Transcript: Gerald T. Perkoff, 1974

This is the interview with Dr. Perkoff, who was born here in St. Louis on September 22, 1926 and who got his bachelor’s and his doctorate here at Washington University, where he also did the first year of internship.

Should I interrupt?  I interned at Utah.

You interned at Utah?

I didn’t take any of my housestaff training here.

I think American Men of Science has you at Washington University for ’48 and ’49.

Really?  I guess I don’t check that thing as well as I should when they send it to me.  And I also did not have a bachelor’s degree.  I was here.

[19]42 to ’44?

[For] ’42 to ’44 I had three and one-half years credit in a two-year period under the accelerated program.

This was during the war?

During the war – we enrolled in the medical school in June of that year and were given courses on the Hill because otherwise the whole class would have been drafted.  The medical school took us and they gave us a course in cell biology, a course in logic and a course in English literature under a man named [Loyd] Haberly, who was a poet.  Then we began the medical school that fall.  So, most of the people in that group had something less than a full four years’ credit in college.

Do you think that they lost anything as a result of that?

No, not a thing.

Do you think we should go back to that kind of option?

I think that option ought to be open, yes.  An assistant dean, whom we later met – I think his name was Davidson [ed. note: Dr. Perkoff is probably referring to Carlyle F. Jacobsen] – of the medical school, told our class that we would never really amount to very much because we’d been war babies and been rushed through school, and had never had adequate time to become educated.  I’m not sure, but some of us may have just decided to show him otherwise.

What then made you go to Salt Lake City where you were a research fellow in medicine and then research assistant professor and so on up the ladder?

I wanted a sound internship in internal medicine.  My intention was (I don’t know how much of this is really of interest in terms of the archiving, but it probably has some relationship to what I’ve ended up doing) – my intention was to return to Washington University, to finish my house officer training here and go into practice in St. Louis in internal medicine.  I applied at a number of eastern schools, to Barnes [Hospital], to Utah, and to [St. Louis] City Hospital.  I was accepted at City Hospital, [and] at Utah, where I applied primarily because Max Wintrobe had gone there, and Balfour Slonim who was a student here before me had interned there and liked it.  And Carl Moore, who was my preceptor, in fact if not in name, at that time, knew Max well and thought it was an excellent place.

We did not have the matching program.  We got these telegrams and we had to respond in a certain number of hours.  About one o’clock in the morning I called Carl and said, “I have the private job at Barnes, and City Hospital, and Utah.  Which is the best job?”  He said, “Utah,” and so I went there.  After I was there a year, military status became important and drafting of physicians started again and my job here [on the Barnes ward service] became uncertain.  So, I stayed as a fellow in metabolism with Frank Tyler, was his first fellow, and found research – clinical investigation – very exciting.  Instead of going into practice [I] decided to stay in academic medicine.

You started out thinking you would go into hematology?  That was what Wintrobe did most.

No, Wintrobe was a hematologist and was well-known.  I never intended to be a hematologist, although I had a number of opportunities to become a hematologist.  I went there primarily because he was known as a good teacher who ran a good medical service.

After you got interested in metabolic diseases then you went to the U. S. Public Health Service.  Was that in the National Institutes of Arthritis and Metabolic Diseases?

Right.  That group, in the summer of 1953, opened the clinical center.  Marvin Rosecan, who is in practice here, and myself had the first active laboratory in the clinical center in NIAMD.  Of the clinical group, NIAMD had had basic scientists working there outside the clinical center for some time.  We worked on diabetes and ketosis.  Joe Bunim, who was the director of NIAMD, came down to watch us run the first blood sugar that day; and that sort of thing.  We spent about fourteen months there.  I went back to Utah after that time.

Where you were then John and Mary R. Markle Scholar in Medical Sciences.  And you were still interested in metabolic diseases.  [Your interest] wasn’t always in diabetes, though.  It seems to me that some of your other articles were on different subjects: march hemoglobinuria and creatine phosphokinase and alcoholic myopathy.

That was a very interesting group [in Utah] and I think it was probably typical of that era and maybe one of the best examples of that era in that people who did clinical research tended to be very general in their approach to things.  The level of information in biomedical science and research methodology, even though it seems, now compared to what I’m doing, far advanced, even then, was really pretty limited.  And as a consequence, you could work pretty much on what you wanted.  The metabolic unit there was part of a thing called the Laboratory for the Study of Hereditary and Metabolic Disorders.

This was at Utah.

[Yes] at Utah.  The grant had the NIAMD extramural grant number of A2.  It was the second extramural grant – the first large one.  Max always told the story that NIAMD, when they granted that grant – which was $100,000 – had neglected that year to set aside money for intramural operations of the extramural program.  And so the grant turned out to be $95,000 and $5,000 was kept back to run the extramural office.  Times have changed!  That [the laboratory] was a three-unit operation, with a biochemistry unit under Emil Smith at the medical school, a genetics unit under Fayette Stevens in the university and a clinical unit at the hospital under Frank Tyler, with a metabolic ward devoted to studying hereditary disease.  In fact, as I look back, it was interdisciplinary research from the very beginning.

The subject of greatest interest there was muscular dystrophy because of the [interest in] genetics in the Mormon Church and the fact that the people who had migrated to Utah from this area in the early years included several people who had facioscapulohumeral muscular dystrophy, which was a dominant form of dystrophy, and so there were several hundred descendants of these polygamous marriages in the area who were available as a unique resource for study.  I began with that group and then began to study hereditary nephritis because a family with renal disease came to us and asked us to study them.  And that became the largest family, until recent years, ever investigated with that disease.  Then I ran the diabetic clinic there for a number of years, which is how I became interested in diabetes, and worked in carbohydrate metabolism, keeping an interest in muscle and renal disease.  We used to see all of the patients with metabolic diseases in the hospital and all of the referrals.

When I came here, I had been working on myoglobin for several years – spending half my day in the clinical setting, keeping all my clinical activities in the morning and then leaving and going to Emil Smith’s laboratory in the afternoon, at the university, which was geographically separate, as it is here.  [I] worked with Bob Hill on myoglobin chemistry.  So, when I came to St. Louis and was confronted with a large number of alcoholic patients at City Hospital, I became interested in muscle disease and alcoholism.  That’s how the work with creatine phosphokinase and with myoglobin in relationship to muscle disease and with alcoholic myopathy came in.  Basically it was an outgrowth of all that time at Utah.

Why did you leave Utah to come back here?

It was an interesting thing.  There are a number of reasons.  There’s a story which I’ll tell you that goes with it – I don’t know if it belongs in the archives, but it’s a true story about Carl [Moore], who remained, off and on, very close to us over the years.  My wife and I basically grew up there – we were young people out of school when we left [St. Louis].  We had our children there [in Utah] and in Washington [D.C.], and raised the three kids there, and it was a wonderful place to live for young people.  But as our children became older, and we felt, being Jewish – we weren’t really strongly religious in terms of practicing religion, but we felt that a great deal of the social and cultural activity of the area revolved around the Mormon Church.  We found no anti-Semitism there and we were well-received always by neighbors, by the church and others.  But as our children had reached teen age, we felt that they might need a broader approach to life.  And so we were sort of interested in the possibility of leaving, even though we were well-established in the school.  I had achieved tenure and all those other things which are supposed to go with security.

Carl came as visiting professor and visited my unit at the V.A. where I was running the medical service at that time.  Came one afternoon – we toured the mountains and then [he] spent just supper with Marian and the family and I.  He did what he really wasn’t supposed to do when he’s visiting professor.  He said Tom Brittingham was leaving City Hospital.  He and I were sitting in the living room and he said, “I don’t suppose you’d ever be interested in coming back to St. Louis?”  My wife, who was doing the dishes in the kitchen, said, “Oh, yeah?  Try us.”  (Laughter)  And really, that’s how we happened to come back to St. Louis.  We thought about it, obviously, a long time and I visited and so on.  But it was out of Carl’s visit that the stimulus was provided that we came.

