FAMILY MEDICINE
A Historical Review of a Youn g Departm ent
by Paul C. Brucker, M .D.
The Flexn er Report, in 1910, introduced dramatic changes in the natur e
of med ica l ed ucation. C linica l instruction was shifte d from physician-prece p to r offices to much more or ganized,
accre d ited tea ching hospitals. Ther e
wa s an em p has is p lac ed upon th e rol e
of full-time clini cal facult y for training
in b oth th e clinical and basic scie nces .
ot sur p rising ly, th e cur ric ulum
b ec ame increa sin gly influ enced b y th e
stud y of tho se d iseas es w hich nec essitat ed the ho sp ita liza tion of p ati ents and
int ensive serv ice s. Examination of th e
selecte d, serious problems of hosp ital
patients b ecame th e norm for training;
and th e problem s that ambulatory
patients had did not attract nea rly as
mu ch atte ntion or ed ucational effo rt.
As specific organ-related kn owl ed ge
increa sed , th e era of specialization
came into its own.
By th e 1950's, fed eral funds for m edical research an d tra ining in resea rch
techniques b ecame an accepted pri or ity. Vast amounts of fund s w er e
direct ed toward th e inv esti gati on of
th ose d iseases w hich typi cally required
hospitalizati on . Studies direct ed tow ard
the prolon gati on o f life, rather than th e
pr even tion of di sea ses w er e ca rried
out, w ith tea chin g hospitals serv ing as
the clinical lab orator ies. Dra m ati c,
2
JEFFERSON ALUM NI BULLETI N
alm ost miracle-like advances were
ma d e in m edicine. Open hear t surgery ,
org an tra nsp lant ati on and d ialysis are
just a few o f th e tech niq ues that
resulted from this co nce ntra tion of
effo rt.
In thi s clim ate o f success and seemingly unlimited sup p ly of resear ch
funds, there w as a stea dy incr ease in
the number of able students who follow ed th eir mentor s into specialty
careers. Even the genera l int ernist, tradition ally th e di agn ostician or th e "doctor 's d oct or ," b egan to disa ppear. Man y
of th e good stud ent s felt tha t the "rea l
ac tion " lay in specialty fields, not in
ge ne ra l m edi cin e, ge ne ra l pedi atrics or
in ge ne ra l practi ce. By 1974 th er e we re
four specialists for eve ry ge ne ra l pr act ition er in th e nit ed Stat es, whi le in
Grea t Britain the re w ere thr ee primary
care physicia ns to one sp ecialist. Preve ntive medicine was not p opular , an d
ther e was a tenden cy not to em p hasize
th e psych ological need s of pa tients and
th e effe cts of illness up on th e social
unit. Man y p erson s came to feel th at
th ey co uld not find a w ell-trained p ersonal physician wh o w ould allow eas y
entry into the medical system and wo uld
help moni tor and manage th eir ca re rega rd less of whether it b e in the out- or
in-pa tient sett ing . They expe cte d an d
SPRING 1988
wa nte d a ph ysician who could provid e
co m p re he nsive and co ntinuous car e.
Allopathic specialty ph ysicians
b ecame co ncerne d as they found them selves incr easingly d ep en d ent up on
primary ca re osteop aths as the only
ref erring p rimar y p hys icians in th eir
co m m unities . T hey too sensed a lack of
properly tr ained p rimary care ph ysicia ns w ho co uld select appropriate,
interesting and co m p lex patients who
w ould require specialized d iagnosis or
therapy.
T he reports of the Willard and Mills
Com m ission in the mid-1960's furt her
called atte ntion to th ese trtjnd s.
ationa lly, the ge neral practition ers
b ecame co ncerne d lest they di sappear
fr om the scene of organized and aca d emic medi cine. They sou ght to
impro ve th eir sta tur e a nd to d o away
with the pejorative, commonly used
la b el of " the local med ical d oct or or the
LMD ." The y recogni zed tha t they
wou ld have to up grade the training and
qu alifi cati on s o f thos e ent erin g practice
in th e 1970's. In 1964 they went to the
Ame rican Boa rd of Intern al Medi cin e
and aske d for approval of a new typ e
of resid en cy training for primary ca re
ph ysician s or family p hysicians. Th e
Ame rican Board of Int ern al Medicine
refu sed the request that fam ily rnedi-
, Paul C. Bruck er, M .D . becam e a
m ember of the Board of Family
Practice in April 1983. During the
next fi ve years he serv ed 011 the
Cont ent Validity Co m m ittee, the
Long-Ran ge Planning Co m m ittee, th e Standard Setting Co m mittee, the Research and Devel o pm ent Co m mittee, th e Cr edential Co m m ittee and the Ex ecutive Co m m ittee. From April
1986 thr ough March 1987 Dr .
Brucker se rve d as SecretaryTr easurer and then fro m April
1987 th rough March 1988 as President of the American Board of
Family Practi ce. H e co ntinues to
be an acti ve m ember of th e
Board's Item Writ ers Committee
and th e Ed ito rial Board of the
Joum al of Family prdcti ce, and
serv es as therepr esentatioe of the
American Board of Family Practice to the American Board of
Medi cal Sp ecialties.
Dr. Bruck er
cine become a subs pe cialty of int ernal
medi cin e. Subsequentl y, in 1969, conce rne d family physicians w er e abl e to
co nvinc e organized ac ade mic medicin e
of the need for a thr ee year, specialty
training program in family practice and
the Ameri can Board of Family Pra cti ce
wa s estab lishe d. Much of the cre d it for
this achi evem ent mu st be giv en to
icholas J. Pisacano, M.D. , who led
man y of the dis cu ssion s relat ed to the
Willard and Millis rep orts, and wh o
beca me the first Executive Secr et ar y
of the Am eri can Board of Family
Practice.
J effer son 's Dean, William F . Kellow ,
M.D ., kn ew Dr. Pisacano w ell. He frequ ently talk ed with Dr. Pisacano ab out
the new specialty of family practi ce
and the possibility of estab lishing a
family medicin e p ro gram at Jeffer son.
