Family Medicine Comes to Massachusetts (cont'd.)
Dr. Stephen Earls, who succeeded Sam Pickens as the director of the Barre Family Health Center, was a resident there from 1974 to 1977. Here are some of his recollections about the challenges faced by the program as a whole:
In the early days of the residency, the whole time I was a resident it was one crisis after another. And probably other people have told you about this. Everything was just developing while we were doing it, so rotations would have problems and there'd be an emergency meeting. Grant applications were due. Everybody was new at this so nobody quite knew the pace of getting a grant application ready for the residency and so there was Carolyn Cotsonas [a lawyer and program administrator who was also married to one of the first-year residents, Dr. Len Finn] and Dick Walton working long into the night to get the application in on time. It was all very chaotic and stressful … Lots of morning meetings to plan this, that or the other thing.--Stephen Earls
Thus, for its first few years, program funding was a subject of constant concern. Ultimately, the Comprehensive Health Manpower Training Act of 1971 (P.L. 92-157) provided funding for training programs in primary care, including family medicine, and Walton was able to apply for such funding. By the late 1970s, the Department was the recipient of its first Title VII grant, administered through the Health Resources and Services Agency (HRSA), a training grant to train residents to be family doctors. Around the same period and of specific interest to the Family Health and Social Service Center of Worcester (FHSSC), Title V of the Special Health Revenue Sharing Act (P.L. 94-63) of 1975 gave financial support to Neighborhood Health Centers. Ultimately, in the words of an early internal history of the department, the Massachusetts Legislature in 1976-77, "specifically earmarked funds for family practice residency training at [UMMS] in order to insure the continued growth of the program. Prior to this time (i.e. 1974-1976) the program did not have state support and was operating with limited grant funds and significant levels of support from the hospitals and the affiliated health centers."(42)
In the words of Caroline Cotsonas, the Department's Administrator:
It shouldn't be underestimated how effective Dick Walton was as a leader and as a negotiator, and we used to make jokes about how he could sell ice cubes to Eskimos and statements like that, and it was really true. He was extraordinarily charming, he was born and raised in rural upstate New York, and he came on like a country boy, except he was brilliant. He was the king of aphorisms - you know, "You catch more flies with honey than with vinegar," and "I sometimes forget that when I'm up to my eyeballs in alligators, I'm here to help drain the swamp," and [he had a] wonderful sense of humor and wonderful leader. He really rallied people around, and he was very politically savvy, he made a lot of external alliances that became very important.
Such alliances, especially with administrators at community hospitals like Worcester City and Holden, became especially important because the residents' services and referrals of patients to the inpatient units meant a lot to the survival of the hospital, at least for a few years.(43)
Walton's powers of persuasion were needed not only to attract faculty and residents, but also to gain commitments from the health centers and community hospitals with which the residency had its affiliations.
In those days [Worcester] City Hospital was the main campus of the program. University hospital didn't exist, it was being built. The medical school was in the Shaw building. We developed at the end of my residency which was in '76, we developed a rotation at St. V's [St. Vincent's Hospital] in OB [obstetrics]—up until that point in time we didn't have a rotation in OB in Worcester. We had all gone and done some OB in Fitchburg and in Pittsfield. That hike to Pittsfield persisted into the mid '80s for some people. At the time, it was a matter of finding places that were receptive to having Family Medicine residents involved in OB. St. V's was receptive but had a very small OB service at the time, unlike today. Memorial was very unreceptive and probably openly hostile to the idea of family doctors being involved in OB. They didn't want family medicine moving into the arena of OB.--Stephen Earls
Curriculum
The curriculum in the early years, when the program was based mostly at City Hospital, demanded a shared spirit of adventure and "making do." Steve Earls told us, for example, "The residents were as involved in developing curriculum and rotations as the faculty. It was definitely a work in progress the whole time I was a resident." As Dr. Walton wrote in a 1975 program description:
The process of residency training is designed to be goal oriented rather than time oriented. Within three years, residents will be evaluated from a set of educational objectives, or goals … It is expected that educational objectives will help both residents and faculty to define [individual resident] needs … Individual resident responsibility will … vary according to the fulfillment of goals.
Residents were expected to master the core aspects of internal medicine, pediatrics, minor (office-based) surgical procedures, preventive medicine, and for some, obstetrics and gynecology. Dr. Babineau remembered that,
Overall, I think, we wanted our program designed so that our residents could go out and do a broad type of medicine, which included obstetrics. This was always the big debate. We didn't expect them to do surgery except perhaps to assist, but they would be trained in medicine, pediatrics, AND obstetrics, because I felt strongly at that time, because I did lots of obstetrics. … So I wanted obstetrics to be part of our program because I felt that, if you're going to be a family doctor, what's a better way to know the family, than to be able to know the mother and carry her through her pregnancy and take care of the children?(44)
Yet, faculty preceptors for some educational experiences, especially obstetrics, were in short supply. Dr. Candib, for example, who entered the program as a second-year resident in 1974 and was hired as a member of the faculty in 1976, wanted to qualify in obstetrics sufficiently to gain privileges at Memorial Hospital, a respected community hospital in Worcester. The only thing for her to do was to take an extra four months' work out in Pittsfield at Berkshire Medical Center. By the time Steve Earls reached his last year of residency, as he recalled, the residents themselves put pressure on the faculty to create opportunities closer to Worcester:
For the basic curriculum, all residents were assigned to a two-person team.
Everyone was expected to round during mornings while in the afternoon, half would work the inpatient units and the others would take
seminars at the various health centers or at City Hospital; team members on the inpatient wards in the afternoons would cover for their
own patients as well as their partners'. At the health centers residents would meet with social workers, nurses, specialist consultants,
and allied health professionals to review patient management questions, or for practice management seminars; at the hospital, they would
attend seminars on "preventive medicine and patient care."(46)
Dennis Dimitri, a 1982 graduate of the program who was based at Hahnemann Family Health Center, explained the rationale behind the curriculum this way:
I think part of why many people went into Family Medicine at that point in time had a lot to do with the social environment at the time, and there was a lot of feeling about the need to provide a different kind of medical care, medical care that was more responsive to patient needs. As opposed to being driven by the academic needs of the medical school, it was driven by the community needs of the people who needed healthcare. And I saw Family Medicine as a specialty that really responded to that. I thought that that was really an important reason to go into Family Medicine, and I also understood, that that meant that you had to be, not just in a hospital environment but in a community health center, in a place where most people got most of their care.(47)