain that if we could recruit Dr. Wentz to be the medical director of our new center, it would almost guarantee its success. When I was given the green light by Mr. Wedel to approach him, I immediately went to Henry and asked him to become my associate.
Although he was understandably hesitant, if for no other reason than his concerns over his practice, he decided that he could do this on a half time basis if we could convince Dr. Ivan Leaman who was then completing a general practice residency at LGH, to join him. Thankfully, Ivan agreed to do this, and Henry not only became my first associate, but continued in both a direct and indirect way to serve as my mentor. He remained in this role for several years until it became too much for him, and returned to full-time practice.
In the meantime, we continued to add outstanding individuals as associates, who served as faculty. The program now has more than fifteen fulltime family practice faculty and 5.5 ob-gyn faculty members. There have been very few of the faculty who joined the department who left over the years. One, John Randall, MD, became the chair of family medicine at Jefferson Medical College after Paul Brucker assumed the position of president of the university.
WHB: What was your educational preparation for becoming an academic family physician?
NJZ: While an intern at Lancaster General Hospital, I considered doing a general practice residency, but I was disappointed in what was offered at LGH as it was more like another year of an internship. I looked at other programs, but they were not all that much different, so I decided to return to the Penn campus, and do a one year residency at the Philadelphia VA beginning in July 1963.
However, I got my draft notice in the early spring of 1963, so I postponed my year at the VA until after my tour of duty. In the meantime, while I in the military, as already noted I decided to explore the fellowship program at Harvard.
My correspondence with Dr. Alpert led to a formal application, and I submitted the required supporting documents. I was offered an interview after my discharge, and I was already committed to begin my internal medicine training at the Philadelphia VA to begin that March (1966), I was offered a fellowship to begin in July, 1967.
During the year that I was at the VA, the residency became formally integrated with the University of Pennsylvania. Dr. James Weingarten, the Chair of Medicine at Penn, and the overall director of both the VA and HUP residencies, encouraged me to stay another year before going to Boston.
This was also to include the opportunity to engage in a one year long weekly Balint seminar offered by Dr Bob Potash. I accepted the offer and completed a second year at Penn with Dr. Alpert’s blessing, which postponed my fellowship for another year to begin in July, 1968.
The first fellow in the Fellow in the Family Health Care Program was Dr Lynn Carmichael, a general practitioner from Coconut Grove, Florida. He completed his fellowship in 1964, and then went on to become the new Chair of Family Medicine at the University of Miami. Just as I think it did for Lynn, the fellowship set the stage for a number of us to enhance our roles in academic family medicine.
People like Drs. Tom Leaman and a couple of his associates participated in brief 3 and 6 month experiences in the program and then returned to Hershey. The program turned out to be good preparation for me for much of what I was going to end up doing at Lancaster was learned in this program including the development of our “Family Health Service,” which was modeled after the Family Health Care Program. While I was in my fellowship (1968-1969) the specialty of family medicine was officially established (February 1969).
Around the same time I had begun exploring various academic opportunities. The place I thought where I wanted to be was at Penn State University at Hershey, a brand new medical school where family medicine was to play a prominent role. I interviewed with Tom Leaman, but they were looking for people with more practice experience.
It was around the same time that I received a call from Dr. Esbenshade, the new DME at Lanaster General Hospital. He told me that Lancaster General was to create a new department that would need someone to direct the department’s new out-patient department with a community medical service and develop a residency in the new specialty of family medicine.
This suited my interests to the tee. What was also of interest that was our program was known as a community medical service, and what LGH wanted was what we were already doing at Harvard.
At the same time our program was picked to become one of the fifteen pilot family practice residency programs in America. As a fellow, it was fortuitous that I was part of all of this. I could not have been better prepared for what I was being asked to do. Moreover, it was also fortuitous that our program in Boston was developed at the time that Medicare and Medicaid was taking off.
WHB: “The family” and “the community” seem not to be regarded as relevant concepts by much of organized academic medicine. But both family and community are obviously important to you personally. Describe how the family and your community orientation affect you as a physician?