He too wa s always mindful of the med ical ne eds of the community and wa s
concerned about the disappearance of
primary care. In 1967, Dean Kellow
invit ed Franklin C . Kelt on , M.D ., and
Da vid W. Kistler , M.D. , tw o o fficerlead er s of the Pennsylvania Acad em y
of Family Ph ysicians, to join him in a
discussion of how the training of the
primar y ca re ph ysician might bes t be
accom plished . Doctors Kelt on and
Kistler abl y exp ressed their belief that
famil y practi ce shou ld be a distinct
program at the Co lleg e.
Th e Beginning of Famil y
Medicin e at ] ef fe rson
In 1971, under Dean Kellow 's lead ership and with faculty ap prova l, a Division of Family Medicine w as esta blished at Jeffer son in the Department
of Com m unity and Preventive Medicine. Willard A. Krehl , M.D ., then Professor and C ha irma n of that d epart-
JEFFERSON ALUMN I BULLETIN
SPRING 1988
3
m ent, wa s enthusiastically sup po rtive
of th e ve nture. Doct or s Kelt on and
Kistler help ed him to esta b lish tw ent yfive p recepto rships in famil y p ra cti ce.
In th e first yea r, 40 students chose the
elective six-week p rec eptorship . In
ge ne ra l, they w ere overw hel m ing ly
enthusiastic a bo ut th e experience!
Shortly ther eafter , in 1972, with
facu lty and Boa rd ap proval, formal
arrangements w ere ma d e to estab lish a
sep ara te Department of F amily Med icine. A sea rc h b egan for th e first
cha irman of the new departmen t.
Jose ph S. Go nnella, M.D ., th en the
Assistan t Dean in C harge of Aca d e mic
Affairs, sub m itted my name to the
Search Com m ittee. D r. Go nnella and I
had worked closely for so me four ye ars
in the d evelop m ent of a progra m for
the evaluation o f m edical care. This
wor k was sub se q ue ntly published and
pr esen ted at sc ientific m eeting s. Wh e n
I wa s initially a p proached to co nsider
the ca nd id acy for th e chairma nship I
was flatt er ed , but at the sa me tim e torn
between the o p p or tunity fo r suc h a
position and the w onde rful one tha t I
had in a 100 ye a r old bTfOU P famil y
practice in Am b ler, Pennsylvani a, a
sub ur b of Phil ad el ph ia. One of m y four
partner s was Dr. Kelton, on e of th e
fam ily ph ysician s so instru menta l in
estab lishing the fam ily m edicin e p ro gra m a t Jefferson.
Dean Gonne lla wa s ve ry p ersuasive !
I ag reed to accept an invitation to meet
w ith th e Sea rc h Committ ee. As far as I
was co ncerned , th e da te of th e first
meeting wa s kept a secre t. All o f the
members o f the Comm itt ee kn ew
about th e time and date, but so m ehow ,
ina d vertently, I wa s not infor med . Fo rtunately, Dean Kellow d iscover ed th is,
and th e night b ef or e the m eeting ca lled
to exp re ss his regr et s about th e ov ersight! We b ot h had a good lau gh , and
afte r so me hast ily rea rranged plan s I
wa s able to m eet w ith th e Com mi ttee
the next d a y.
The Sea rch C ommittee was impressive . T hey had an und erstand ing of
primary care, w ha t th e fo rmation of a
new d epartment mi ght enta il, and th e
d irect ion that th ey wa nted th e d e par tment to tak e. It w as a tribute to the
ca reful prepara tory wo rk th at had go ne
4
JEFFERSON ALU ~I I BULLETIN
int o the d ecision to form suc h a
d e partment. Aft er an enjoy ab le m ee ting w ith th e Committee, I returned to
Am b ler, o nly to b e ca lled that sa me
evening b y Dr. Kellow to d et ermine if I
wa s w illing to meet with some of th e
o the r chairmen in the Colleg e. N ota b le
a mo ng those w ith w ho m 1 m et was
Thomas D. Duane, M.D ., th e C hairman
of th e Department of Ophthal m ology,
a nd a lso C ha ir ma n of the Curricu lum
Committ ee. Dr. Du an e took a gre a t
d eal of tim e in exp laining th e int ent of
th e newly revised curr iculum , w hich
incl ud ed a manda to ry six-w eek clerkship in fam ily med icine. Robert L.
Brent , M. D., the Professor and C ha irman o f the Department of Pediatrics,
in an unselfish manner was helpful an d
encoura ging . Robert T . Wise, M.D ., th e
Ma gee Pr of essor and C ha irman of th e
Deparment o f Medicine, ca utiously
sup p or ted the conc ept of th e new
d epart m en t and curricular cha ng es; b ut
he w as co nc ern ed about the quality of
m edical student training that a ne w
d epartm ent w ith new facult y migh t
ma ke ava ilab le. I ap prec iated his
co m m ents and co ncern about ma tt ers
of q ua lity .
After seve ra l w eeks of di scu ssions,
the w ell-laid p lans, th e rece pti veness of
th e se nior fac ulty, and th e encour a gem ent o f Dean s Kellow and Go nnella,
all con vinced m e tha t th e new chairmanshi p w ou ld b e a w ond erful o pportunity. 1 was plea sed that th e Colleg e
saw fit to off er suc h a position , and on
January 1, 1973, I b eca m e th e first Professo r and C ha irma n of th e new
d epartment in b oth th e Medical College and Hospital.
Parentheti cally, almost simultan eously w ith m y ac cepting th e p osition
th e chairma n o f th e Haas Community
Fund , Mr. Hich ard Bennett, ca lled
Dean Kello w to ask w hy the fun d s
w hich the fo und a tion had awar d ed the
Medical College in 1971 to es tab lish th e
new d epartment had not yet b een used .
Wh en Dea n Kellow told him th at "a D r.