What was the job at City Hospital?

The job at City Hospital was to set up a full-time Department of Medicine at City Hospital.  Basically, the idea that Carl had and that I had – in which I really, as is evidenced by the fact that we’ve turned to other things in recent years, I really think was an outmoded idea at the time, although neither of us knew that – was that we could have here a Harvard-type system with three equal competing departments of medicine as existed at that time at the Boston City Hospital, the Peter Bent Brigham, and the MGH [Massachusetts General Hospital].

What were those?

Those were the departments of medicine of the Harvard Medical School; each one with its own chairman, each one with full professorial rank, and so forth.

Like the Japanese system.

Or the English hospital/medical school-type system, which it resembled very closely, I think.  The idea was that I would set up a department at City Hospital.  And Stan Wessler came and did succeed, I think, in setting up a quite-independent, although now closely-integrated department of medicine at Jewish Hospital, analogous to the BI [Beth Israel Hospital in Boston].  When I was at City, I had the feeling (and it was the thing that really decided me to come) of rolling up my sleeves and going to work every time I walked into the place.  We did recruit a young faculty of four or five full-time people.  It rapidly became clear that it was already too late to have an independent housestaff, and Carl and I worked out the system which presently exists for rotating the housestaff as part of the university setting.  We got grants, as you may remember, to improve the library at City Hospital, which I think frankly, I’m proudest of that of anything that happened there.

We’re lucky to have you.

It’s a great place for the students.  We got a grant for research laboratories which ultimately were built, but after I left – they were all so delayed that they in fact did not get built until a time when there was some question in my mind as to whether they should have been.  There are lovely laboratories there now.  It was really, I think, too late to have a department in what became a very old image, which was the municipal hospital supported by a city with poor people who had no other source of medical care and who, in essence, came and people taught with them, hopefully in a sensitive way, and in return they were provided medical care.  Clinical investigation and other things were done in the classic manner.  It was beyond the time that that could be done.

So it was your experience at City Hospital that led you to leave clinical chemistry per se to go on to the broader questions of health care delivery.

Right, directly.  The process that happened also was of interest to me and may be of interest to others.  When Medicare was passed in 1966, the census in municipal hospitals all over the country dropped rapidly as older people now had a mechanism of payment by which they could seek private medical care.  The census on the medical service – that half of it that Washington University was responsible for at City Hospital, sharing it with Saint Louis University – dropped by about 30 or 40 percent.  We began keeping the statistics there really for the first time about medical service census and found the pattern of admissions had dropped, so that instead of averaging out at something like 85 or 90 [patients] over the year with peaks of 100 to 110 in a facility that was only supposed to take care of 85 or 90, that the peak was 85 or 90 and that the average for the year ran around 60.  In August and in December that we would have 40 to 50 patients on the service.  It became clear that it was no longer the major teaching resource that it had been in terms of numbers, and that people were opting out of the system.

We looked first at what we could do to stabilize it as a teaching resource.  For the first time I looked at medical care as something that was done as a process and structure rather than something you did in order to do teaching and research.  All the problems that we had all known about but ignored for years just came in full-force.  We developed a plan there, which I still think was a good plan, for taking part of the medical service at City Hospital and remodeling it into a private unit.  In trying to involve the general practitioners who were still left in the city of St. Louis, in a way in which they would refer patients to the City Hospital private unit in the same manner that rural general practitioners refer patients to a state hospital that is a university-operated hospital for consultation in return for medical care.  We developed a mechanism for bringing the physicians in and making rounds with us so it could be a continuing education kind of thing.  Carl Moore, Walter Ballinger, and the Dean, and Bill Danforth all thought it was an excellent idea.  The Mayor and Father [Lucius] Cervantes, who was his major adviser, thought it was a good idea.  The people at Homer Phillips [Hospital] didn’t object to it, even though it was going to be done at City Hospital.  But we could never get adequate grant funding for it.

Did you get cooperation from the local physicians?

Yes.  I visited more general practitioners than I knew existed in St. Louis and they were in favor of it.  They were a little suspicious because it was the medical school, but the medical society and others all accepted this.  We tried to get funds from the Commonwealth Fund and failed to do so.  I personally think that had we been able to initiate, at that time, a private unit in that hospital it might have been an example of what I think ultimately will be the fate – it sounds negative, but the fate in a positive sense – of municipal hospitals is that they should be remodeled into private-type facilities or a new facility should be built for poor people comparable to what is available for other people, and that they should be operated as community hospitals related to medical schools, much on the model of Jewish Hospital, which has private physicians who admit patients and full-time faculty who help with the housestaff programs and help take care of people and provide consultation.

Isn’t the image of the urban city hospital so low that for a while it’s going to be difficult to get patients to come in?

I think that’s correct.  I think it would take new facilities and an informed medical public, which would be in those hospitals with their own patients before it could ever come about.  It may well have been that it was too late at the time we had this idea.  I don’t know.  But we never did get a chance to try that.  At the same time that that was going on, Bill Danforth was becoming interested in evaluating ambulatory care here.  My interest in medical care was known to him from some other point of view than the direct research and teaching aspect of patient care.  And it was through that whole process at City Hospital that I became interested in doing the kinds of things that we ultimately ended up doing here.

How did you first set it up?  You say you didn’t get the grant from the Commonwealth Fund.  Did you just give up that idea and start another—?

That idea died.  There were no other funds available; there were no public monies available.  We just had to give it up completely.  It turns out that the city has since invested some funds in the hospitals, but in a much more generalized way than that and not for that kind of a purpose.  The events which took place here at the medical school after that period of time really were based in that sort of, I suppose, mental preparation and understanding of the kinds of problems that existed and so on.  But one didn’t directly lead to the other in any logical way.

How did you first set up the health care research unit here?

The way in which this came about was as follows.  The medical school and the Barnes Hospital, predominately now Bill Danforth and Mr. [Edgar M.] Queeny, were quite concerned about the negative aspects of clinic operations.  The hospital and medical school both being concerned about the loss of money, the disparity between income and outgo in the clinics.  And my view of it, without specific knowledge, is that Bill was considerably more cognizant of the medical aspects than Mr. Queeny, as he should have been.  That the patient care was bad; that it was fragmented, that it was expensive.  There were long waits and that people would attend many clinics, just as they did in every other clinic setting, even though this institution had recently built a new clinic building.  It wasn’t a bad physical plant, but it was organized in an old way and it was not oriented toward general medical care.

So, Bill, and I think Mr. Queeny, helped fund this (but I’m not sure), invited Kerr White, who was then and is now (well, he’s not chairman any longer – he’s gotten out of the administrative responsibilities) Professor and Head of the Department of Medical Care and Hospitals of the Johns Hopkins School of Hygiene and Public Health, to come as a consultant.  Kerr came and spent several days, [and] interviewed people in the full-time faculty, interviewed people on the private staff – people like Dr. [Michael M. ] Karl and Dr. Loeb and Dr. Bricker and others – who knew about the medical school from their point of view.  He recommended finally, in a detailed letter, which I think is an excellent analysis, that the solution to the clinic problems here weren’t short range.  That it would be a mistake, for example he thought, to get a director of ambulatory services.  Because in his experience elsewhere, such people spent their time calling up people to say, “Why didn’t you show up in clinic?” and in essence playing the role of chief resident all the time rather than modifying the medical care system in the clinic.  Rather, he thought that two units should be set up here.  One, which he called a Division of Medical Care Research, which according to the ideas then was to be based in the Department of Preventive Medicine to do research in medical care.  The other was the Health Care Planning Unit, which was to be based in the clinic and jointly funded by the medical center and the medical school.  And the third was a recommendation that the school set up a family practice training program.  The idea of a family practice training program was really not well-accepted in the medical school at all as it wasn’t in most medical schools at that time, and I really don’t think it ever got beyond Kerr’s letter.