NJZ: Let’s face it, individuals come from families and people and families make up communities. Conceptually therefore there is a good bit of logic in caring for individual patients in the context of their families and the communities in which they live. Getting to know one’s patients in that context allows the physician to better care for the patient.
Therefore, when we started the program in 1969, we consciously chose the name “Family and Community Medicine”. Obviously, the family concept is integral to the specialty, and a concept that I came to value so highly back to the days growing up on Pearl Street in Reading.
The sixties was a time of change, and family medicine as a specialty was part of a new paradigm with its community focus to help solve America’s health care delivery issues.
Unfortunately, the family has been undergoing a break-down for some time and particularly evident throughout the sixties. Much of what we witnessed as to the ill-health of the community was the direct effect of the ruptured family structure.
In the light of all this, and what I thought was needed was to find within the new specialty we were about to create and develop was a breed of family physicians who would take a leading role to restore the health of the family and our communities.
Therefore the Lancaster program’s philosophy was to recruit physician leaders, who would be “Part of the Solution, and not Part of the Problem.” This slogan was on a banner on the wall right behind my desk. To support this notion we established a requirement that beginning in the second year we would require each resident to declare a community service project designed to make the community healthier.
One of the most pressing challenges in our community was the alcohol and now raging drug problem. Again we considered caring for the patient with an addiction best managed in the context of the family and community. It take a “village” to help restore people with addiction to be restored to health, so we embarked on finding ways to build a support team, and that might not include the patient’s biologic family.
Often times these victims come from seriously impaired dysfunctional families, let alone broken homes or broken neighborhoods. But we were going to try. We also accepted the fact that “family” doesn’t always mean that the person is married or still a member of his or her biologic family. It was increasingly common for patients to live as unmarried couples and in non-traditional family settings.
In the meantime, we have witnessed that many of the welfare programs put in place during the sixties had inadvertent consequences on the family unit. It is common, and increasingly so, to have many women today who wish to have a child out of wedlock in order to “earn” or acquire a welfare check. Sometimes it doesn’t even matter who the father is so long as the unwed mother can have a child to raise, which qualifies them for welfare assistance.
In 1969 we took on the addiction problem so seriously that we developed a unique addictive disease program that was to be integrated into the program’s new hospital-based “Family Health Service.” The addictive disease unit received federal, state, and local funding, and it included a “methadone clinic” and a “family counseling center.”
The patients enrolled in this program had to include a member of their family or intimate other. Together they were involved in the care process. They were seen in the family counseling center, which was made up by the patient’s family physician, nursing personnel, a social worker, psychologist, and a minister. The social worker, psychologist, or minister served as the patient’s personal counselor, but group therapy sessions were part of the program. It was amazing what we were able to do for addictive disease patients.
We soon were involved in the development of a half-way house and worked with the County’s various drug and alcohol task forces and other services to minimize incarceration. Although it was common in the beginning to admit patients for withdrawal, once the “Addictive Disease Program” was established that was rarely necessary.
The program grew quickly, and began to dominate the other resources of the residency program, and when the five year NIMH grant was exhausted, the program was taken over by the county’s offices of Mental Health and Retardation (MHMR). However, we did demonstrate that psycho-social issues can best be managed by addressing the pathology emanating from both the family and community.
Having our residents taking on a community service project provided our residents the opportunities to test their leadership skills. To engage the community’s resources, we went to every agency in town, and met with their directors and discussed our new program. We asked them to offer our residents a meaningful role in their agency or program.
We explored different ways how our residents might help solve problems. This included tobacco consumption, radon exposure, and air pollution (Lung Association) to help prevent lung cancer; alcohol and drug addiction (Lancaster County office of Alcohol and Drug Abuse); teenage pregnancy (Childrens and Youth); homeless (Mission Center); health education (schools); etc.
