Proceedings of the 25th National Conference, April 14, 2014: the 24th G. Gayle Stephens Lecture (Flinders)

We gratefully acknowledge the sponsorship of the Penn State University Hershey Medical Center Department of Family Medicine for funding the transcription and editing of this section of the Proceedings of the Twenty-Fifth National Conference:

This section follows: Proceedings of the 25th National Conference; April 14, 2014 (Second Plenary Session, LeRoy Questions and Comments)

 

 

Mark Clasen, MD, Ph.D., Wright State University (Moderator) [Dr Clasen is a Senior Fellow of the National Conferences]: Our next session acknowledges the passing of one of our esteemed colleagues, Doctor G. Gayle Stephens. I don’t know if there are words to describe the affection that many of us had for Dr. Stephens.

Doctor Rick Flinders has been intimate with Gayle and his family, and has recently been engaged in a series of interviews of him. He is going to take the next presentation, the 24th G. Gayle Stephens Lecture, in tribute to him.

25PHCA - Flinders Slide38

 

Rick Flinders, MD; Santa Rosa Family Medicine Residency Program, Santa Rosa, California
Rick Flinders, MD; Santa Rosa Family Medicine Residency Program, Santa Rosa, California

Rick Flinders, MD, Santa Rosa Family Medicine Residency Program [Dr Flinders is a Fellow of the National Conferences]: Good morning. I want to make two things very clear, from the beginning. To give this talk as the 24th annual Gayle Stephens Lecture is greatest honor of my life.

Though it also gives me great sadness to have to say in honor of the late Gayle Stephens , I am both thrilled and daunted by the prospect.

The list of those who proceeded me is August and included names like Gayle Stephens himself, Lynn Carmichael, John Geyman, Marion Bishop, Perry Pugno, Josh Freeman, Donald Frye, Norm Kahn and many others. And though in many ways I feel out of my league, I welcome and I cherish this moment.

The second note that I wish to emphasize is that while Gayle’s career illustrates the very best of our history, his legacy is of even greater significance. In its power to illuminate our present and our future, the canon of his written work over the past 40 years already contains everything we need to know to become good physicians, as well as to teach good medicine.

A portrait of Gayle Stephens
A portrait of Gayle Stephens

George Gayle Stephens was more than a great physician. He was also a great man – a once in a lifetime, generational leader, who shaped a specialty and who, in my estimation, had more influence on the social reform of medicine than any other individual of our time.

He was a lifelong scholar, writer, orator, philosopher, theologian and teacher. He was also my friend.

I got to meet him twice. The first time was in 1987 when he spent two days in our residency program as visiting professor. That visit shaped me as a family physician and teacher.

The second time was in July of last year when he agreed to be interviewed as part of a fellowship I had been granted by the Academy Center for the History of Family Medicine. That visit has shaped me in a different way and has left an indelible impression on my understanding of medicine and of life.

We met at his home in Dillon, Colorado at 9,000 feet of elevation in the Rocky Mountains, seven miles from Keystone. We arranged to meet for two hours between breakfast and his obligatory afternoon nap. He talked for six hours, concluding at Pug Ryan’s Pub over French onion soup and a locally brewed porter.

He was sharp, lucid, buoyant and impassioned. I got the impression he believed his remaining time was short. He told me he still missed medical practice. He still had hope for the future of family medicine and where he felt the political energy of our specialty now lies.

He talked of growing up in his tiny home town on the shore of the Mississippi River, deep in Mark Twain country, where he played, fished, milked cows and where there was no high school. He talked of his father, why he went into medicine, his early education and his life changing encounters with Michael Balint and a certain professor of psychiatry from Northwestern University.

He talked about the Medicare debate, the Willard Report, which was his Bible; which he followed verbatim in starting one of the first family medicine programs in the country. And he talked about the Affordable Care Act.

He challenged me to ask interesting questions. Ok, what ten books would you put on the reading-list of all pre-med students? Where did you come up with that parable of the Big Red Bull? Have you ever considered convening a Keystone Four? And what would you say if you were giving the 24th Annual G. Gayle Stephens Lecture; (He gave the first one.)

When we parted, he made it clear that the interview wasn’t over, that it had only just gotten started. And for the past year, I became the undeserving, but fortunate beneficiary of his sense of urgency through an email correspondence that included many reflections from the last year of his life.

