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:
Donald Frey, MD, Creighton University, Omaha, Nebraska [Dr Frey is a Fellow of the National Conferences]: Rick, that was just beautifully done. I’d like to make a couple of comments, very quickly, mainly because if you have a choice between listening to Don Frye or John Geyman, you better listen to John Geyman.
I was asked to play this role because I was the 23rd Annual Gayle Stephens Lecturer. The only problem is I never met Dr. Stephens, so I can talk a little bit about this but, what I have to tell you is you’re probably thinking well gee this guy was a family medicine chair for nearly 15 years, how could he have not met Dr. Stephens?
And the reason, because I was teaching at his Jesuit Institution, and those guys don’t let you out much; so I didn’t get a chance to do that.
What I would like to say is I think there were some things that we went through at Creighton University that Dr. Stephens would really understand, and would embrace as we move forward.
A number of years back, not too long after I took over the Creighton chair, we had a very severe financial crisis in our institution and in our department. Rick Flinders mentioned the fact that his residency program a couple of times might have lost its accreditation, but we came really close to losing our entire department of family medicine.
We had a dean who frankly didn’t care, and couldn’t have been happier, I think, if we had lost our department of family medicine. So we’ve learned very quickly if we were going to fix it, we had to do it ourselves.
The Parable of the Flying Pig
We had to come up with a vision. I believe that the vision we chose was one that Dr Stephens would have appreciated. First, we created as a department mascot,a flying pig; as in “that will happen when pigs fly”. We were going to be that flying pig. We were going to show people that we could do that.
The Parable of the Non-Existent Box
At the same time we needed a department motto. What was our motto that we came up with? Our motto was “there is no box”. What do we mean by that? We derived it from the movie The Matrix. (If you haven’t seen it, the original movie is actually very interesting. I’m not talking about the two follow-up movies,)
There is a scene in The Matrix where Neo, the hero, goes to see an Oracle who can see the future. Neo, sitting in the Oracle’s waiting room observes a number of little children doing some interesting things, Neo is watching one who is bending spoons. The kid hands Neo the spoon and says “you try it.”
Neo looks at it, Nothing happens. Then the kid says “Don’t try to bend the spoon, that’s impossible. You can’t bend the spoon, The spoon only bends when you realize the truth.” Neo asks “What truth?” The kid replies: “There is no spoon.”
“There is no box”. Don’t try to think outside the box. We create our own boxes in our thinking.
I think this is something Dr. Stephens understood, You can’t think “outside the box”; You can only get there when you realize there is no box. Dr. Stephens understood; get away from the box entirely. Let yourself go there on your own.
Over the years we successfully dealt with our financial difficulties. We turned a $1 million deficit into a $1 million surplus. Over the same period our school of medicine blew up and nearly took the university down with it.
And so major changes occurred and all the people who were in charge of those things disappeared. And what happened? I became the Vice President of Health Sciences; Betsy Kimball, our administrator, became head of the practice plan; Tom Hanson, our residency director, became Associate Dean for Medical Education; and Dr. Mark Goodman our senior faculty member became the departmental Chair.
Wisdom and heresy
What we had to deal with at that point in time were some very entrenched attitudes, and we could only do that with a great deal of difficulty. But what I learned very quickly something else Dr. Stephens would embrace, it’s not important whether you’re the smartest person in the room, you’ve got to be the wisest. And what Dr. Stephens had was wisdom. He understood the importance of wisdom.
As we move forward into the future, one of the subjects I talked about in the 23rd Stephens Lecture, was revisiting Dr. Stephens’ earlier lectures about family medicine as counter-culture. For its role in the 21st Century, maybe we should think of family medicine as heresy.
We need to understand that the Big Red Bull today is the Big Red Ticking Time Bomb that is likely to blow up. Our healthcare system will face enormous consequences should that happen.