Some residents served in an advisory role; others took on projects and others conducted studies, etc. A faculty person was given the task as advisor and coordinator. This aspect of the community medicine curriculum proved to be very successful. One example involved a resident, who did a rotation at Nazareth Hospital in Israel in his second year. When he returned, he decided to establish a foundation to help Nazareth Hospital, and before he graduated, he helped raise more than $50,000. Now the foundation raises millions each year.
Another example is a resident in the early seventies who was annoyed that some hospitals throughout the country, including our own, still allowed smoking, and in some cases still had cigarette vending machines. He worked with the Lung Association to send a letter to every hospital in the country, proposing that they change their policy if smoking was allowed in the hospital or if vending machines were still be used. We did not have statistics to determine what effect this had, but it we know from feedback received by the local Lung Association it was significant.
Of course today, it’s unheard of, and even employees can’t find a place to smoke at the General. Each year we recommend two or three residents for the AAFP Bristol Myers Squibb Family Medicine Leadership award. There are years when we have had 2 residents receive one of the 20 such awards that are given each year. The residents from the Lanaster General Hospital have received AAFP resident leadership awards than any other residency program in the country.
WHB: How did you implement “family and community medicine” within Lancaster General and the rural communities in the geographic area it served?
NJZ: One of the big issues that affected the development of the family medicine residency programs were the requirements that the Family Health Center had to care for a broad spectrum of socioeconomic groups; it could not be solely indigent care. However, we were not about to abandon our goal to develop a comprehensive health care program for the low income or medically indigent people of our community.
Part of the dilemma was that the medical staff insisted that the hospital-based unit was not to compete with the private practicing physicians, so to open up the practice to a wider socioeconomic spectrum created a challenge. We also realized that our hospital-based unit offering services to low income people who were now on medical assistance could attract maternity patients, a much needed group of patients for our residency program.
At the same time we were aware that the southern Lancaster County area was devoid of physicians. Three of the practicing physicians were over 65 and one wanted to retire, and there were only two others, both osteopathic physicians who did not utilize our hospital. The area was seriously underserved and there were several community leaders who were eager to get more physicians into their community, and showed interest in our proposal to place our center in Quarryville, which was the borough right in the center of the area.
Moreover, the chair of the department of “General Practice” was one of the three practicing GP’s who was over 65, and also welcomed the idea of placing our family practice center in his town. However, we had to convince Dr Thomas Johnson who was about to visit our program that the 15 miles distance was not going to be too far from the hospital. At that time, the existing requirements of the Residency Review Committee on Family Medicine (RRC) limited the distance the “model unit” could be from the mother hospital to 15 minutes, not 15 miles (30 minutes).
It was our good fortune that Dr Thomas Johnson was who he was, for his opinion as to approval of a program weighed heavily on the Family Medicine Residency Review Committee. Moreover, Tom was advocate for programs that could demonstrate innovation. He insisted that at this stage of our development that the RRC needed to be flexible. He gave programs like the one we were proposing in Lancaster the opportunity to prove that their model could work.
The RRC gave us provisional approval, and hence we were allowed to establish our model unit in Quarryville, while providing our residents the three year continuity community medicine experience at the hospital based facility. Hence our predicament was converted to into a positive “innovative” idea.
We were able to prove that our residents could have two highly complementary practice experiences one in a rural-based “model family practice unit” caring for a wide spectrum of socioeconomic groups and the other a “community medicine” experience caring for a medically indigent population in the hospital-based urban setting.
With the institution of Medicaid, the medically indigent were quickly identified, and perhaps not surprisingly, many more who qualified came out of the woodwork. Unfortunately too many physicians were dissatisfied with the reimbursement and were not anxious to add “new” patients who were on medical assistance, and that included maternity patients.
Again that created more opportunity for us and allowed us to quickly build our two practices. We called our new hospital based unit the “Family Health Service,” or if you will, a service in family health care, a take-off from the words that were used to describe our program in Boston, which was called the Family Health Care Program.
The residents would not begin their model unit experience until their second year when they would spend 2 to 4 half days per week in the new “Southern Lancaster County Family Health Center” in the borough of Quarryville, with a population of 2000 people in a drawing area of almost 300 square miles where more than 15,000 people lived.