When was this?

This was in 1967.  Bill [Danforth] then, on his own and with the assistance of Bob Shank, put together an application to the Kellogg Foundation which was a tripartite application, with the third part of it being something that wasn’t in Kerr’s recommendation, which were funds for augmenting the Graduate Program in Health Care, then called Hospital Administration.  They put together a grant application which contained things – a request for funds for salary for a director of a medical care research unit, secretary, and computer time; for a director of a health care planning unit, secretary and computer time; and for some funds (now I don’t remember just what) for the health care administration program.  That grant was awarded.

At about the same time, Dr. Paul Robinson, who was then medical director of Metropolitan Life Insurance Company, and several others from Metropolitan Life Insurance Company, were trying to find a medical school which would be interested in working on problems of costs of medical care.  The interest of the insurance companies had been stimulated by a conference held under then-Secretary of HEW Wilbur Cohen.  This conference on costs of medical care was a published conference in which Mr. Cohen said in simple terms, “You guys better get to doing something or the government is going to do it.”

Dr. Robinson that year was a forty-year alumnus of Washington University, or the next year was going to be, and he was planning to come by for the reunion.  I believe Paul Robinson was in Sam Soule’s class.  They [Robinson and his associates] visited here and four other schools (I don’t even know which schools – I believe there were four other schools) to see whether there would be interest in receiving a grant to study ambulatory care, group practice, and costs in some combination.  That really came as a kind of a surprise to the School, I think.  Dr. [M. Kenton] King appointed a group, which was chaired by Dr. [Robert] Shank and on which Dr. Willard Allen and Bob Frank and Lil Hoekstra, who was then Administrator of [St. Louis] Children’s Hospital, myself – I think Walter Ballinger who had just come was on that committee – and I don’t remember if there were others, to try and decide what ought to be done.  Issues discussed included such things as whether it was proper for a medical school to accept funds from a private insurance company to work on something which might ultimately have potential financial value to the insurance company.  To try to come up with the guidelines as to what we ought to do in such a relationship, whether it was an academic thing at all to study health care, and so on.  They reported obviously positively that this was appropriate to do.  After that was done, we had funds – they awarded us $100,000 a year for five years – so we had funds for somebody to do studies of group practice, we had funds for medical care research and funds for health care planning.

What happened to the Kellogg Foundation?

The Kellogg Foundation gave the money for the health care planning and the medical care research.  That came to about $79,000 in direct costs, plus matching money from the medical center for that part of it which was to be data in health care planning in ambulatory settings, of about $34,000.  So there was something over $100,000 from them for five years.  When we began to look at how this ought to be put together, my idea was and I really think that this was my notion, although Bill and I worked so closely together at that point that there really is no way in the world of separating out who said what, I don’t believe (although at the time I tried to keep a diary, and I just ran out of time to keep a diary)—

Is that diary something you would like to put in the archives?

I don’t even know if it’s still available.  If it is, you can have it.  But I don’t know if it’s still around.  Although the other paperwork and stuff you’re welcome to if we can ferret it out.

That we really had salaries for three chiefs and no Indians is what it amounted to.  We tried to decide what was the most functional way of setting this thing up.  First of all, we decided that it ought to be one unit and all of the grantors said that that was fine.  If we wanted to put it all together into one unit that was okay, as long as the functions were discharged.  Secondly, we really didn’t discuss at great lengths whether it ought to be a department, because it became apparent to both of us immediately that a department in this new area would not really have a very good chance among the strong departments here in the School.  Well, I don’t believe that even Bill or I, who understood more about this than others perhaps did at that time, I don’t think we really recognized what this field amounted to.  Certainly, among the traditional people who were responsible for major departments in the School, like Carl [Moore] and Ollie Lowry and Roy [Vagelos] shortly thereafterwards in Biochemistry, and Walter [Ballinger] and at that time Dave Goldring,  was still acting head of pediatrics, and so on, I don’t believe that they recognized – I’m not sure we did – that there was a methodology, a scientific approach to human problems which could be embarked upon, which could increase knowledge and be useful in the education of physicians.  This was sort of considered pantywaist kind of stuff, powder puff weight, you might say.

Isn’t that really the difference between your point of view and most of the community medicine attempts?  Most of [these] are attempts to be good guys and to help people in difficulty, while your aims were to give better education and to increase knowledge.

I think there’s no question that our emphasis is different from the traditional, what is now the usual – not traditional yet – community medicine groups.  Most departments of community medicine have been started either in response to funding or by young people who have been given an opportunity to work somewhere in relationship to a school – usually outside.  I think that’s very important, because I think it’s very self-defeating to work outside the major power structure of an institution.  With an idea of being a change agent in a situation which needs change, so that they have tended to work outside, doing whatever research could be done in a community setting.  [This is] often modified, as is appropriate, by the people who are being researched, if you will, but never well-accepted in the internal structure of the educational institution.  Until recent times as has gradually been happening better in some places like St. Louis U., like Meharry Medical College, like Mt. Sinai – although even there there’s a lot of contest still going on.  Whereas we chose to begin inside the School, in direct relationship to all of the departments, to begin with an experimental approach.  One, to learn how to do research in this area and two, to demonstrate that this was an academic area where facts derived from experimental settings could be used to base change.

I would have to say that we were rather idealistic, even though I think the approach has been a very effective one here and that it has been possible over the last five years to do an experiment which turns out to have been a unique experiment.  To use the experimental data to bring about a change in a medical care program and in teaching.  Those things were so.  But, we had the rather naive view, in fact, that facts themselves would sell people because they were facts.  What we found was that scientists remain scientists until the effort of change affects their own bailiwick and then they react like humans, like other people do.  It took diplomacy and agony and a lot of things besides facts to get whatever changes.  But it basically was a conscious decision, which I think was the correct one here, to work inside the institution, subject to the Executive Faculty and with the responsibility for convincing the people who were responsible for the School that what we were doing the right thing to do, rather than to work outside that power structure, even though it might have been easier initially to do so.

What problems did you face in persuading the Executive Faculty and the others that this was a good idea?

We didn’t have any trouble persuading people that it was a good idea to do an experiment, which I think says something both positive and negative about the attitudes of people working in an academic setting.  The idea of doing research is an accepted concept in medical education.  The idea that we would develop study and control groups, that we would evaluate the effect of a different form of medical care on medical care utilization by the study of the control group was easily accepted.  In fact, when the first information began to come from this study, it was presented at various basic science and other seminars.  People were sort of surprised to see how scientific in fact it was; that there were errors in the methods, that you could recognize those errors and interpret in the light of those errors, and that you could evaluate what you got.  The difficulties that we experienced were in trying to integrate this kind of work in a medical care program which was not as experimental a program, which was to be used as an educational device, and which had a priori the need for patient care as part of it.  Although we provide a tremendous amount of patient care in a medical center like this, the patient care which is provided by full-time faculty in general is provided in the pursuit of teaching and research.  Clinical research and laboratory investigation, both of which are based on the biomedical sciences, can all be done with relatively small numbers of patients overall.  In fact, one designs the experiment independently of the patients and then seeks the patients who fit the experiment.  Patient care research is the converse of that.  You must have a patient care system or you can’t do patient care research.  Therefore, you must set out with a population that seems large in the framework of what has been traditionally accepted as the kind of patient care population you would deal with for other forms of clinical research.