Bru ck er" had b een invit ed to cha ir the
d epar tm ent he was as to und ed , fo r I
had b een Mr. Benn ett's friend and per sona l ph ysician for 13 ye a rs. Fortuna tely, this relation ship has co ntinue d
until tod a y. Mr. Benn ett wa s the first
SPRING 1988
One of th e initial problems wi th the
am b ula to ry clerkship was w here to
place 223 junior stud ents. Sufficiently
lar ge outpatient activities with exce llent
sup erv ision had to b e ident ified .
official" fam ily practi ce pa tien t at
Jeff erson !
Th e Beginning of th e
D epartment
By the tim e I a rrived on campus in
March 1973, ren ovati on s to the old
Sco tt Library on th e first floor of the
College bu ild ing wer e nearl y co m p lete .
T he attracti ve new fac ility includ ed
five offices for fa cult y members, an
office for the cha irma n, and ad eq uat e
space for clerica l help . Missin g, howeve r, wa s the furniture, w hich had not
a rri ved on tim e. I b egan my tenure
w ith an old army d esk and a search for
a d esk cha ir.
At o ur m eeting that first d ay, Dean
Kellow repeat ed the previous cha rge
that 1 was ex pe cted to estab lish under gra d ua te, gra d uate and postgraduate
teach ing programs, and eve ntua lly,
once th e d epar tm ent was estab lishe d ,
to d evelop a resear ch p rogram . A ve ry
pl easant memor y abo ut the d evelo pm ent of these programs is th e sup port
lent b y Dea n Kellow , Dean Gonnella
and Mr. Tho mas Murray, the Business
Ad mi nistrator o f the C ollege. T hey
always had tim e to listen , to eva lua te
and to off er co nstruc tiv e advice,
rega rd less o f the ma gn itude of the
problem or their bu sy sche d ules.
Th e Undergraduate Family
M edicin e C urriculum
The first manda tor y Family Med icine Ju nior C lerkship was sta rted in the
Fa ll o f 1974. T he cur ric ulum , w hich
w as d esign ed for this clerkship ,
e m phasize d th e d evelop ment of an
a m b ula tory expe rience that w ould provide ready access for pa tients, allow
co ntinuity and co m prehensiven ess o f
ca re, and give att en tion to the ps ych osocia l need s of th e fam ily. Sim ultan eo usly, a cur riculum wa s d esigned for
the se nio r yea r elective. Even in 1974
th e Cu rric ulum Com mi tt ee wa s aware
of th e up coming em phasis that wou ld
b e p laced on a m b ulato ry ca re tra ining.
j efferson's cur riculum wa s way ahead
of th e tim es!
Resident Rob ert Motley , M.D. , '85 chec ks patient Rob ert Smith as Clinical Assistant
Professor Richard C. W ender, M.D. and Mrs. Smith look on.
JEFFERSON ALU MNI BULLETIN
SPRING 1988
5
Amon g the existing Jefferson affiliations wa s the Wilmington Medical Cen ter. Th ere, und er the direction of Den e
T . Walt ers, M.D ., was an exc ellent
resid ency program. It wa s a logical
choi ce to include Wilmington Medical
Ce nter as one of the first affiliate sites
for the und ergraduate clerkship. Simul taneously, the C hestnut Hill Ho spital
expressed a rekindled desire to estab lish a famil y practice resid en cy program and to accept und ergraduate student s for the clerk ship. Harry Kaplan,
M.D . wa s nam ed the first dir ect or of
this pr ogram . Up until the pr esent tim e,
both of these institutions ha ve made a
valuable co ntrib ution to the und ergrad uate teachin g. Still, the Department lack ed an ad equate number of
spac es.
In late 1973, a discussion wa s begun
with the Richard K. Mellon Foundation
and representatives of the Latrobe Area
Hospital in Latrobe, Penn sylvania,
abo ut the possibility of an affiliate progra m in famil y medi cine. Th e Hospital
wa s seeking to estab lish medical
schoo l affiliation in order to attract an
eve n bett er and more di verse medi cal
sta ff; to improve the qu alit y of patient
care , seco ndary to the stimulus that an
ed ucational program wo uld provide;
and to serve as a training site for famil y
ph ysician s wh o w ere sore ly need ed in
Latrob e and the sur round ing rural
co mmunities. After an exte nsive study
b y the Mellon Foundation about the
adv isability and feasibilit y of such an
affiliation and ed uca tional pr ogram,
the Foundation gav e the Latrobe Area
Hospital a grant to build a clinica l outpatient faci lity wh ere the students
co uld see ambulatory patient s, and also
to estab lish housing for both the und ergra d ua te students and anti cipated family pr acti ce resid ent s. This wa s a great
assist!
On ce the Lat robe Area Hospital Affiliati on was well und er way, the Co llege
turn ed to face a soc ietal co nc ern for the
bett er distribution of family ph ysician s.
In 1974, there were severa l co unties in
Penn sylvani a with just tw o or thr ee
famil y ph ysician s. Conseq uently, the
Physician Shortag e Area Pro gram
(PSAP) was established . Under this pr ogram the College would acce pt as
a
6 JEPPERSON ALU MN I BULLETIN
many as tw elve qualified stude nts from
eithe r urban or rural ph ysician shor tag e
areas, with the und erstanding that these
students would pursue the und ergraduat e famil y medicine curriculum at Jefferson , selec t a famil y pr actice resid ency program, and eve ntually return to
a "shortage ar ea ." This program has
b een ver y successful. It wa s exp ande d
in 1978, and at the pr esent tim e it
allows the Coll ege's Admissions Committee to pr ef erentially admit up to
twent y-four students per yea rproviding their academi c cre de ntials
ar e similar to thos e of othe r student
ap plicants. Man y of the student s w ho
ha ve gone through this program ar e
now practicin g in shortage areas . Its
success has attracted a gre at deal of
regional and national attenti on .