In the meantime, the residents would continue to care for their patients in the Family Health Service one half day each week for the entire three years. Today the southern end of the county has doubled to more than 30,000 people.
To help the practice get started in Quarryville with full community support we capitalized on the benevolence of its community leaders and established a community advisory committee. They did much to assure the success of the center. What made some anxious was that the physicians who were caring for them were doctors in training.
However, we quickly pointed out prior to 1969, and even in many cases even then, a physician could be licensed in PA and set up practice following their internship. We pointed out that all our residents would have completed their internship by the time they began caring for patients, but in addition to that a senior faculty person with years of experience would be their preceptor or proctor and be available to provide immediate consultation and advice.
It did not take long to reassure the citizenry, and they soon were singing our praises, expressing appreciation for the excellent care that they were beginning to receive. Our practice grew very quickly.
WHB: Describe how the indigent community served by Lancaster General Hospital affect the character of its family medicine residency program?
NJZ: Our objective was to develop a family focused and community oriented health care delivery system, so the demographics of Lancaster City and County was important in our planning of the residency program as we proceeded to establish two very different family practice centers.
The various federal and state legislative initiatives incentivized community leaders, hospitals, and other new health care entities to reach out to the medically indigent and develop new programs to care for underserved populations.
We took it upon ourselves to learn not only who are patients were, but where and how they lived. At the time about twenty percent of the population of the city was medically indigent and an increasing number were Hispanic; today it is more than twenty-five percent. Most of these people would have ready access to the hospital-based Family Health Service, but this was not adequate.
A federally qualified community health center in the heart of the city’s southeast where the low income and highly concentrated medical indigent live was also established, and today it is staffed by several of our graduates. Its outstanding director is also a graduate.
Historically going back to before the war years, the hospital established an outpatient clinic staffed by volunteer members of the medical staff, and for the most part, this clinic served the community’s medically indigent well. However, the care tended to be fragmented and too many health care issues went unattended.
So, with the establishment of the new Family Health Service, we gradually did away with all the specialty clinics, and were left with our faculty and residents. Over time, 85 or more percent of the patients’ needs could be met with residency program’s faculty and residents.
With the establishment of Medicare and Medicaid it was now possible to obtain consultation in most of the offices of our specialists; however, we did have some consultants that insisted that their clinics be retained, as they preferred to see their patients with the residents who were rotating on their service in the OPD.
Their clinics are viewed as a consultation service. This worked out surprisingly well, especially as the residency program grew. In some situations patients requiring surgery or highly technical services are sent to the nearby Hershey Medical Center, but most surgical procedures on the medically indigent are cared for by LGH doctors.
The model unit In Quarryville was able to attract a wide socio-economic group of patients to the practice. Much of the success of this endeavor can be attributed to the center’s community advisory committee. We were able to educate the community about the high quality services that we were to provide along with the staffing of both young physicians and senior faculty.
Once the practice was well established, and after about ten years the advisory committee was disbanded. The center was also the recipient of funds left in the estate of Walter L. Aument, who died in the forties.
The money was to be used to build a hospital or health facility, but the corpus was never large enough for a hospital, but more than adequate to be used to build a brand new facility, so within five or more years after the center was operational, a new center was built and the name of the center was changed from that of the Southern Lancaster County Health Center to the Walter L. Aument Family Health Center.
The fact that the program developed these two unique health centers, one serving an urban medically indigent and the other a rural based community, had undoubtedly affected where are residents ended up in practice. In fact more than one-third of the graduates have chosen to settle in Lancaster County.
It is not surprising that the hospital-based Family Health Service has influenced a number of the graduates to serve in clinics or community health centers serving medically indigent populations in underserved communities throughout the United States.
Nearly 2/3 of our graduates are practicing in communities of less than 30,000 people. This includes those who have settled in Lancaster County. Others have chosen careers in missionary work, or at least included missionary work after entering practice; taking months to years off from their practices to serve in places like Africa, the Philippines, and in Latin and South America.