So that when we began to talk about the need to have twenty-five or thirty thousand enrollees in a program in order for the program to be financially self-sufficient, and not be a drain upon the medical school – where in fact, to be a good example for teaching it has to be financially self-sufficient – the concept of “enrollee” immediately got translated in the minds of people accustomed to thinking about patients [only] as patients.  The notion that there would be 25,000 patients – which was incorrect – that rapidly became accepted in the faculty as what was going to happen.  People became very concerned, and this was a concern throughout the country, that since biomedical research funds were being decreased, that people traditionally trained to do biochemical research in immunology or hematology, or in shock in surgery, or what have you, would now have to spend part of their time doing primary care and taking care of runny noses and they wouldn’t be able to work in their laboratories.  This represented to them a perceived threat which seemed very real.

It became possible over a period of many months really of constant discussion to point out that 25,000 enrollees in fact meant 25,000 enrollees and not sick people.  That based on our experience in the experimental program, we could say that there would be something like four contacts per year per enrollee with physicians and most of those would be with primary care physicians, who would not be people presently doing highly specialized work, unless they chose to change a career and become a primary care physician.  These would be additional faculty recruited into the medical school.  For example, the hardest time I had was with my own department, Medicine, and I suppose that’s appropriate.  We had a faculty meeting in Olin Penthouse one evening and Carl said, “This is the night you’re to ask Gerry questions.”  And I spent three hours sitting under a lamp on a stool in the middle of this group while they gave it to me pretty good.  In a subsequent faculty meeting was the first time I really got the kind of acceptance that later became now automatic in the Department of Medicine.

I showed them that based on our own data, in our own medical center, with them providing the specialty services, that at 25,000 enrollees – that if we excluded dermatology, which is the largest referral we make – that out of 25,000 people there would only be something like 100 to 150 visits to specialists in any given year in the Department of Medicine.  And since it’s an eighty-man department of medicine, that’s something less than two patients per year for each one of them.  Now in fact, it’s fewer for the immunologists than it is for the cardiologists, etc.  But it placed it in perspective and allowed them to see that this really was not 25,000 people, all of whom would have to have cardiac catheterization or something of the sort, which was sort of the rampant notion that came.  That was the first major kind of problem – was to place this in perspective as far as medical care was concerned.

The second thing was the issue of whether or not this would set up a competing set of departments.  Most multi-specialty group practices are in fact just that, and contain primary care physicians, surgeons, otolaryngologists, obstetricians and all the rest in their own group.  So the question legitimately was asked, “What will you do?  Suppose you get 25,000 people.  How many surgeons will that take?”  Well, in fact, it takes about two full-time equivalents.  One surgeon can care for about 15,000 people in general surgery, say.  It became a proper concern of the Department of Surgery that we not hire surgeons directly.  It became a proper concern of the Division of Cardiology that cardiology be referred to the specialists.  That that became easy to resolve because our whole concept of the Medical Care Group, as an experiment, was that it not be duplicating of any other service in the medical school.  So, we never had in the group, other than general internists and pediatricians and obstetricians.  And all specialty services always were provided by the specialty departments.  And so we committed ourselves – and it was a matter in part of faith, of them and us and vice versa – that we would not hire people independently or try to.  That there wouldn’t be a second division of cardiology.  And if a man was recruited into the group to do general internal medicine and he was a cardiologist, that the cardiology he saw would be seen in the Department of Medicine.

Is this different from the general idea of the health maintenance organization?

It’s different in mechanics but not in concept.  The concept of having specialists to do specialty work and generalists do general work is part of it.

But in this case it isn’t part of the group.

That’s correct.  It’s not part of the group in physical location – that’s correct.  When we applied for membership for Medical Care Group in Group Health Association of – whatever the name of the group is, I’ve forgotten now (the plaque hangs on the wall over there) – we were able to write down ninety-seven members of the group because there were several general surgeons and several orthopedists and several this and that and the other who in fact take care of our patients, but they aren’t physically located or administratively located as part of our group.

How is the financing of that [handled]?  Do you pay them a fee for service or are they part of your salary scale?

In the original experiment, the generalists were salaried in the group and we paid on a fee-for-service basis for all specialty services.  We did this for two reasons: one, we had no way of doing otherwise and, two, we really wanted to see what medical care cost and what proportion of medical care could be assigned to each specialty versus generalists, etc.  Based on that experience, when we set up the enlarged Medical Care Group, we negotiated with most of the major specialty care provider groups a capitation.  Just as we receive so many dollars per month per person in our group, we pay so many cents or dollars per month per person to each of the specialties for the provision of medical care services.  We chose to negotiate these sums with each group that provided one percent or more of our [patient care] out of Medical Care Group expenditures, under the fee for service system.  And all but one of those groups agreed to capitation, the one being orthopedics, which still we pay on a fee-for-service basis because they won’t accept a capitation.  We still pay fees for groups that we use very little, like plastic surgery, where the demand is very, very small.  Cardiac surgery we would pay, if we had such a task, on a fee-for-service basis; neurosurgery, etc.  General surgery we capitate and radiology we capitate and the Department of Medicine and so on down the line.

Where did you get the people in your group who are full-time – your internal medicine and pediatrics group?  Did you get them from the medical center or did you recruit them from general practitioners in the area?

Both.  We recruited from general pediatric practitioners from the area [but] not from general practitioners as the family practitioner would be defined.  A physician, Dr. James Turner, who was in practice for sixteen years here, who trained here and went to school here, who moved in full-time as a faculty member a year ago this January with his practice.  He’s a salaried faculty member with all of the rights and obligations of a faculty member.  He’s paid a salary that’s his whole income, and any fees that are collected go into a clinical practice fund for us like they do for any other department or division.  The second pediatrician was Dr. Paul Simons, who’s a graduate of this school, who trained at Einstein, and was in the Public Health Service in New Orleans.  His post with the Medical Care Group is his first clinical post in practice – he never was in private practice.

The first full-time internist was Dr. Owen Kantor, who was chief resident at City Hospital after having a fellowship in rheumatology.  The others all are from within the medical school: Dr. [Carl] Harford is with us part-time, myself a small portion of the time, and Dr. Gerald Morris.  And we’ve added for next year a young man named Dr. Steven Friedling, who’s trained here and would have gone into practice.

Do you have any trouble with salaries, since private practitioners claim that they make more money?

They claim correctly.  The interesting thing about this is that in the last five years it’s become more difficult because internal medicine has become more and more specialized, even in a five-year period.  As it has become more and more specialized, the income of private practitioners in internal medicine has skyrocketed.  The differential between what we’re able to pay, even at an augmented salary scale in the Department of Medicine now over what it was five years ago, is much greater now than it was then and therefore its harder for us to recruit internists than any other – than any other, we’re only recruiting other pediatricians – than pediatricians, where the differential is not so great.

How do you get around that?  What do you offer to them to make up the difference in salary?

We think that there’s a great deal [to offer].  First of all, the test will still be in the pudding as to whether this represents a satisfactory career for these young men who choose us.  We offer them first of all a salary which is, I think, quite adequate from the standpoint of a young person beginning.  It’s close to what they would get the first year they would be in private practice, but it isn’t exactly the same.  There is, in addition, the fringe benefit package for the medical school and the university which is very significant.  Particularly, if they look forward to college-age children it amounts to [a] fifteen [to] seventeen percent add-on to income.  Secondly, we offer them a way of life which is different from private practice in that they would be working in a group where there are people available to them for taking their duties in turn and for consultation.  That they can get that in private practice, but not as easily.  More importantly, they are working in a setting where they are responsible for teaching, which is exciting, [and] where there is investigation going on in which they can participate, which is intellectually stimulating.  And I think even more important than that, the opportunity to be part of the medical school where they can attend conferences, participate in rounds and keep themselves up to date is [important].