If that occurs, it will take those of us who carry forward Dr. Stephens’ legacy, the notion of embracing pigs that fly, the notion of embracing the fact that there is no box, and the importance of wisdom. We should take those things, carry them forward and understand that we also carry out Dr. Stephens’ legacy when we do that. John.
John Geyman, MD, University of Washington, Emeritus, Friday Harbor, Washington [Dr Geyman is a Senior Fellow of the National Conferences.] All well said, Don, and Rick, a great tribute, and so well done.
I’d like to start with a brief summary. I did a festschrift for family medicine several years ago, which is, as we all know, the German word for looking at the body of work a person has done over a career. I concluded back then that Gayle has been a hero of mine forever.
For me, he’s been, and remains by far the most thoughtful, original and eloquent voice in our field. And best represents the moral conscience of the entire medical profession.
His wide-ranging intellect connects us with history, gives context for where we are now and envisions alternative futures for our specialty, our profession and society; truly a Renaissance man.
A Visit to Witchita’s Wesley Hospital Family Medicine Residency Program
I first met Gayle in 1969 – a couple of months after I left my practice in Mount Shasta California for Santa Rosa. I wanted to go around the country to see what the “good programs” were doing. They were all early, Of course the first place I went was Gayle’s residency program in Wichita, Kansas.
And the first thing I saw in Wichita was the library. Gayle took me to the library. And he spent a lot of time there, and that was always important to him in teaching and practice and anywhere else.
What I want to do now is to draw a little bit from quotes over the years in different context from this festschrift and then I want to spend several minutes on what I think he would say now.
I was fortunate enough to be a close friend for more than 40 years. I talked to him a lot along the way. And I think I have a sense of what he thinks now and where he’d go next. It’s already been alluded to a bit, but I’ll try and add a few things.
Writing About the Physician as Healer
His first paper was actually in 1965 in The Journal of the Kansas Medical Society on the subject of the physician as healer, the earliest subject he wrote about. In that paper he said that one of the paradoxes of our time is that the healing relationship seems most in jeopardy at a time when we need it most.
There are many forces that threaten to depersonalize the meaning of a doctor and patient. Preoccupation with a disease of a person is detrimental to good medicine. Health is not a commodity that can be purchased in any quantity for as long as one has the money.
One can buy the mechanical appurtenances of healing, but one cannot buy that essential ingredient – a physician who really cares about the patient. That’s classic! Doesn’t he cover a lot right there in 1965, early on as a leader of a residency program, and teacher and clinician?
Then a few years later in the mid-1970s, he discusses the teaching and learning of clinical wisdom. He did a lot on that. To quote just a few words from that period of his work: “Every clinical diagnosis, except the most trivial and transient, should include an appropriate assessment of the patient’s personality.”
“The wise physician knows it’s not enough to determine what condition the patient has, but also what patient has the condition.”
“Accurate personality assessment has relevance for all aspects of the clinical situation and enables the physician to make a number of informed decisions about management and to predict important characteristics of the developing doctor, patient relationship.”
One can only guess at how often diagnoses are delayed. Unnecessary and risky tests are ordered and inappropriate treatment prescribed, because objectivity is subverted by unrecognized personality factors.” That’s an example.
Here he is in the mid-1970s on reform in the United States. Just a few words, but this shows the breadth of his thinking as just amazing:
“Beginning about 1890 historians have identified several themes of reform in the United States which have been expressed culturally, politically, and socially. Each of these themes, agrarianism, bureaucratization of the professions and utopianism has influenced medicine and medical education. First at the turn of the century and in the activities of the AMA in promoting public health and in establishing natural science, natural sciences as a basis for medical education and practice.
And then he goes on since World War II and such is that. And he thought so broadly, he could draw – as we’ve heard already from so many, just different disciplines and put it in a context, where we are now, how we got there and where we might want to go in the future.
Here he is in the late-1970s: “The physician as a moral agent”. He describes four aspects of medical practice that bear on that subject. The fate of altruism, we’ve heard a little bit earlier, the style of practice, individual and group morality, and the uses of counseling and psychotherapy; such wide-ranging thinking.