WHB: How did the Lancaster residency program achieve its pre-eminence in obstetrical family medicine?
NJZ: Much of its success is based on the fundamental philosophy of the program and the steps we put in place right from the beginning to develop a proactive high level maternity care service.
However, one of the major issues that our specialty faced in the early years was that of establishing clinical departments of family medicine, which means that the chair of the department would be authorized to grant clinical or hospital privileges to its members.
In the case of Lancaster General, the Department of General Practice was an administrative, not a clinical department, and did not have the authority to grant hospital privileges. That was a problem, especially in obstetrics, since there was growing resistance to allow family physicians delivering babies, and although this was not the case of our faculty, many programs were running into all kinds of resistance all along the East Coast.
We did not have difficulty acquiring a set of core privileges in internal medicine and pediatrics as general practitioners were caring for their adult and pediatric patients in the hospital. They even played a role in overseeing the educational experiences of the interns during the years of the hospital’s rotating internship.
However, with fewer and fewer general practitioners incorporating obstetrics in their practices and none by the time the residency program got started, the assumption was that incorporating obstetrics into the curriculum was going to be short-lived. Because we had an administrative department all of a general practitioner’s privileges in the care of a hospitalized patient were determined by the respective chairs of the clinical departments.
Privileges were not granted the chair of general practice. In our institution it required a steady and persistent argument and documentation and a major change in the bylaws to establish a clinical department. We were able to easily determine our “core privileges” in internal medicine and pediatrics, but it took more negotiations to determine that privilege in obstetrics.
This became a long and arduous process, and of course required careful language to assure that all parties could be satisfied, and especially the hospital’s board. What made obstetrics particularly difficult, I suppose, was the worsening litigious climate. Eventually, and after about ten years we did provide convincing evidence that our department chair should be given this authority. If we were insistent that we granted this authority from the beginning, it probably wouldn’t have happened.
The issue of granting clinical privileges for the care of the hospitalized patient, was also on the heels of the Joint Commission on the Accreditation of Hospitals (JCAHO), which insisted on maintaining the highest standards. Their own stance in those early years weren’t all that supportive of family medicine. Of course that did change in time as well.
In the meantime, our volume of obstetrical patients kept increasing, especially among the growing number of medical assistance patients. It was also a fact that the majority of the high risk patients were from among the medically indigent. To make things even more stressful for all concerned was that the number of maternity patients cared for by the residency program was increasing.
Although malpractice cases were increasing quickly throughout the seventies, eighties, and nineties, it took about twenty years since the inception of the program to experience our first law suit. This in no small measure was a reflection of both the increasing number of high risk patients as well as the worsening litigious climate of our community. The stress on the private practicing ob/gyn that was being called in consultation was enormous. Something had to change, so in time, after several unfortunate lawsuits, it was agreed that the program needed its own full time ob-gyn faculty that could work side by side with the family practice faculty and his or her ob/gyn colleagues.
In 1995 LGH authorized the hiring of its first full time obstetrician-gynecologist faculty. He and his associates to quickly follow was there to provide consultation for the family practice faculty.
Our residents obviously continue to get superb training in obstetrics, and more than a third of our graduates continue to choose to include obstetrics in their medical practice. Sometimes, this is not possible though, not because the graduate doesn’t want to do ob, but the practice that they join does not include maternity services in their practice.
Moreover, many programs, especially on the East Coast do not provide their residents adequate experience in obstetrics, and understandably many programs have very few of their residents doing ob after graduation. To bring greater clarity to the realities of medical practice and the family medicine obstetrical curriculum, I have advocated an obstetrical curriculum with three skill levels.
Level I skill level does not necessarily mean that the resident would acquire the needed psychomotor skills to deliver a baby competently, but it does mean that they have had the experience of delivering babies under supervision and would follow enough pregnant patients in the model unit to acquire a level of competence in meeting their prenatal care needs.