But isn’t a group that is interested in all the things that you mention not characteristic of the total group of health care providers in our country?  Won’t you be able to take your experience and extrapolate?

Yes, I think so.  It’s not characteristic, and that’s why I think it’s going to be more viable.  I think that the health care providers in the country who don’t continue to keep themselves up to date, who don’t participate in teaching, tend to be the ones who become more stultified and out of touch with things.  More and more, whether in relationship to medical schools or not is not quite so critical as to a center where there is activity of an intellectual variety going on.  More and more, medical practice is tending to organize around a base center with satellites.  In that people are beginning to practice medicine in our own community – I think St. John’s Mercy [Hospital] is a good example of a non-directly-medical school affiliated (it is affiliated with the University of Missouri) medical center which is accumulating the specialty talents to do the specialty work, providing a locus in the center for men and women to practice medicine without moving from institution to institution, and which will serve a geographic area, not dissimilar to the concept we have here.  The reasons that it will become of importance for people to practice in that setting will be similar to those here.  There will be support for them in the center.  There will be intellectual interchange in the center.  Their lives will become less complicated by virtue of the fact that they can turn to others and they can get help for their complicated problems.

Do you say then that such a system is more likely to be viable in an urban setting or a large town setting than in a small town or a rural area?

At the present time I think there’s little question about that because one can see the systematic relationship between a group of primary health care providers, a set of specialists, and a set of backup services which include major hospital services.  But I think that the future rural health care may take the present form – this form – with some modifications.  For example, the whole social movement in our country, although this has been partially reversed by some of the young people in the country, has been from rural to urban.  Economically, it seems likely that that will continue.  Therefore, it seems to me unlikely in the future that large numbers of physicians will choose to practice in small communities as individuals.  Therefore, they’ll practice as groups and to practice as groups they’ll require hospital backup.

Barring some major modification because of fuel shortages and things of this sort, I think that in the future we will see shopping centers and medical care facilities set up at interstate highway crossings, perhaps not in towns but between towns.  The transit time from the health facility to the hospital may be no greater in the rural setting than it is from the suburb into the urban setting.  That physicians may in fact staff such units by living in the city and commuting to the health care setting, and perhaps being on call at night in some kind of rotation in the health care setting for emergency provision of services.  That transportation will become as much a part of this as location.  If that were to be the case, Marshfield, Wisconsin is the example that everyone cites that’s grown up that way kind of automatically.  I think it’s a very viable setting – it serves 100,000 people in a town where only 17,000 people live.  The concept of a primary medical care group in a facility which offers something like 80 to 90 percent of the services needed in locus with specialty backup in hospital is a viable kind of concept for the rural setting.  Whether that in fact will come about or not, I don’t know.

At the moment, that seems to be a fairly difficult thing to bring off.  I know a physician down in Poplar Bluff, one of our graduates, who practices with five other people in a health care/hospital setting – group practice.  He tells me that they’re very overworked, that they can’t do all the things they need to do and that their patients don’t really want to go somewhere else when they think it would be better to send them somewhere else.  Do you think that your description of what you think will happen is going to happen in the near future or are we talking about 200 years from now?

I think if you define “near future” as twenty years that this will begin to happen.  If you define “near future” as five [years], it will not happen.  I think that people don’t want to go far away for medical care, but I also believe that part of the reason for this is that the physicians have educated the populace not to want to go away.  If we teach our patients that we cannot serve them as well as they deserve to be served, rather than what we in general do – we try to indicate that we’re the ones that they should turn to – that people will come to recognize that we’re interested in their best welfare.  We may need three levels of care.  We may need primary health care; we may need local hospital-type care on a secondary level that’s close by in which the primary health care provider can provide secondary care.  For example, treatment for uncomplicated pneumonia, congestive heart failure, surgery for relatively simple kinds of procedures.

But I think that one of the problems with an area like Poplar Bluff is that there is no specialty backup.  There is no defined responsibility which allows a man who does cardiac surgery or nephrology, for example, to say, “I know that I can make a living by practicing here.  I will have enough patients to keep me busy.”  Whereas, if there is some regionalization of health care so that regions are defined so that the most-specialized person can depend on providing enough service to keep him busy, that you will see organization come in this way.  That means that only very rarely would one have to go to a neurosurgeon and when we have to go to a neurosurgeon we’re usually knocked out and if we go one block or 100 miles, we wouldn’t know the difference.  I think that they ought to go to where the best care is for them.

Regarding the Kennedy Act – are health maintenance organizations going to help that or do you think it’s going to make the present situation last longer?

No.  I think it’s going to help.  First of all, the Kennedy Act really isn’t the act that was enacted.  It’s a compromise between the Kennedy Act and the House bill which heavily emphasizes the House bill.  The only major features out of the Kennedy Act which remain in the final bill are important features, and will help the situation.  One is an override on any restrictive state laws against prepaid group practice, which was in the Kennedy Senate version and was not in the House bill.  That is retained in the final bill.  A second feature is the requirement that employers offer prepaid group practice as one of the options to their employees if they have twenty-five or more employees, with certain characteristics, and there is a prepaid group practice available.  And the third is that there are at least loan funds, there are no other kinds of funds, available for the startup costs of such practices.  There are no direct grant funds for such purposes.   All of the patient care monies which were in the Kennedy Bill, all of the consumer input which was in the Kennedy Bill – the support for allied health personnel training, quality control, a whole variety of other things – are out at the present time.  So, that’ll have to come as future things, whatever things are perceived later legislatively as being appropriate.  But to have a first piece of national legislation which interferes with restrictions on an organized form of medical care, be it prepaid group practice or some other organized form of medical care.  In this act is the elimination of restrictions on what are called “independent practice associations,” which is a terminology that’s designed to include foundations, for example.  It provides for more than one option in organization of medical care to provide cost-conscious, quality controlled medical care services.  That makes this piece of legislation a landmark bill even though the amount of money – sounds large, $300 million – is just a drop in the bucket for what will ultimately be necessary.  So it’s these probably less-well-known provisions of the bill which I think are much more important frankly than the loan provisions for HMOs and that kind of thing, in the long run.

I’m interested that the federal government doesn’t really have the right to supersede state legislation unless it’s interstate commerce or roads.

I’m almost certain that will be a contested provision in the bill.

You mentioned the quality control which, of course, will come as soon as anybody looks at these.  I got an article out of the paper about a physician in North Andover, Massachusetts who has practiced for twenty years and is going out of practice because he says it’s a “police state” and the new federal law limits the time patients can stay in hospitals and so on.

I saw that.  I would have to say that I think that’s an overreaction to the situation.

Let me go back to your work here.  In 1969 you wrote a very interesting article with Malcolm Peterson and others on what you hoped to get done in this.  There were four things that you listed and I’m going to ask you: Do you think that in the last five years you’ve done them?  Then I’m going to ask you about the future.  One of those was the development and operation of experimental programs in medical practice and health care.  You’ve done that.  Health care planning and research in ambulatory services at WUMSAH [Washington University Medical School and Associated Hospitals].  Do you really think you’ve settled that or is this just a continual change?

No.  That’s a constant thing, and in fact, that’s an activity which we engaged in very heavily for the first two or three years in terms of research in relationship to the emergency rooms and clinics.  And [we] participated actively in the initial planning related to the emergency center and ambulatory care center, and in which we do very little right now.  Partly, that’s because we have devoted our major efforts toward the development of the group practice and partly it’s because any planning for ambulatory care which is done now, quite properly I think, is being considered in the much broader context of the entire area.  As such, it’s out of our hands.  I think that as we now do some of the things that we’ll talk about, in the future we’re going to have people here who will once again want to do specific research projects in this area.  And that our teaching programs will re-involve us in the traditional ambulatory care settings, which are inadequate and which I think we’ll want to begin and try to change.