Dr. Stephens dwelled in the world of medicine. But he was equally accomplished and comfortable in the world of psychology, philosophy, religion and literature. In a 30 minute presentation on the occasion of last year’s Annual Gayle Stephens award to a senior medical student at the University of Alabama Birmingham, (what I believe to be his last public appearance), he quoted from Goethe, Harvey Cushing, W.R. Houston, John Verger, and Peter Matthiessen to just name a few.

Those of us who seek to continue the work of family medicine and a more distributive justice in healthcare shall be quoting Gayle Stephens for many generations to come.

Gayle Stephens' Message
Gayle Stephens’ Message

What was his message? Near the end of his life Mohatma Gandhi was approached by an intrepid news reporter who had the nerve to ask “Mr. Gandhi, what’s your message?” Gandhi looked kindly at the man and said simply “My life is my message.”

I believe the life and work of Gayle Stephens speaks for itself, but if we had to condense his message, let’s say his legacy to a 21st Century sound bite, it might take two lines. “Good medicine is the right of everyone.” And “the best medicine is ultimately personal.”

From the very beginning to the end of his career, to my knowledge, Gayle never once deviated from his own dead center core of the doctor-patient relationship – Its practice, its understanding, its teaching, its personal and professional boundaries, and its moral and humane foundations. He made it his life’s work, and his life’s study.

In spring of 2002 I received a grant from the Center of the History of Family Medicine to tell the story of family medicine in Santa Rosa. My premise was that the roots of social reform and development of our little chapter was a microcosm of the national movement, which led to our specialty in 1969.

My proposal was to talk to people. To interview both our local leadership and the national leadership who were participants in the fountainhead of the national movement.

Doctor John Geyman
Doctor John Geyman

I talked with this man, Doctor John Geyman, our founding director in 1969, who practiced in Shasta for how many years John? Seven? Way up in the northern hinterlands of California.

Learn this from him: if you need a coronary care unit, you can start your own. If you need an intravenous pace maker, you can make your own.

If you need to make a house call, you can fly your own plane. I also learned that UFOs existed, and they were called the Union of Flying Octogenarians. And finally I learned, Rick, you got to talk to Gayle Stephens.

Doctor Perry Pugno
Doctor Perry Pugno

I also talked to this man, Doctor Perry Pugno, who not once but twice saved our residency program in Santa Rosa from extinction. And I learned that he became a family doctor in hopes of really becoming an astronaut.

I learned that, we’re training pluripotent stem cells, who go out into the communities and become exactly the kind of physician that community needs. And if you want to understand the 21st Century of family medicine, read what we wrote back in the 1960s, 70s, and 80s. Also, Rick, you really got to talk to Gayle Stephens.

So I went back to history’s archives in Leawood, Kansas, where I spent a wonderful four days digging in the tribal soils for nuggets of wisdom.

AAFP Archives, Leawod, Kansas
AAFP Archives, Leawood, Kansas

I found a gold mine. Its name was Gayle Stephens. When I got home, I sent him the following request. “Dear Gayle, I’ve wanted to speak with you ever since I visited the Sanders Archives last year, but I feared I’d be a bother. John Geyman, Perry Pugno and Don Ivey all persuaded me otherwise and urged me to contact you regarding a possible interview.

I’ve attached a copy of my fellowship project, as well as, my recent book A Collection of Stories and Essays Written from Santa Rosa Over the Past Forty Years. I hope you won’t find me presumptuous, but the majority of these stories and essays are a direct result of your advice to me all those years ago, to think, reflect and write about what we do; something that Gayle practiced his entire life. Thank you in advance for your consideration, and a life time of inspiration to us all.”

Within 12 hours, I got a reply back “I’m pleased to be interviewed by you. I’ll be living in Dillon, Colorado this summer. Let’s pick a date. I’ll look for your Santa Rosa reader. We’ll leave ‘Bama on May 22nd.”

And then I begin to formulate questions: “Gayle, in advance to my study, my project began as a history; my concern increasingly includes the future, both for its promise and uncertainty for family medicine. I’d like to hear your best guess as to whom we might be training in the future, and what they might, or might not be doing. Your decalog to the graduating class of 1979 is a touchstone for our specialty.”

Are any of you present at this National Conference familiar with Gayle’s decalog? It was a graduation address in 1979 and serves almost as an enduring Ten Commandments of our specialty.

A Decalogue for Family Practice Residents Entering Practice–G. Gayle Stephens.