We believe that such ob skills would mean that the graduate in practice would recognize the “medical care” of their pregnant patients, even though they are not their patient’s obstetrician. This in effect means that would be able to competently manage their patient’s medical needs for a presumed non-obstetrical reason, but still recognize the obstetrical consequences of the medical problem in question. This means that the resident would also have acquired enough competence to provide prenatal care at least for the first and second trimester if need be.
Level II skill level indicates that the resident is considered competent to perform a normal uncomplicated delivery. Yes, that also means that the resident knows when complications are occurring and has the ability to know what to do in an urgent situation, and know when consultation is necessary.
Level III is the ability to do obstetrical surgery (Caesarian Sections and even emergency hysterectomy) without the immediate backup from an obstetrician, although consultation may still be necessary under extraordinary circumstances.
Every program must be able to provide the residents adequate experience to get their graduates to do Level I obstetrics, but in my opinion not all programs are capable of getting their resident to reach Level II. To train family physicians for Level III, the resident would have to complete an obstetrical fellowship.
I would go so far as to recommend that our specialty create a Certificate of Added Qualifications (CAQ) in obstetrics to certify that the family physician has achieved Level III competency skills. I believe a program such as ours would have little difficulty providing such a fellowship, the political ramifications, notwithstanding. With a CAQ in obstetrics, I would hope that any family physician should be able to receive obstetrical privileges at any hospital where they choose to practice.
Our institution performs over 4000 deliveries per year, and our residency program is responsible for more than 800 of those patients. The maternity service grew as predicted, and I might add nearly 20 percent of our deliveries come from our center in Quarryville.
Currently we have 5.5 FTE obstetricians and 12 family medicine faculty performing and supervising our residents in maternity care. Even with 39 residents in the program, all of our residents are trained to reach what we consider Level II competency in obstetrics with both the numbers and the supervision to assure that the program provides high quality maternity care.
At the time of my retirement in 2002, our strong obstetrical curriculum made our program particularly attractive to Dr Stephen D. Radcliffe, one of our leading family physician authorities in maternity care. He is the lead author and editor of Family Practice Obstetrics, a major textbook on the subject.
WHB: Do you believe the reasons for becoming a physician in 1960 are still present a half-century later?
NJZ: Yes, without any question I would still go into family medicine. The fundamental reasons why people choose a medical career haven’t changed. Dr David Loxterkamp writes in “Piece of My Mind “ in a recent JAMA issue, of so much of what we value, there is no profession more highly valued than the medical discipline. For those of us engaged in a medical career we are fortunate to have the opportunity and privilege to do something useful to society and to affect people’s lives in a positive way.
What is of particular value and inherent in that experience is the relationship that is formed between the doctor and patient. I still see people 43 years later, who have been part of my being in a very special way. My own practice is somewhat unique in that it is made up of the people of Greek-American heritage and some are even my relatives.
They are representative of a unique subculture of America, not unlike the many other ethnic groups that make America what it is. We have been together through sickness and health for sure, but in many nonprofessional settings including social affairs, the church, weddings, baptisms, funerals, and in various other venues.
WHB: You are one of the pioneers of the family medicine movement, and were particularly concerned with implementing one of its institutiona innovations, the family medicine residency program.
With four decades of experience and tens of thousands of graduates, what elements of the family medicine residency do you regard as unambiguously successful? Are there elements that you believe should have been constructed differently from the beginning?
NJZ: The evidence we have as to our success is manifested in our graduates. They speak volumes. Of the more than 450 graduates of our residency program to date, less than three percent have changed their specialty and only one that I know of left medical practice all together.
Our graduates are changing the world for the better. I can think of hardly anyone that has disappointed me. I am proud to say many have become leaders within our specialty. Five that I know of have been chosen by their state chapters as the outstanding family physician of the year. More than a third of the graduates are practicing right here in Lancaster County, and their work is exemplary. That includes what they have accomplished in their individual practices as well as their contributions to the community at large.