The very fact that you’ve set up a kind of commercial institutional method of providing medical care gives you less flexibility than you would have had in the past when you were still doing research and where the money was not one of the main things.  Do you feel that in the future you’re going to be less able to change than you have been up to now?

I don’t really think so.

This is the second part of the Oral History interview with Dr. Gerald Perkoff on January 8, 1974.

You had asked whether or not I thought being involved in what is, in part, a commercial medical care provision – an organization within the institution – limited our flexibility for change in the future.  In some ways in might and in other ways not.  For example, I sort of have the feeling that everybody has a certain amount of emotional energy that they can expend in change and development.  As you know personally and as may be evident from our discussions, the amount of energy invested in this in the past five years has been very significant.  And I honestly, particularly at discouraging times – I don’t happen to be discouraged right now – I honestly question how much energy any one person, myself particularly included, could invest in multiple new efforts.

I think when one sees any new activity grow, you see a gigantic input.  Dr. [Philip R.] Dodge’s Department of Pediatrics is a perfect example.  He’s done just a magnificent job with that department in the past five years.  But now, Phil’s department is running along like a really good department, but it isn’t changing a great deal.  My guess is that it would be very hard for him to expend that kind of energy again to do another new thing all over again from scratch.  I’ve spent the years at City Hospital doing this kind of thing and doing this and in the sense that I may very well have run out of gas sometime in the future too, it may be easier for me without even knowing it to put most of my energies into what’s going on rather than into new things.  In that sense, this could be quite limiting.

Unless you can build into the system some input from other people.

That’s what we’re trying to do.  That’s what I was about to say – that I really don’t think that if we succeed with what I hope will be the next part of this, I don’t believe that we will be limited.  That is, that as should be evident from our discussions, that even though there are some things that have happened we haven’t talked about.  For example, Dr. Larry Kahn has set up a pediatric nurse-practitioner program which is, I think, one of the most important things our division has done.  It’s now a tuition part of the medical school and he’s training people who are out in various settings doing important things – I didn’t mention that with the students this morning – for the community.

We’ve done the experimental work, some of it, in the ambulatory care and we’ve certainly conducted the experiment in medical care related to prepaid group practice.  Our major research effort has been conducted on a specific project by a few people, all of whom had no real prior training in any of the basic sciences of health care research.  We’ve learned as we’ve gone, but we’ve had biostatistical input as we’ve needed it, by getting it from Dr. [Reimut] Wette’s group.  We have not had medical economics input; we’ve had only a minimal amount of sociology input.  There hasn’t been an epidemiologist in the school during the entire time that I’ve been located at the medical school, and so on.  Those are the basic sciences of health care research.

So that we look upon our next task, and under the Johnson Foundation to develop the division and the teaching practice, is to recruit into the school academic people whose major task is research in health care.  Dr. [Robert E.] Shank has been working for over a year on a search committee – he and Hugh Chaplin and John Holloszy and myself.  We think we may be close to getting an epidemiologist finally, to set up a division again in the Department of Medicine.  We’ve made an offer recently to a medical economist, one of the bright young people in the country, whom we hope we will jointly get between the Department of Economics and us.  Dr. [Murray L.] Wax in Sociology and I are jointly recruiting for someone in medical sociology – hopefully, two people, if we can find the funds.  We’d like to try again to refurbish our skills in biostatistics and so on.  What we want to do in the next several years is to build a research group here which has the characteristics of an academic unit devoted to research.  That group then should be able to study aspects of the medical care system which will provide other alternatives for doing things than the prepaid group practice.  Which may tell us that that’s not a cost-effective mechanism and that that ought to be changed in some way.  I think that would be consonant both with what we’ve done up to now and with the philosophy that appears to be a functional one in this medical center: that research be done, that facts be developed, that selling be done based on those facts, and that change then be brought about on those grounds.

Will that have to come out of the money of the Medical Care Group or will it come out of other funds of the University?

That can’t come out of the funds for the Medical Care Group.  Because even if we weren’t committed, which we are morally, not to pass on the cost of teaching and research to the patient, you in fact couldn’t pass on the costs of research and teaching to the patient for two reasons: one is, when a person enrolls in a prepaid group practice they enroll for a set of services which are written down.  These are the services that I get that I pay for.  Research and teaching is not included in that.  The second thing is, that if we assigned the cost of research and teaching to the patient or to the enrollee, we would price the package out of the market.  It would become too expensive for people to buy.  It’s almost too expensive anyway, the way things are today.  So, these are activities which have to be supported in other ways.  The teaching activities at the moment are supported on a contract.  Insofar as we can identify that the trainees in the setting are productive of patient care, it will be appropriate to cost that portion of trainees’ salaries to the Medical Care Group, that they are productive of medical care – similar to the way in which Mallinckrodt Institute of Radiology costs part of its radiology services to the residents who read the films – because they do read films.  To the extent that the teaching costs time of other physicians, space, etc., that will have to be funded by other sources that are responsible for training – either the medical school or the hospital or outside grants.  The same is true for research.

Isn’t this going to bring you into conflict on the town and gown problem again in that other health maintenance organizations not based on University medical centers cannot do this without charging the patient?  Either they have to charge the patient or they can’t keep up with what is going on.

You mean in terms of providing training and doing research?

That’s right.

I think it means that any group that provides training and does research has to support that from outside funding of some sort.  This is another reason which leads me to believe that the most interesting places in which to work will be those which can do this.  That isn’t just medical schools.  We tend to believe that medical schools are the only places where research is done.  In fact, the Kaiser Foundation Health Plan (not the family foundation, but the industrial foundation) has had large sums of research grants in health care over the last ten years.  Some of which have been excellent and others not, like some of our grants.  Presently, [Kaiser] competes quite well for research monies in the field of health care.  In fact, they have not discharged what I think are their responsibilities in the teaching area, even though the Kaiser Plans are located where there are medical schools.  They have very little relationship to teaching and I think it’s a responsibility they’ll have to take on.

Do you think research funds are going to be available or do you think the federal government’s cutting of research funds will make this impossible?

It’s going to make it a much more difficult thing.  There’s no question about that.  It would be silly for me to imagine that there’s going to be a lot of money compared to what there once was.  I’m on the Health Services Research study section and I can say that there is money, that we have an inadequate number of good grants, that the really good grants which are submitted and approved are funded.  And one of our big problems is in the development of enough groups with enough talent to do training of new people in this area, and with the federal government’s present short-sighted view of research training which applies also to health care research training.  Right now there aren’t enough good grants for all the money.  There are plenty of grants but many of them are inadequate.

Sounds like the library grants.  You did mention the educational programs for allied health personnel which is what you call them in here though now the terminology has changed.  Would you like to say something about that?

We have done two things in this regard, both of which I think are important, neither of which do I know will be in fact the way they’re going to be done in the future.  The whole issue of how primary health care is going to be provided is a changing one, as far as I’m concerned – I think we’re just learning.  First, as I mentioned before, we have a pediatric nurse-practitioner training program.  That came about in an interesting way.  Larry Kahn, who was in private [pediatric] practice, joined our group full-time.  Initially, he was going to be a practitioner in the group.  But he’s a very creative man and rapidly became interested in research, and we got other people to do the patient care in the experimental program and he’s now become, in essence, [my] alter ego.  If anyone else is responsible for the division, it’s Larry.