  • Reflect on your professional experiences.  Within the bounds of protecting patients’ privacy, think, talk, and write about your clinical stories.
  • Humanize and personalize the Microsystems in which you work.
  • Find some way to practice charity; i.e., willingly give a part of your services consistently to those who cannot pay.
  • Don’t turn your practice into a mere business.  It may not be less, and it should be a great deal more.
  • Don’t give up the reform ethos.  Keep on the side of responsible change in education, practice, and social justice.
  • Don’t lose faith in the power of relationships and the therapeutic use of self.  (Or, don’t hire anybody to save you from spending time with patients.)
  • Learn to distinguish between uncertainty and ignorance; only the latter is remediable and potentially culpable.
  • Try to see that the groups in which you hold membership are at least as moral as you are.
  • Act at all times as if the patient is fully autonomous; the weaker the patient is, the more vulnerable you are to violating his/her personhood.
  • Worry less about patients becoming overly dependent on you than about your becoming undependable.

“Can we still teach it and make it work in the present system for those we draw into family medicine in the 21st Century?”

“Dear Rick, The decalog still stands. I devoured your book. I took it with me to the University of Alabama Birmingham’s Department of Family Medicine. I get 30 minutes a year.” Now he’s professor emeritus, he’s been that since 1988 and he gets 30 minutes a year at U. Birmingham.

“I spoke on The Doctor Himself as a Therapeutic Agent, a title from R. Houston’s article in the Annals of Internal Medicine in 1938, the Art of Treatment. I focused on the difference between a doctor’s job and a doctor’s work. The job that you get paid for, and the work that one does for love.”

Articles | 1 February 1938

 Content Title

THE DOCTOR HIMSELF AS A THERAPEUTIC AGENT*

Author Name

  1. R. HOUSTON, F.A.C.P.

Ann Intern Med. 1938;11(8):1416-1425. doi:10.7326/0003-4819-11-8-1416

 

“And elaborating on the work I turned again to Cushing’s Consecratio Medici for devotion:

 

Author: Cushing, Harvey,1869-1939
Subject: MedicineMedicine
Publisher: Boston : Little, Brown, and Company
Language: English
Digitizing sponsor: Open Knowledge Commons and Yale University, Cushing/Whitney Medical Library
Book contributor: Yale University, Cushing/Whitney Medical Library
Collection: medicalheritagelibrarycushingwhitneymedicallibraryamericana

https://archive.org/details/medicalheritagelibrary

 

 

John Berger's "A Fortunate Man: The Story of a Country Doctor
John Berger’s “A Fortunate Man: The Story of a Country Doctor” (1997)

“John Berger’s A Fortunate Man which describes the British country doctor John Sassall gets beyond lifesaving to a new understanding of crisis in patients’ lives.

“And Peter Matthiessen’s Snow Leopard in which only those who tend the Himalayan blue sheep can ever glimpse the rarest of the great cats.”

I asked him what he would say if he were giving the 24th Gayle Stephens lecture. I’ll summarize from his remarks. He replied: “If I were capable of speaking on a theme, which I am not now, I’d like to address the vicissitudes of maintaining a doctor-patient relationship, from the patient’s perspective.

Peter Matthiessen's "The Snow Leopard"
Peter Matthiessen’s “The Snow Leopard” (2008)

If you have a doctor, things fall apart quickly when you enter the hospital, especially when your illness is life threatening or complicated.

Strangers appear, whose roles and prerogatives are confusing. Your doctor’s group members and their on-call arrangements, consultants and their associates, proceduralists and their teams, administrative doctors for nursing units, pain management, skilled nursing, hospice, rehab, etc.

“The sicker you are, the less you know or remember about your providers. You are moved through the tertiary care system as on an assembly line. And if you survive and return to your home, you receive requests for payments from providers you do not recognize, whose services you’ve never heard of. One needs to be in perfect health to cope.

“I have just been dealing with these issues from the summer, so I can quote chapter and verse. We are all doomed to be gored by many oxen. Who will be on the patients’ side?”

Rocky Mountain Pilgrimage 7/13/13
Rocky Mountain Pilgrimage 7/13/13

That was in December of 2012. Now, I put on my hiking boots and backpack, and made what I call my Rocky Mountain pilgrimage on July 13, 2013

Gayle and I talked about what we were planning to do., “Should we make this a history Gayle? Or how about, I said. a conversation that gives us less obligation and restriction, right?” That’s what we did.

You see, over the shadow, up there before the skyline lies Dillon, Colorado. It’s a beautiful lake where Gayle has had his home there for many, many years.