Two thirds of our graduates are in communities of less than 30,000 people. The year that I retired as program director in 2002, a recruiter in New England called me, and she said to me that “I have been working in physician recruitment nearly as long as you have been a program director, and I have to tell you that when we have the opportunity to place a graduate from your program, we know from experience he or she is one of the best, and we have no trouble placing them almost anywhere they wish to go.”
Of course, our residency programs are constantly undergoing fine-tuning and change is inevitable, but fundamentally I would not change the overall structure of our program. I think the opportunity our residents have had to work in two different settings with two different socio-economic groups is a major strength of our program.
Moreover, I have been impressed when our residents are empowered and have been given the opportunity to exercise their leadership skills, as many have proven to be formidable.
Our residents have proven to be leaders as practitioners as well as in the academic family medicine community. More than ten have become program directors, one a dean, another a vice dean, two became chairs, and one a vice chair of family medicine, in medical schools, and many more have become full time academic faculty. Others have risen to become Vice Presidents for Academic Affairs or Chiefs of Staff of their hospitals.
Many are directors of large medical groups and one a top ranking officer of one of the major private health insurance plans. The current AAFP Division Director for Medical Education is one of our graduates. He was also president of the Association of Family Medicine Residency Directors as was one other of our graduates.
WHB: Are there things about the structure of the three-year residency that you would change now?
NJZ: Do we need a four year residency? I don’t think so. We have implemented a number of CAQ’s, and we still keep adding. We may wish to add another in Obstetrics. As I already mentioned the obstetrics curriculum needs to be revisited. The reality is that the vast majority of our graduates are not including obstetrics in their practices, and those that wish too often run into resistance from the ob-gyn community and hospital credentialing committees.
A CAQ would provide the added assurance that a family physician who wished to do full service obstetrics including surgical ob would satisfy more vigorous credentialing criteria. There are also changes taking place in the care of the hospitalized patient, with fewer family physicians caring for their hospitalized patient.
However, the development of the patient centered medical home concept is also addressing the changes taking place in our medical practices. Continuing medical education is extremely important, and I believe the American Board of Family Medicine with the Maintenance of Certification in Family Medicine has also reinforced additional ways to assure the public of that family physicians are keeping abreast of the latest developments in clinical practice and maintaining their competence skills in family medicine.
I still direct the Family Medicine Review Course for Temple University, and I can attest to the value of such ongoing continuing medical education as we receive constant positive feedback as to helping our physicians keeping current as well as helping them in preparation of their boards.
WHB: The latest health reform act was enacted under politically divisive circumstances? Are there elements that you are pleased have been enacted? Are there unintended consequences of the legislation that you predict will occur?
NJZ: I am very pleased that many more people will have adequate health insurance as health care has become so expensive that no one can get sick and expect to receive the care they need without it. I am also pleased with the assurance that no one with a major health problem will lose their health insurance, nor that someone with an existing health problem will be unable to obtain insurance.
Yet, one has to be realistic about our ability as taxpayers to pay for it. Moreover, our current debt problem seems so overwhelming that I am not sure where the money is going to come from to pay for this unless the American people are willing to experience an increased tax burden. Instead we are talking about how we might be able to reduce expenditures for health care. I don’t know how this is going to play out, but in the long run we have to find better ways to cut costs or lower the cost of delivering medical care.
There are many ideas that have been proposed, and we have to embrace those that will or at least might work. It doesn’t make sense to me for example why Medicare or Medicaid expenditures can be twice as high for the same demographic group of patients in one sector of the country vs. another.
Medical liability factors are another variable that can be controlled when there is the political will to change that. Making the patient the center of how money is spent for medical care (medical savings account) is another idea that needs further exploration and experimentation.
Whatever is put in place, and whatever the good intentions might be, there are always unintended consequences and the potential for abuse. Both Consumers and Providers have learned to manipulate the system, but safeguards, or if you will, regulations (a hated term for many) can minimize that as well. I always thought that if there was an adequate or high enough co-payment that would reduce the overuse or abuse potentially.