Then we all know his book, The Intellectual Basis of Family Practice, 1982, a remarkable book. And here he is on the gatekeeper role. I really like this and a huge amount of relevance to where we are now. Here it is 1989, here’s what he says about gatekeeping. “My experience with contracted gatekeeping is that it is an untenable and hopelessly conflicting role that undermines the voluntarism and earned trust which lie at the heart of the family physician’s effectiveness. By introducing elements of compulsion and control into the physician-patient relationship, gatekeeping transformed an intimate relationship into a hard-edged contract between strangers.
“A bad exchange under any circumstances; gatekeeping involves family physicians in structures of power, secrecy, and risk that are foreign to their traditions and ideals and reduces their role to that of a corporate watchdog. The role is so untenable that I predict it will be eliminated future versions of managed care.”
Well, we’re looking at future versions of managed care right now. Most docs around the country are employed by hospital systems. 2300 docs in Southern California are employed by one insurer. Come on!
Gayle wrote a lot about professionalism. He wrote about family physicians as agents of political and social change. I’ve always loved this quote. Here it is at Keystone in 2000. “Among the lessons that ought to have been learned during the last 30 years is that the natural evolution of change is not necessarily in the public interest. That the bête noire of change is not necessarily socialized medicine as the AMA tirelessly warned us for decades compared to the Draconian intrusions of industrialized medicine on free choice and privacy, and that organized medicine hospitals and medical schools are not dependable fountains of wisdom and leadership in the midst of change”
Our “expert institutions and organizations” have exposed themselves to be bastions of resistance, self-interest, and exploiters of the public purse. More than anything else they resemble the Medieval clergy in maintaining their death-grip on privilege, power, and self-aggrandizement.”
It sounds like the Jesuits.
Lessons for Contemporary Times
We had conversations many times about how disappointed he was about what’s happened in the system and the culture of medicine, how medicine and healthcare have been commercialized. And he was disappointed, I think, in the role of family medicine, which started as a counter-culture movement, but hardly is counter-culture now.
He saw most of our organizations and institutions as not providing leadership for change. We heard earlier how the specialty societies are more interested in their own members’ needs and less interested in changing the system. I’m glad to have heard fromNorm Kahn as to what you’re doing in your newer conversations, but we need a lot more than just conversations among organizations, because organized medicine is not being a change agent itself.
What would Gayle do?
Where would Gayle be right now, if he were right here? I think he would be giving us historical context and looking ahead at what our real problems are. He would be quite disappointed in our specialties and organized medicine in terms of leading change. And, as alluded to earlier, he would ask, “who is on the patient side”?
I hastened to look at the Academy’s “Future of Family Medicine Project”. The Academy, in that document, number one, never looked at how we finance healthcare and never answered basic questions like who is the healthcare system for? And is healthcare a commodity on an open market, or should we transform to a not-for-profit system? Those questions have not been asked, even by our own Academy. So, I think Gayle would continue to be disappointed in that.
I really liked Jim Herman’s idea of the model of cultural change. We’ve got a cultural problem in our profession versus the needs of the public.
Think of what could happen if we were to pursue change in the way Jim’s diagram worked, starting within just family medicine and the American Academy of Family Physicians and work on that cultural change across other specialties. What could happen if the American Academy of Family Physicians became the first medical organization to go for financing change. That would give us a not-for-profit situation and return healthcare to where it should be, putting patients at the basis of it instead of having the medical-industrial complex running it.
I’m going to stop there. I’m sure Gayle would be much more eloquent and much more up to date in looking at the next ten years. But from many conversations I know he’s been disappointed in the lack of leadership in leading cultural change in family medicine and elsewhere and organized medicine. Thank you.
This section is followed by: Proceedings of the 25th National Conference Stephens Tribute (Pugno, Mills Questions and Comments).