The Stephens home in Dillon, Colorado
The Stephens home in Dillon, Colorado

It’s no accident that the three conferences that constitute family medicine’s equivalent of the Philadelphia Conventions were held up there seven miles away in Keystone, Colorado.

This is a photo from his deck overlooking Lake Dillon, with EJ, his high school sweetheart and wife of 67 years. Seven miles from Keystone, site of historic family medicine conferences 1, 2, and 3.

Some thoughts of Gayle Stephens
Some thoughts of Gayle Stephens

To sample of the kinds of things he laid on me during those six hours, he said: “The benevolence of the physician springs most properly from a sense of gratitude, not from feelings of philanthropy.” He elaborates on this later on.

He also said: “You know Rick, it’s good to be loved, but it’s better to be needed”. At that point he was really talking about our relationships with the specialists, who as long as they need us for referrals, love us. But you know what I mean.

Finally again I think some of his best advice “We should all think, reflect, and write on our experiences in medicine, within the bonds of patient confidentiality.”

Gayle stated: “I was born in Ashburn, Missouri, in the heart of Mark Twain country; 93 miles from the birthplace of Samuel Clemens”. How ‘bout that. There’s some similarities there. He wasn’t born that far from Abraham Lincoln either, or Harry Truman. And somehow he merged elements of all those characters together.

“On the west shore of the Mississippi River, we were a tiny village of 120 people in Northeast Missouri. We didn’t have a high school, and kids in our town didn’t go. My dad was the town grocer. He was also the owner of the general store, the post master, and lots of other things.”

My question number one was “When did you decide to become a doctor?’ When did you guys in the decide to become a doctor? Who decided by the age of 10? Alright. I should have known Mark, yeah. I decided when I was about 24. Chuck? Five, God almighty. Did your dad tell you to do it? There you go, yeah. And I think that’s what Gayle felt; with good reason. Why?

Gayle said: “When I was ten, my father said I should go to high school, take Algebra and Latin, and be a doctor. It never occurred to me to think that my dad didn’t know exactly what was best for me.”

I responded: “But you said there was no high school in Ashburn, remember?”

Gayle replied “There wasn’t then, but the year before I was eligible to go to high schoo,l the school bus route was changed to stop in Ashburn so they could take any students to the county high school 18 miles away”.

Coincidence? No. I inquires: “Was your dad on the city council?” Gayle laughed. “No, he was mayor.” How many students that year went to the county high school from Ashburn? One.

I remarked: “So maybe you’ve got some politics in your genes, Gayle.” No surprise. He said: “It never occurred to me that my dad didn’t know exactly what he was talking about and what was the best thing for me to do.”

“And if your father had told you to become a grocer?” “I probably would have become a grocer. And I added a damn good one probably as well.

Then I asked, “When did you stop practicing medicine? You retired in 1988, but kept seeing patients for many years, for example, as locum tenans for your brother’s practice. When did you stop for good?” 2012. “Just last year?” “Yes.” “When did you start practice?” “1955.” “Really?”

Then Gayle pronounced: “My wife says I’ve got five minutes left. Ok, it’s the truth. Cause if I do, I got to cut to the chase, alright.

I spent one of the most wonderful days of my life there in Colorado. I learned that Gayle’s devotion was to the doctor-patient relationship.

We know about the doctor-patient relationship. We gravitate towards it, but we don’t necessarily understand it, or why we go that direction. Gayle knew. And he had the brilliance of intellect and the generosity of heart to truly, deeply understand it.

We talked about the Affordable Care Act. I asked “Did you like it?” He said “I’d rather have half a loaf than none at all. “What’s the next step”, I asked? “He said, what you and John Geyman are promoting – ‘single payer’ financing.

I asked “Where’s the political energy in our specialty?” He said it existed within the special constituencies, especially LGBT.

Warnings from Eisenhower, Reimann and Stephens
Warnings from Eisenhower, Reiman and Stephens

“We’re well represented, are highly organized and have formidable delegates. Remember, social reform is our history.

The acquisition of unwarranted power and influence. President Eisenhower in 1961 said “beware the military-industrial complex”.

Arnold Relman retiring from the New England Journal of Medicine said “beware the medical industrial complex”.

And our Poet Laureate, Gayle Stephens, said: “Up on the hill lives a big red bull who eats and he eats and he never gets full”.

The origin of the First G. Gayle Stephens Lecture
The origin of the First G. Gayle Stephens Lecture

I asked “Where’d you come up with that metaphor?”