I still believe that in any system, you have to give more responsibility to the patient as to how they use the system. Moreover, I have constantly preached that a physician should never order a pharmaceutical, laboratory test, or any other test, or procedure unless he or she knows the intervention will help and would cause minimal side effects.
Defensive medical practices, notwithstanding, we as physicians must be more fiscally responsible on how we influence the cost of medical care. We must teach our residents that we are stewards of the health care dollar as it is our professional responsibility. Patients who choose to use the ER should also know their out of pocket costs are going to be much higher.
I like the idea of being able to make evidence-based decisions, but that’s not always practical. Although I think the Electronic Health Record (EHR) has both positives and negatives, in my experience it takes longer to complete a medical record. Still there is a major advantage to have a lot of data at your fingertips, including easy access to consultation reports, lab, imaging, etc. There is little question that this increases quality of medical care, but it also takes time (increased cost) at each visit to want to read all these reports.
WHB: Are there elements of the health care reform legislation that you regret?
NJZ: The Medicare and Medicaid legislation proved to be divisive. The leaders of organized medicine fought any kind of government insurance as they believed government intrusion in medicine will compromise the relationship between the doctor and the patient.
At the same time people inside and outside of medicine have argued that health care in a civilized society should be a right and not a privilege just as many believe that an education should is a right and not a privilege. And when health care becomes unaffordable for the vast percentage of its citizenry, especially among its non-working poor, government becomes the only resource to make it available.
However, it is also true that government and the growing third party system may interfere with what some physicians may think is in the best interest of the patient. In my opinion, however, this is very uncommon, and rarely compromises patient care in any serious fashion.
At the same time many people have benefitted from government health care insurance. Physicians’ incomes have increased and many people have received medical care services that would not have been possible otherwise.
Let’s face it, if one views Medicare and/or Medicaid or even insurance coverage from one’s employer as an entitlement, there can be abuse; and indeed, there have been abuses on both sides. Abuse or no abuse, health care costs have escalated, but it is astonishing that health care costs have reached such astronomical heights.
Even as a medical student (1958 to 1962), it was apparent that medical care was becoming increasingly more expensive. It is also a fact that “free” health care is abused. I witnessed this while in the military as some will go to the doctor even for frivolous reasons; they will ask for expensive tests or pharmaceuticals, and even insist on an antibiotic for their child’s cold; so long as they don’t have to pay.
There is also a difference on how doctors practice medicine if a patient has to pay out of pocket vs. if a third party will pay the bill. We witness this in the care of the Amish vs. those who have insurance at our center in Quarryville. Obviously I may be exaggerating to make a point. However, for good or bad reasoning, all would agree that costs are determined by who is footing the bill.
Still, I became an early advocate of government insurance, as a way to see to it that underserved people (the poor and elderly) could get the care they need. Now nearly all of us (99 %) can’t get the medical care we desire, let alone need, without health insurance.
Personally, I endorse universal health care, and I don’t object to an unipayer government subsidized health care delivery system. The simple fact is that I just can’t see how we can have an equitable and humane and effective health care system if people can’t access it because they don’t have insurance.
The challenge is to find a way to do this in the most intelligent, most thoughtful, most economical way possible, and without damaging the relationship the patient may have with their doctor or doctors. I think that’s possible, and frankly we just have to.
WHB: What is future of Family Medicine?
NJZ: Basic concepts of family medicine have not changed. Family Medicine is the specialty of primary care, and it is the backbone of our health care delivery system. It is the specialty that assures people holistic, continuous, and comprehensive health care. It means prevention and that includes primary prevention and even to a large extent secondary and tertiary prevention.
We work with our specialist colleagues to assure high levels of secondary and tertiary care. We pay attention to the psychological and sociological factors, and often to their spiritual nature as well for that too affects health outcomes. A sound doctor-patient relationship remains a most important component in assuring high quality primary care.
It is incumbent for all family physicians to understand that and to keep working to develop the best possible relationship with our patients so they can believe and trust in us and be assured of effective high quality care.