The Residency Program
Shortly aft er arri ving at Jefferson in
1973, I sub mitted an ap plication to the
Resid ency Review Committee for a
famil y practice resid ency to be estab lished at the University Hospital. Much
to my dismay, in September 1973, this
application was not approved. On the
same da y that the Department wa s notified of this I made telephone arrangement s with the ed ucational represent ative, Rob ert Graham, M.D ., at the
American Aca de my of Family Physicians in Kansas Cit y, Missouri for a
con sult ative appointment . He agr eed to
see me that sa me night. Aft er I arrive d
in Kansas Cit y that evening , the tw o of
us stayed up until the wee hours of the
morning rewriti ng the applicati on. T he
next day the application was retyped
and resubmitted to the Residency
Review Committee. In Decemb er 1973
provisional approval was finally
ga ined , and the Department was abl e
to begin the first fam ily practi ce residen cy at J efferson in Jul y 1974.
Resid en cy Review Committee
ap proval was just the first hurd le to
ove rcome in starting the pr ogram. T he
next major one wa s to ob tain salaries
for eightee n residents, six for eac h of
thr ee yea rs. Weeks of meetin gs with
ad ministrators, committees and
dep artment al chairm en followed .
Understanda b ly, no existing resid ency
program wished to give up residency
positions so that salaries could be
ob tained for the fam ily practice resident s; and sim ilarly, there was only a
fixed amount within the University
budget for training house officers . T o
furth er compo und the pr ob lem , man y
of th e existing resid ency programs,
with increased servic e demands,
wa nted to expand their own plans.
Th e solution to the probl em cam e
ab out rather unexpect edl y. When Peter
Herbut, M.D ., the Presid ent of the
University, asked me to give a progress
rep ort to the Board of Trustees on the
sta te of the new department, I q uickly
realized that it wo uld be emba rrassing
to the Presid ent to share my frus trations with the Board . Three days
before the sched uled meeting I met
Clinical A ssistant Professor Robert L. Perkel , M .D .
SPRING 1988
with him to ask th at I b e exc used from
giving the report. When Dr. Herbut
di scover ed the reason for m y hesitancy,
he found th e necessary fund s for th e
resid ency p ositi ons with a sing le phon e
call. Three d ays lat er I was ab le to give
a glowing report to the Trustees.
The d ela y in th e approval of th e
resid en cy a p p lica tion and in obtaining
salaries for th e residents hamper ed our
initial recruitment o f residents. It was
impossibl e to promise a p p lica nts eithe r
a salary or an appro ved progra m pri or
to th e end of December 1973, just several we eks b ef ore th e d eadline for th e
ati onal Int ern and Resident Matching
Program. Much to our surprise, however, four out of six p ositi on s w er e
filled throu gh th e Mat ch and th e
remaining tw o wer e quickl y filled afte r
th e match results were announced . A
full co m p lement of six resid ents w er e
enr olled to b egin th e first famil y practice resid ency program at Jefferson in
Jul y 1974! These tru stin g pioneers and
the m edi cal schools which th ey represented w ere: David C heli, M.D ., The
Medi cal Colleg e of Pennsylvani a; San dra Harmon , M.D ., T emple Unive rsity;
Franklin C . Kelt on , [r., M.D ., Jefferson
Med ical Colleg e '74; Allan Kogan,
M.D ., Baylor School of Medicin e;
Jam es Plu mb, M.D ., Jefferson Medical
Colleg e '74; and Mar gar et Fritz Stock well, M.D ., The University of
eb ras ka .
Facilities
Initi ally, th e Department lack ed tw o
requisit es for b oth the under graduate
and th e gra d ua te pr ograms: clinical
space and an ad equate patient p opulation . Fortunat ely, funds to d evelop th e
overa ll program w er e available from
th e Haas Com m unity Fund and th e
Dep artm ent of Health, Education and
Welf ar e. The go vernment funds wer e
to b e used for funding preceptor ship
ac tivities and th er e was a st ip ula tion
that th ey had to b e used b y Jul y 1,
1973. The real priority, however , was
to estab lish an outpatient famil y practice ce nter. Ther ef or e, in ea rly June
1973, I p etition ed th e govern ment to
allow th ese funds to b e used to assist
with co nstruction. They agr eed , but
stip ulated that th ey had to b e d esignat ed for sp ecific constru ction prior to
Dr. McGeh ee
July 1, 1973. The "sq ueeze" was on.
Working w ith th e University's ar chitect , w e d esign ed a new Family Pra ctice C enter for th e Edison Building at
Ninth and San som Str eets. The blueprints w er e hand-deliver ed to Washing ton , D .C. , and w er e appro ved just
three days before th e grant exp ire d .
Despit e our haste, this design pro ved to
b e very practical and fun ctional. The
Department occupied this Center until
1978, when w e mo ved to th e fourth
floor of th e new Unive rsity Hospital.
F acuity Recruitment
C on comitantly, with the esta b lishment of the c urriculum , th e approval of
th e residen cy program, and th e building of a clinical facility , a search wa s
b egun for qualified faculty. I had the
rare op portunity to recruit a brand new
full-time faculty, but at th e sam e tim e
recogni zed that m y cho ices w ould b e
scrutinize d carefully by the othe r
m embers of th e facult y. I was a war e of
th e fact th at it wo uld b e difficult to
recruit ab le faculty to teach primary
ca re , for th er e was not an ab undanc e of
suc h individuals and the d emand, w ith
all th e new training programs in pri mary care, was high .
Edward H . McG ehee, M.D ., '45, a
friend and colleague of mine, was the
first p ot ential cand idate to b e co nta ct ed. Trained as an int ern ist, wi th
ad d itiona l trainin g in he matology and
p athology, Dr. McGehee was a much
loved and resp ect ed "fam ily physician"
practicing genera l int ern al medi cin e in
th e C hestnut Hill section of Philad elphia. He was w ell kn own for making
house calls on his bi cycle, workin g ve ry
lon g hours, and alwa ys b ein g ava ilab le
to th e stud ents who cro wded his pri va te office. Dr. McGeh ee had cha ired
the Department of Med icin e at C hestnut Hill Hospital, and had serve d as
Ph ysician to and Hem at ologist to the
Pennsylvani a Hosp ital and the Ben jamin Fra nkli n C linic.