He came to me in the beginning and said, “Henry Silver is doing this work out in Colorado about pediatric nurse-practitioners.  What do you think about it?”  We read this stuff together and I said, “Gee, I think that’s a good idea.”  In the first year of our program we had funds from Metropolitan and Kellogg which we weren’t spending for patient care because we were just getting going.  I called both of the responsible parties and asked if we could use some of those funds to have an initial group of pediatric nurse-practitioners, and so Larry took that money and set up a group with three trainees.  And the second year we partially supported it from the program and the third year it became a tuition-supported program.  There now have been twenty-seven graduates.  This year there are another ten or eleven trainees; next year there’ll be twelve.  We have an approved, but not funded, training grant that we hope the new release of funds from the nursing service will fund, for augmenting that to sixteen and putting it together with a Master’s program at Southern Illinois University School of Nursing.  Of the twenty-seven presently graduated, sixteen are working in various public health settings caring for poor people in rural and urban settings.  Some are working in private practice, some are teaching, some are working in clinics and we think [they are] really providing a major input in health care.  Twenty-seven people isn’t a lot of people, but it’s better than no people.

The other thing which we’ve done in this area, which I’m very pleased about because it’s an example of inter-school cooperation, although the program itself has not yet developed to what I would think it could, is to be part of what is now called the St. Louis Inter-Institutional Program for Physician Assistants.  Some three or four years ago when I was Chairman of the Dean’s Committee of the V.A. Hospital, the V.A., for the first time, put together some funds which they said were for the training of Type A or the Duke Variety of two-year program for physician assistants.  [These were] mainly hospital-based people and mainly, in the V.A.’s view, designed to augment the inadequate ward staffing of V.A. hospitals.

Saint Louis University put together an application for such a program which came through the Dean’s Committee.  My friends in that group know that I was critical of that application and as Chairman of the Dean’s Committee insisted that it not go through in its form.  Instead, said that I thought that we should not have competing programs in this city and that we should have one program.  Beginning with that group, and with a group which was – I don’t remember even the name of it – the Allied Health Consortium, or something of the sort – which sort of met under the auspices of the regional medical program – we involved the junior college, S.I.U. [Southern Illinois University] at that time (although they don’t have active input into the P.A. program), the V.A., Washington U., Saint Louis University, and the Saint Louis University School of Nursing and Allied Health.  In the planning of a combined application, which then went into the V.A. and was funded, which is based in the Saint Louis University School of Nursing and Allied Health, which is put in the catalogs of both medical schools, which has clinical training, basic academic courses given in the Saint Louis [University] School of Nursing and Allied Health and in the Forest Park Community College, which has clinical training mainly in the V.A. Hospital but also at Saint Louis U. and in the City Hospital in the Washington U. medical service.  It now has graduated its first group of some ten physician assistants and has another group in training at the present time.  It’s predominately a Saint Louis University program, but our input into it can be as active as we choose and we don’t have two programs each competing for funds.  So there is [a] P.A. program here.  We will be hiring a P.A. in our group, to help with health assessment examinations and minor illness care within the year, I’m sure.  So, we’re committed in our program to the hiring and training of physicians’ [assistants] in relationship to allied health.

Where do you see these P.A.s going?  Mostly into urban practice as physicians’ assistants or out in rural practice or both?

Both.  They can work in any setting where a physician will define his tasks and delegate those tasks which he’s too highly trained to have to continue to do, to somebody who’s trained to do them.  That can be in any setting.  There are other forms of physician assistants that we don’t train – the Med X being one of the characteristic ones, developed in [the state of] Washington – people who take three months of didactic work and then twelve months of work with a specific physician whom they then work with.  There’s some question as to whether they’re transferable – whether they could leave and go to work for another physician – because they’ve been trained only with one.  So far they’ve been able to move about.  There’s concern on the part of physicians that such individuals might set up a practice of medicine and have to be licensed.  In fact, their practice will have to be controlled in some way.  My own view is that the assistant isn’t the one who should be licensed; I think that the physician should be licensed as to whether or not he’s good enough for an assistant to practice with.  But that’s kind of revolutionary and doctors don’t like that sort of thing.  There are physicians practicing, for example, with health problems – alcoholics and others – whom I think it would rapidly become clear the P.A. would be a better health care provider than the physician.  I don’t think such a physician should be allowed to have a P.A.  Under most licensing schedules which have been developed in other states, the P.A. would be certified and any physician who wanted could hire such a person.  I think that’s not the right way to go about it.  But that kind of thing is coming.  Whether it’s really the way medicine will be practiced or not in the future, I don’t know.

Do you think there will be other kinds of allied health personnel that you would like to see trained?

There are now many other kinds being trained, other than the traditional variety.  There are some places training orthopedic assistants and some places training emergency room specialists.  I think that the most interesting activity in this light is Dr. [Malcolm] Peterson’s activity at Hopkins, which neither he nor I nor the people there know how it’s going to turn out.  They’ve set up a new School of Health Services there, which takes people at the baccalaureate level, introduces them into a core curriculum of science and social science and task assignment, that runs for about three years.  At the end they can then specialize and become nurses, physician assistants and other kinds of primary health care providers.  The whole framework of primary health care will depend, in part, on what is perceived as the need for delivery and whether or not physicians will function by delegation of responsibility.  It’s really quite clear that much of what physicians do in offices, from a physical point of view you don’t have to go to medical school for four years and take four years of training in order to do.  It’s the judgmental aspects that are in question, and that’s the open issue, I think.

Even here at Washington University they are training something they call medical historians, which is nothing but somebody who takes the histories of the patients.  One of the other things which you’ve said – you were interested when you started in seeing what could be done about the care of the indigent patient.  How has your work in the past five years brought you closer to that?

It’s brought us closer in concept and method but it has not brought us closer in terms of providing health care for the indigent patient.  I am not disappointed in that except insofar as it’s slow, because I think that the ultimate method by which the indigent patient should be cared for is the same system that everybody else is cared for.  I look upon the Medical Care Group as one kind of example of how one system of medical care ought to be set up.  It’s our commitment to enroll at least a third of the people in that program from present publicly-supported groups.  We had hoped that we would have national health insurance by now and if so we would be actively enrolling people who would have the option of going to the clinic, to a doctor on the corner, or to nobody, or to us in this program.  We are presently working toward next summer as the deadline for when ward patients in medicine will no longer be separated into separate units and will be hospitalized in the same kinds of facilities and cared for by the same people at the same time as private patients.

Insofar as our work has permitted us to understand an organization for medical care – not necessarily the organization for medical care – and insofar as it’s been possible to identify ways of teaching and research with patients that allow the patients to be part of the private – meaning by “private” the same as others – kind of system, then I think that this is the way indigent patient care ought to be provided.  No matter what the payment source is for patients, whether it’s a member of the Mallinckrodt family _____(?) or some poor black teenage mother who lives two miles north of here, that that person should have the same system, the same facilities, the same benefits, and the same relationships to teaching and research as anybody else.  I think we’ve learned ways in which that can be done.  Getting them done is another matter.  I still think it’s a mistake in the long haul to have a neighborhood health center set off to the side that only cares for poor, black people in a housing project.  Although obviously, that’s far better than having nothing to care for such people, but it doesn’t get them any closer to the mainstream of the medical care system than they were before.  In the long run, I think that’s wrong.  Our goal is the long-run goal.  The day when someone asks us how many indigent patients we’re taking care of, the answer is “Zero.”

Wouldn’t your care have to be different, because with indigent patients you’re going to have a different mixture of disease and health?