Gayle replied: “I wrote it overnight at Beaver Creek, Colorado in response to what I heard the first day [at the Second National Conference on Primary Health Care Access]”.

The big red bull! He’s still alive!

This is head of United Healthcare in 1990, 2005 his stock options were worth 1.7 billion and his annual pay was 37 million.

If that alarms you that it might not be enough, he’s also assured a guaranteed $5 million annual retirement after he retires.

25PHCA - Flinders Slide 29The pharmaceutical industry, latest drop for hepatitis is a grand a pill. We read that yesterday.

The parable of the big red bull, ok last…what is the secret for caring for the patient? Remember this is October 20, 1925. The secret is, caring for the patient; Francis Peabody.

So what does our poet laureate say on May 3rd, 2012 before the American Academy of special, of Family Practice for Special Constituencies?

Gayle's Advice to Physicians
Gayle’s Advice to Family Physicians

“The secret is, give a damn.” Now he goes into seven reasons why giving a damn was his last advice to family doctors. And these are they:

  • 1) Give a damn!
  • 2) Be There!
  • 3) Talk to your patient
  • r) Keep your promises
  • 5) Stop whining! Start resisting!
  • 6) Be grateful
  • 7) Your time as patient will come

I have a list of things I love about Gayle Stephens but don’t have time to discuss or explain. He always wrote his lectures. He read William Faulkner, Jack Kerouac, and Sigmund Freud, and just about everybody else.

He took up the piano when he was 60. He was a lonely, outspoken voice in the assassination of his friend Dr. George Tiller. He was funny, he was friendly and he was kind. He told me, “Kid, I like your style.” I had to throw that in. He made me proud to be a family doctor.

My last communication with Gayle was a poignant one, but provides a suitable conclusion for this talk. It was from his inspiration that I wrote it and serves both his purpose and message of the 24th Annual Gayle Stephens Lecture.

I had taken to calling him the Abraham Lincoln of family medicine. The title from which he humbly demurred, of course, but in doing so revealed his lifelong admiration of Abraham Lincoln and in particular his fondness for the Gettysburg Address.

Of course he knew it by heart. He claimed it was one of the greatest speeches in the English language, pure oratory he told me; and said it bore a timeless eloquence, almost approaching scripture. Gayle would know.

So on New Year’s Day, I sent out the following message to residents and faculty as a New Year’s greeting I copied it to Gayle asking his advice of it as a draft of a portion of our lecture today. It was called Future of Family Medicine and the Gettysburg Address Revisited. I’d like to close with this.

Happy New Year fellow faculty and residents; a couple meaningful anniversaries have reawaken in me the self-appointed provocateur of uninvited inquiry into who we are and what we do. Ten years ago our national leadership rolled out the Future of Family Medicine, a turgid but well-intentioned document, aimed at guiding our future for decades to come.

It turns out the future has happened faster and a little different from what we anticipated, and this April, exactly 10 years after the first installment today, the future of Family Medicine 2.0 will be released.. I know what I’d like it to say. This is where the other anniversary comes in, the 150th anniversary of the Gettysburg Address, with apologies and gratitude to Abraham Lincoln.

“Two score and five years ago, 1969, our fathers and mothers brought forth upon this profession, a new specialty; conceived in compassion and dedicated to the proposition that all patients are created equal. Now we are engaged in a great civil conflict of healthcare policy, testing whether such a specialty so conceived and so dedicated can long endure.

“It is for us to be dedicated here to the unfinished task, which they who preceded us have thus far so nobly advanced. It is for us to remain dedicated to the great task lying before us, and that we here highly resolved that this specialty shall not have arisen in vain. And that healthcare that is personal, comprehensive and durable over time for each person, for the whole person, and for all persons shall not perish from our vision.”

In Memoriam, George Gayle Stephens, MD
In Memoriam, George Gayle Stephens, MD

It was the only message to him to which he never replied. Apparently he had suffered his disabling stroke around the day it reached him. But I’d like to think he still got it, that he enjoyed the familiar language couching a vision of family medicine that he more than any other helped to create.

I’d like to imagine he was in the process of crafting one of his thoughtful replies before disaster struck him. I can imagine him saying, heck, I can almost hear him saying: Rick, John, Perry, Norm, Josh, Bill, Mark, all of you the vision is as clear and necessary and as threatened as ever, whether it perishes or not, is up to you. Thank you.”

This section is followed by: Proceedings of the 25th National Conference – G. Gayle Stephens Tribute (Frey, Geyman).