D r. McG ehee w as ver y settled and
sat isfi ed in his estab lishe d pract ice.
Initiall y, he and his wife, Carolyn, wer e
dubious about th e po tenti al of joining
th e Jeffer son facult y. However, after
many meetin gs, and wi th som e recru iting help from Drs. Gon nella and Kellow , Dr. McGeh ee b ecame "so ld" on
the entire id ea of training famil y physicia ns, and in 1974 he return ed to his
alm a m ater as Pro fessor of Fa mil y
Medicin e.
JEFFERSON ALUMNI BULLETIN
SPRI NG 1988
7
Dr. McGeh ee's co m ing to Jeffer son
gave m e th e id ea o f a pp roaching an other
co lleague an d friend to b oth of us, William . Meb an e, III , M.D. Doct or
Meban e practi ced p ediatrics in Chestnut Hill for many yea rs and he too was
ac tive on th e staff o f th e Chestnut Hill
Hospital. In 1974 he w as coaxed away
fro m his very successful private gro up
pr act ice to b ecom e a Clinical Professor
of Famil y Medi cin e. He remained on
the J efferson ca mp us for tw o yea rs;
and in 1976 he m oved to th e a ff iliate d
fa m ily m edi cin e program at Chestnut
Hill Hospital, wh er e he ser ved as an
Associat e Director of th e training progra m until 1985, when he b ec ame its
Dir ect or.
The C hes tnut Hill com m unity did
not tak e lightl y to the loss of tw o of its
most resp ect ed ph ysicians to th e new
d ep artm ent at Jeffer son . I received
man y co ncerned phon e calls about th e
situa tion. Fortunately, m ost of th e
C hes tnut Hill resid ents w er e under stand ing about th e need for go od rol e
models in training future physicians.
The number and int ensity of th e calls
testifi ed to the quality of th e two
facult y members th at had agr eed to
co me to Jeffer son . In ac tua lity , many
of th e ca llers follow ed b oth ph ysicians
to Jeffer son as th eir patients. The
loyalt y of th ese initi al patients and th eir
enr ollment in the Jeffer son practice
wer e extre mely valuab le in training th e
first students and residents.
Outpatients
The full-tim e faculty's privat e patient
p opulation was not in itself suffic ient,
how ever , to co nd uc t an ambulator y
ca re progra m . A mu ch lar ger number
of patients was required. In 1974 th er e
was a fortuitou s change in th e Hospital' s policy and organizational structure: th e traditional outpatient clinic
sys te m which had b een in place was
disbanded in favor of a more traditional "privat e" sys te m. With a lar ger
number of ad ult, m edical clini c
patients to b e pro vided for , th e Hospi tal felt fortunat e in ha vin g a new
d epartment so int er ested in ambulat ory
ca re and in need o f suc h patients for
tea ching. Dean Kellow and th e Vic ePresid ent for Health Services, Frank J .
Sw een ey, Jr. , M.D. , '51 felt that it
8
JEFFERSON ALUMN I BULLETIN
Clinical Assistant Prof essor C h risto pher Chamb ers , AJ .lJ., w ith th e Mur rell
family
w ould b e highl y appropriate for th e
Family Medicin e d epartment to tak e
ov er th e care of these patient s. In 1974
the transfer was made.
At first , the clinic patients w er e skep tical that th eir needs could b e tak en
care of in a sin gle large, clinical facility.
They wer e used to b eing referred to a
number of subspecialty clini cs, primarily focu sed on the tradition al medical
and surgica l spcialties . Usua lly, ther e
wa s no appointment syste m and it was
first co me, first served; a process that
nec essitated lon g hours of waiting. It
was rare that the patients would see th e
same physician over a prolonged
p eriod of tim e.
Wh en famil y m edicine b ecame
responsibl e for this patient population ,
ev ery effo rt was made to assign a
primary physician for eac h patient.
Appointments wer e made, and in many
instances, th e nec essity for multiple
subs pecialty typ e visits to oth er physicians or faciliti es wa s elim inated . This
SPRING 1988
was a tremendous change for a large
number of individuals. At first they
w er e shocked and dubious. T he initial
ap p ointment co mp liance ra te wa s 20
per cent. As tim e w ent on and pro fessional relationships d eveloped w ith the
Family Medicin e sta ff , the appointment co m p lianc e impro ved . Two yea rs
lat er , a p proxim ately 60 percent of th e
pati ent s kept their ap po intm ents.
Initially, about 60 percent of th e family m edi cin e patient population ca me
from the disbanded clinic system. This
patient population wa s not abl e to
afford th e traditional professional fees
and this meant that th e Institut ion had
to subs id ize th e clin ical operation . This
subs idy, necessary for th e program and
appreciat ed , was negotiated on an
annual basis. This was always a trying
tim e for m e and the Hospi tal's ad ministration . Primar y ca re training is the
mos t expensive kind of training, for it
requires a great d eal of co ntinuou s
supervision and th e rew ards for serv ice
Dr . Bru cker and resident William Th ompson , M .D ., '87 revi ew th e pr ogress of
are considerably less than they ar e in
the procedural typ e sp ecialties.
Inpatients
Th e responsibility for the management of the inpatients gen erated from
the Department's outpatient population
aroused a great deal of discussion .
From the ver y beginning the Chairman
of the Department of Int ernal Medi cine, Rob ert I. Wise, M.D. , was
genuinely concern ed that family physician s might not poss ess the necessary
knowledge and skill to car e for adult
pati ents in a hospital setting. He had
num erous an ecdotes to support his
concern. Many members of the
Department of Medicine felt that fam ily practice in the United States should
be similar to gen eral practice in Gr eat
Britain , where inpatients were customaril y ref erred to the hospital-based spe cialists. Members of the Family Medicine department, on the oth er hand ,
vigorously disagreed with such a con cept and felt capable of handling
gen eral medicine typ e patient s in the
hospital setting. In addition, the accred iting organizations for family practice
training insisted that the famil y ph ysicians must have such responsibility. In
fact , the y encourage d family ph ysicians
to ask for obstetrical and surgical privileges , something which I did not and
still do not think is appropriate for family physicians to request in a geographic setting such as Philadelphia.