I think we’ll have to add services that we don’t presently have, mainly outreach services and educational programs.  Where this has been looked at elsewhere, the utilization of a prepaid group practice by [low income groups], for example, turns out to have a higher missed appointment rate than other people in the plan – this is done in two locations in Kaiser.  It turns out to have a higher telephone call rate and a higher initial utilization [rate] by children.  But other than that, the utilization [rate] remains about the same as other people’s.  The initial unmet need is about twice as high in many indigent populations, but it is a need which can be met.  The major unmet need is one which exists for everybody and that’s dental care, which none of us do an adequate job of caring for.  It’s not part of our program – yet.  I hope it will be one day.  So there would be an increased provision of certain kinds of services and some outreach in educational services which would have to be added.  But I don’t believe the system itself would have to be modified in a major way.

How would that modify your costing problem?

Oh, it would complicate it.  As a matter of fact, one of the provisions that’s in the new HMO bill that I consider a negative – we tried to get it out – is that community rating would be used and that the same rates would be paid in [an] HMO for everybody.  That presents a problem whether you’re talking about poor people or not, because older people use more medical care than younger people.  Therefore, for the same rates to be paid say for Medicare-covered persons as for young people of age twenty to thirty presents problems to an HMO.  It means that the overall rate is high and therefore, the young person pays, in part, for the older person’s medical care.  I personally don’t consider that inappropriate because I think that people have to pay for other people’s care in a variety of human services, but it ought to be faced directly and done directly so that people know what they’re doing.

I think the same thing is true for medical care for the poor.  If they “community-rate,” then the overall cost for everyone will be higher because you will not be able to charge the government more for people whose medical care needs might be higher than you would [charge] somebody else because such a system – theoretically and I’m sure in actuality – would to a certain extent be subject to abuse.  But that presents real problems, unresolved problems, in terms of patient [care].

I wondered when you started enrolling the Washington University staff and faculty whether you weren’t going to get a skewed picture.

We do.  We expected it, we’re prepared for it, and it’s probably going to cost us money.

Actually cost you money?

Our deficit for this group [the Washington University group] will probably be a little larger, because mainly singles enrolled, as would be expected from the rate structure.  Although we haven’t seen all the enrollments yet, a goodly number of them are likely to be the older, single members of the faculty rather than the younger, single members of the faculty.  This means that we’ll probably have increased utilization by that group.  It’s been experienced in other university settings.  But, first of all, we want to provide the care anyway.  And secondly, if we can do a good job of caring for the faculty, who will be a highly critical group we believe, then that should be one of the best selling points for our program.  So, that’s a calculated risk that we’ve taken, knowing that’s what’s going to happen.

Has it been successful?  Have you gotten your twenty to twenty-five thousand enrollees?

No.  We expect that not to happen for another two and one half years.  But we’re only about 300 behind our projection for now.  But we only got there with this enrollment.  That means we have some months of being below our projections.  This is a thing which goes in a step-wise fashion, rather than in a steady growth phase.  We project that next year, if we achieve our enrollment projections for a year and a half from now – that is, a year from this next July – we should be at 14,000 or so [which is] certainly at the maximum utilization of our present space.  If we do achieve that enrollment level, then the medical school will experience no deficit in the next academic year that won’t be made up for by grants.  That means that in the succeeding year we should approach breaking even without grants, which was our original projection.  The deficit this year will be of the order of magnitude that we expected, in the neighborhood of $150,000 and that the medical school budgeted for.  When you asked earlier who is going to pay for the development of this, the medical school has taken on an unusual obligation that most medical schools would not do.  The University itself has underwritten this program to the extent that grants don’t underwrite it.  They’ve made a major commitment, which is unique, I think.

The last question I have is, what do you plan to do next?  What do you think is the next step in this?

First of all, I’d like to see the training program be successful.  By successful I mean exciting to teacher and student, so that it attracts each year six or eight or ten physicians who are interested in general internal medicine and pediatrics.  Because if this program can’t justify itself from an educational point of view then one of its major justifications for being run by a medical school is no longer operative.  Educationally, I think, it has to demonstrate that it can succeed.

The second thing I’d like to see is for a strong research group to have input into both the practice, the teaching, and into other studies in areas unrelated to prepaid group practice – [areas such as] the economics of hospital care and things of this sort; the economics, sociology and cultural aspects of ambulatory services; a wide variety of research activities.

The third thing is that ultimately I would like to see dissolution of the clinics.  I think that there shouldn’t be clinics any longer in time, that ultimately we and others have to set up systems whereby people are cared for whether they’re paid for by the government or otherwise, without distinction.  I think that’s part of this overall new town, new medical care system kind of planning, which is probably one and two, maybe even three decades in duration for this medical center.  I really can’t see very far beyond that.

Thirty years is a long time.

I don’t even know if I can see thirty years.  In terms of the next several years there’s little question that there’s plenty to do in these areas.  In fact – and I think this is important – the fact that we have a building has made everybody recognize that we’re there and people attribute to us considerably more success than I personally feel we have achieved at this point.  To have a building and a beautiful place is considered success by most people, but until in fact [the program] demonstrates financial viability and in fact is caring for people adequately and teaching, it’s just a tool that we use to get there.  We could still fail, there’s no question about it.  I don’t think that’s going to happen, but if we don’t enroll people and if we make bad calculations, or if something over which we have no control happens – for example, if the Cost of Living Council decontrols hospitals and hospital costs skyrocket – then we’re in bad trouble.  Because then the market price of our package goes way out of keeping, and so on.  So, it will be several years before we really know, in fact, that we’ve made it, even though the building suggests that we’ve made it.  So I feel there’s a lot to do before we really have demonstrated our viability.

Nobody can in this time know what the future will be financially, but you certainly have demonstrated up to now that it’s a viable idea.  Is there anything else which I didn’t think to ask you that you think we ought to put on the tape for future historians of medicine?

There are all kinds of things that one could talk about, some of which we have written down in the papers and whatnot [which] we will try to get together for you.  (I frankly am honored that they are to be included.)  I really think that it’s not yet clearly understood – maybe this is a bias on my part and it shouldn’t be clearly understood as well as I think it should – that educational institutions have to define a responsibility that they’re discharging.  I think that we have come beyond the time when to have an Oxfordian scholarship approach in which scholars “scholar” and other people “do” is viable.  Our unit has kind of been the focus around which that sort of difference of approach in education and research and patient care has focused over the past five years.  The things which we’ve dealt with – the discussions in various committees and the decisions to enlarge the practice and all the various aspects of how much you pay people and whether it’s as “good” to do clinical practice as research.  “Good” in quotes meaning that the same bright people do it with the same creativity.

All these issues of what’s academic and what’s not face every medical school in the United States, and probably every public service institution besides medical schools.  The contest between what is academic and the utility of research, which clearly it’s useful – penicillin being the classic example and all the other things which everyone can properly cite.  The contest between the utility of research for research’s sake, the utility of research as an educational tool for stimulating young minds, and the utility of actual service provision for people as an educational tool.  There is some mix in there that we haven’t really properly approached yet and that it’s changing in the context of our society.  Health care, whether you call it community medicine or health care research or what have you, happens to have been the arena over which much of this has been done and will be done.  I think the same things will apply in other kinds of education than medicine and in other kinds of service area than health care.  I think this is part of a big social movement and I don’t believe that medical schools really know that, most of them, yet.  We certainly see that in all the discussions we’ve participated [in] – traditional versus non-traditional, good and bad, right and wrong.  There are all sorts of shadings in that which somehow never quite come out in a finished product with a sign outside.

I think this is generally true.  People don’t realize that they’ve taken part in a large change in growth in society, until twenty years later they look back and say, “My, goodness.  This is what happened.”  We’re very grateful to you for this and I’m very happy to have you say that it will be all right to have other people listen to this tape.

Oh, yes.  There’s nothing on here that anyone, if they’re willing to sit and listen for this long, shouldn’t hear.

We’d be happy to have any of the papers, or any of your diaries or anything that you have.

I’ll have the girls begin to fish out some of this stuff.