Man y meetings ensued to resolve this
dilemma. Dean Kellow and Dr. Sw eeney convened the leaders of eac h
department in an effort to find a satisfactory solution. Finally, Warren D.
Lambright, M.D ., an associate of Dr.
Sw eeney in the Hospital's administrative offices, effe cted a solution: All
inpatient s would be admitted to the
Hospital on the medical service. All
qualified faculty in the Department of
Family Medicine would rec eiv e secondary appointments in the Department
of Int ernal medicine. The Chairman of
the Department of Family medicine
would b e responsible for the quality
of the family medicine patients ' care
(III
in-patient ,
and the professional cond uc t of his
facult y. Should ther e be some flagrant discrepancy, the Chairman of
the Department of Medi cine wou ld
have the right to interv en e if the care
did not meet the usual stan dards .
Dr. Wise felt com for table with this
arrangem ent , and incid ent ally, not onc e
felt obligated to co me to me to complain about inpatient ca re issues. A
similar arrangem ent wa s established b etw een Dr. Wise and myself for outpatient care. A see mingly insur moun tab le
hurdle was passed . T en yea rs lat er, in
1984, Willis C. Maddrey, M.D ., the
subsequent Chairman of the Department of Medicine, suggested tha t the
Department of Family Medi cine have
its own inpatient ser vice, since it had
long since demonstrated its ability to
car e ad equately for suc h pati ent s.
Thus, in tw o years, the new Depart ment had a sound faculty, und ergrad uat e and gra d uate program s, aff iliate
programs, an outpatient facility with an
ad equate patient population, and the
privilege to admit and care for general
JEFFERSON ALUMNI BULLETIN
SPRING 1988
9
adult medical patients in the hospital.
Without the Institution's real commitment to the program, not nearly as
mu ch could hav e b een accomplished in
such a short period of tim e.
Maturation of th e Department
Unde rgrad uate Programs
On ce esta b lished, the new d epartment grew quickly. By 1976, four additional full-tim e facult y had b een recru ited : Pet er Amadio, Jr. , M.D ., '58;
Su Hain , M.D .; Howard K. Rabinowitz,
M.D. ; and Elmer J. Taylor, M.D .. '52.
Th eir specialty representation, whi ch
espe cially suited a primary care training pr ogram, was in a proportion that
has rec ently rec eived favorable
national attention. These ph ysicians
were trained in internal medicine, fam ily medicine and pediatrics.
In addition to the family medicine
facult y, the department has alwa ys
enjoyed the coo pera tion of faculty
members from the oth er department s
in the Coll ege. Throughout the fift een
years that I have b een at Jefferson , no
facult y person has ever refu sed to
co opera te; and in fact many have
voluntee re d to teach in the program.
Thi s spirit of coope ration ha s led to a
healthy integration of Family Medicine
into the Unive rsity setting.
With the increase in the number of
facult y ca me an increase in the amount
of under graduat e teaching responsibil ity. The department became involved
in the freshman clinical correlation
courses, and the Medicine and Soci ety
Co urse in the sopho more year, tea ching
epide miology and exploring medicolegal and ethical aspects of health-care
delivery issues.
Becau se of the dem and from th e
seniors electing the famil y medicin e
tra ck , the rural pr eceptorship progr am
had to b e expa nde d . With the help of
fed eral fund ing, ca re fully selec ted fam ily ph ysician pr eceptors in rural offi ces
from Vermont to orth Caro lina were
chose n to serve as pr eceptors. Howard
K. Rabinowit z, M.D . has been resp onsible for the supe rv ision and or ganization of this pr ogram. It allows the student s to see unselect ed problem s in
various typ es of co mm unities, to live
and particip at e in the co m munity, and
10
JEFFERSON ALUMNI BULLETI N
to ha ve one on one teaching. The students ar e always amazed at the diversity of problem s which th ey see, and
they become increasingly impressed
with the rol e that psychosocial factors
play in keeping individuals well and
restoring them to health. The preceptors have d ev eloped a real esprit de
corps! Ev ery year th ey return to Jefferson for a thr ee day workshop to upgrade their medical knowledge, to
introduce them to the potential senior
preceptees and to discuss ways in
which the program can b e improved .
The Department also added two
more affiliate programs to th e thr ee
that were alr eady in op eration. The
Bryn Mawr Hospital program, under
the supe rv ision of D. Stratton Woodruff, M.D. , wa s added in 1975, and the
Underwood Memorial program in
Woodbury, NJ was added in 1983.
Resid en cy Programs
The first resid ents to enter the program in 1974 performed admirably.
They proved to b e good ambassadors
for the Department. It was not long
b efore the resid ency program dev elop ed a creditable reputation both
insid e and outside of the institution.
Residency applicants wer e quick to
recognize the potential ad vantage of
bein g abl e to train for family medicine
in a medi cal school setting. The initial
hurdle of attempting to fill the residen cy class was soon ove rcome, and
aft er th e first yea r of the program there
has b een a lar ge pool of qualified
applicants from Jefferson, and from
medi cal schoo ls all ove r the country.
All of the gra d uates of the residency
program ha ve pa ssed the certifyin g
examination of the Ame rican Board of
Family Practice. They are engaged in
practices that ran ge fro m hamlets to
metropolitan cities in the Unit ed States.
Sev eral ha ve go ne outside of the country to pract ice. T en of the past graduat es and seven of the 18 current resident s are J efferson alum ni.
In 1978, the resid en cy program
received full accred itation . On e con stant concern of this acc rediting bod y
is the belief that famil y physicians
trained in the No rtheas t sho uld be
eq uip pe d to do obste trics and sur gery .
After many discussions with the Residency Review Committee we reached
a compromise. All of our residents
receive a certain amount of obstetri cal
training as specified in the Residency
Essenti als for Famil y Practi ce and all
of the resid ent s expe rience a two
month surg ical rot ati on with em phasis
on dia gnosis, pr e- and post-op care.
For those w ho plan to practice ob stetrics, a six month obs tetrica l fellowship
is av ailable at the co mp letion of the
thr ee year resid ency.
A ssociat e Professor H oward K. Rabin o witz , M .D . w ith pat ient A d rianna Yanez
and her fath er .
SPRING 1988
The presence of the Family Medicin e
pr ogr am at J effer son , togeth er with a
nati onal trend toward int er est in primary car e, ha s result ed in a significant
incr ease in the number of Jefferson
grad ua tes go ing int o famil y medicine
resid en cies. In 1973, approximately
thr ee grad uates per year electe d to
specialize in famil y medicin e. At the
pr esent tim e approximately 16~ of th e
Jeffer son graduating class es ente r the
field -a number somewhat above the
nati onal average.
Four gra d ua tes o f our program ar e
curre ntly full-time fa cult y members in
the Department. They ar e: Christopher
V. Ch amber s, M.D ., Rob ert L. Perk el,
M.D ., Michael P. Rosenthal, M.D. and
Richard C. Wender , M.D . In addition,
four of our grad uates serve as faculty in
resid en cy programs elsewher e. The
Dep artment ha s attempted to create a
resid ency program whi ch is op timally
d esign ed for all resid ents , regardless of
their eve ntual practice typ e or location.
Postgraduat e Pro gr ams
All diplomates in famil y practice ar e
required to tak e at least 150 hours of
ap proved co ntinuing medical ed ucation co urses eve ry thr ee years in order
to q ua lify for the mandatory recertification exam ination that is giv en eve ry
seven yea rs. This requirement makes it
fitti ng for the Department to co nd uc t
annual continuing ed uca tio n co urses .
Som e of these hav e been cond uc te d at
Jeffe rso n, while many ha ve been held
elsew he re, frequently in co njunc tion
with some othe r spo nso ring b od y such
as the Unive rsity of Delawar e, the
Alumn i Assoc iation or a me d ica l
soc iety.
Left to right : Elm er]. Taylor , [r ., M.D. , '52, Pet er Amadio, [r ., 1'.1.0. , '58 and
Edward H . McG ehee, M .D .,·'45.
L eft to right : Health Ser vices Research Fello w Sandy Peinado , M .D . with
R esearch A ssociat e Prof essor Donald J. Balaban, iH.D.
Resear ch Programs
Other than clinical trials co nd uc te d
b y various member s of the faculty,
there was no concerted research foc us
in the d epartment until 1982, w he n
Donald J. Balaban, M.D. , M.P .H.
join ed the d epartment as Resear ch
Associate Pro fessor of Family Medicine, an d b ecam e the direct or o f the
Greenfield Research C enter. Before
coming to Jeffer son Dr. Balaban wa s
affiliated with the Leon ard Davis Institut e at the Unive rsity of Pennsylvani a,
wh er e he wa s inv olv ed in health care
JEFFERSON AL
~I NI
BULLETI N
SPRING 19 8
11
d eliver y resear ch , especially the stud y
of fun ctional outco mes in chronic cond itions. He b rought with him an enthusiasm and expertise to conduct similar
researc h at Jeffer son , and was anxious
to be involved in the faculty's scholarly
efforts. In ad d ition to this role, along
w ith Rich ard L. Brown, M.D. he has
been resp on sibl e for the D epartment's
Facult y Fe llowship program. The w elltra ine d juni or faculty and the Research
Ce nte r's presen ce lent an important
aca demic stim ulus to the D epartment.
Resear ch q ues tions b egan to be rais ed,
and me tho do log ies w er e d eveloped for
p ursuin g the answers.
Economic Influenc es
In 1982, the advent of the Prosp ective Payment System (PPS) for hospitalizati on brou ght changes in the fundin g
and d elivery of ca re. It was no w
ap pa re nt that society was go ing to
impose limits up on the cos ts of inpatient ca re. For the first tim e in Am erica n medicin e, there wer e d ebates abo ut
the ra tioning of ca re and,th e effe ctive ness and effic iency of ce rtai n types of
ca re . T he pri vat e, co rp ora te sec to r
began to exe rt a stro ng influ ence up on
the organiza tiona l structure of health
ca re d eliver y, including the pa ym ent
mecha nism . Alm ost overn ight, medicine ca me to assume mu ch mor e of a
bu siness posture. While differ ent typ es
of ca pita tion syste ms sp ru ng up for th e
we ll and em p loyed , gove rn me nt subsidi es for the care of the poor and the
elde rly becam e limited. It wa s apparent that hospitalizati on , the m ost
expensive part of health care, w ould be
cu rta iled . The PPS was particul arl y
thr eat enin g to mos t of the nati on 's
teaching institutions, for the majority of
them are locat ed in urban poor ar eas
w here m uch of the care has to b e
subsi d ized .
For the first tim e in 60 years, the
outpatien t se tting and the co ncep t of
am b ulatory care b egan to tak e on a
new significa nce, w hile at the sam e
tim e me d ica l schools were turning out
a surplus of ph ysician s. T erms such as
"compe tition" and "doctor-glut" we re
common lan gu age, and resid ents and
stude nts began to b e co ncerne d abo ut
finding a job after finishin g resid en cy
training.
12
JEFFERSON ALUMNI BULLETI N
Dr . Perk el makes
a house call.
J effer son was attuned to these
trends, and in its long-range planning
attempted to ensure that the institution
w ould remain fiscall y sound, while still
fulfillin g its mission of ed uca tion,
patient ca re and research . The
D epartment, in coo pe rationwith the
hospital administration , particip at ed in
vari ou s typ es of ca pitation payment
programs. Some of these w er e
d esign ed primarily for the wo rkingw ell, but other suc h as HealthPass we re
create d fo r the poor and the elde rly . In
1986, sat ellit e fam ily practice ce nters
w er e esta b lishe d in the Fairmount section of Philadelphia, and in South Philad elphia; and in 1988 a third sate llite
office wa s starte d in China town. Th e
purpose of the satellite offices was to
be involved in the community, provid e
needed primar y ca re, and serve as a
source of pa tients for the ed uca tiona l
programs.
In order to sta ff these sate llites , the
Dep artment again invited severa l of its
grad ua tes to participate. Da vid J. And er son , M.D ., co m pleted his resid en cy
in 1987, is the staff ph ysician for "J effcare," an HMO type program that is a
SPRING 1988
subs idy of Blue Cross. John W. Strin gfield , M.D. and Ju d ith Shimer Stringfie ld , M.D. met and trained togeth er in
our resid ency p ro gra m. Aft er grad uation in 1983 they entered privat e practice in North Carolina, but returned to
open the first Jefferson sponsor ed satellite in the Fairmo unt sec tion of Phila d elphia in Aug ust 1986. David E. Nicklin, M.D ., who gra d uat ed in 1984, and
Ne il S. Sko lnik, M.D. , who graduated
in 1987, staff the South Philadelphia
fam ily medi cine p ractice on a part -tim e
ba sis. Dr. Nicklin also has a pri vat e
pr acti ce in West Philad elphia, and Dr.
Sko lnik p ursues his writing int er ests
an d traini ng w hen no t pr acticing at the
satellite. C lem ent C. Au, M.D ., wh o
was gra d ua ted from our program in
1985, retu rn ed to his nat ive Hon g Kon g
bef ore rejoin ing the d epartment to
open the new practice in Chinat own,
just north of the well-known Chinatown "arch."
It is still too early to evaluate
the impact of these cent ers . Th e
training of stud ents and resid ents in a
ca pitation model requires skill, for
int elligen t use of resources and logical
Dr . Au and Patient .
Instru ctor Cle m ent Au, M.D . w ith recep tion ist Th anh Tra n in th e ne west sate llite
ce nte r.
Geriatrics Program N urse Coo rd inato r Su zanne Sh erry w ith
Dr. Perkel. Belo w right: In stru ctors f ohn W. Stringf ield , Af. D .
and l udith String field , M .D . at th e Fairm ount ce nte r.
M erle Happ e, receptioni st in th e bu sy
Pat ien t O ff ice, w ith Dr. Amadio.
JEFFERSON ALUMNI BU LLETIN
SPRING 1988
13
decision analyses ar e required in order
for the practice to remain finan ciall y
sound . T his parti cul ar typ e of expe rtise
will be even mo re important as the
resid en cy grad ua tes becom e d ep endent
upon these mod els for em ploy ment.
The Dep artm ent is continuing to do
research on these programs so that
there will be a factual and statistical
basis for the managem ent d ecisions
whi ch will be required.
1984, wh en he becam e the first Ellen
M. and Dale S. Garber Pr ofessor of
Family Medi cine. We all we re proud
that Dr. Garber left suc h a herit age to
his C olleg e and to the new dep ar tm en t
of which he had becom e ve ry fond.
In 1982, Mrs. ellie T . Haac, who
had been a pati ent in Jefferson Hospital rep eat edl y over a span of 50 yea rs,
left a gen erous sum to be used for
departmental program s.
As the Department's pro grams expanded , the offi ce space on the first
floor of the Coll ege building was no
long adequate. The Pew Memorial
Trust came to the rescue with a very
gen erous grant for renovations to be
made on the fourth floor of the Curtis
building. The Department moved to
these new offices in 1983.
In an increasin gly restri cti ve financial
climate, the Research Division had difficult y funding vari ous research pr o-
Benefactors
Left to right: Instructor Neil S. Skolnik, u»; Residents William Thompson, MD ., '87
and Janice Nevin, M.D ., '87, and Assistant Professor Richard C. Wen der, M .D.
Th ere have been a number of indi vid uals who have contrib uted most
gen erously to the Department during
the 13 years of its existe nce, and this
histor y wo uld be incomplet e without
mention of their special contributions.
Th e Alumni Association of Jefferson
Medical College in 1973 voted to make
an annual contribution of $50,000 to
help sponsor the Alumni Professorship
in Medicine. Thi s honor , along with all
hon orary lifetime membership in the
Alumni Association, are distinctions of
w hich I am most proud.
On e ve ry loyal alumnus was Dal e W.
Garber , M.D ., '24, a respected gen eral
pr actiti oner in Delaware County, Penn sylvan ia. I had the good fortune to
meet Dr . Garber in 1976 on an alumni
spo nsored continuing medical ed ucation trip to the lowlands of Europe. He
b ecame ver y interested in the Department and, after seve ral years of finding
out more ab out the Department and
how it functioned , decided to establish
an endo we d professorship in Family
Medicine. The chair was awarded to
Edward H. McG eh ee, M.D ., '45 in
14
JEFFERSON ALU MNI BULLETIN
SPRING 1988
jects and stipe nds for fellows. Mr. Gustave Ams terdam, a member of
Jefferson's Boar d of Trustees and the
Board of the Etelka J. Greenfi eld
Fo undation, b ecame aware of this and,
ac ting as an intermediary, coordi na ted
a generous gift from the Foundat ion to
the Research Division. In recognit ion of
this gift , the Resear ch Divisi on was
ren amed the Etelka J. Greenfield
Resear ch C enter of the Department of
Famil y Med icine in 1985.
All of the ind ivid ual gift s, plu s the
dedi cat ed efforts of man y indi viduals
in an institut ion that has b een most
sup por tive of a new dep art ment, ha ve
allow ed mu ch to be accomplished in a
shor t tim e. A solid foundation has been
established and hopefully, in years to
co me a recapitulati on will demonstr at e
that a great d eal has been accomplished to fur ther Jefferson's and Famil y
Medi cin e's mission.D