1 CONNIE ADLER Dr. Fitzhugh Mullan, interviewer Adler: I am Constance Adler, but everybody calls me Connie. Mullan: What is your date of birth? Adler: 4/27/48. I always sound so much like I'm from New York on tape. It surprises me. It doesn't sound like that to me normally. [Laughter] Mullan: You, I presume, didn't, from that comment, don't come from New York? Adler: I do. I grew up in New York City. Mullan: Oh, okay. That was a lead-in to tell me where you come from. So tell me where you come from. Adler: I grew up in New York City. Originally we lived in the City, and then moved out to the suburbs for high school. My father escaped from Germany in '37, a German Jew. The rest of his family was killed in the camps. My mother came from a family, largely Irish-English family, that had been in New York for millennia, it seems, but a real New Yorker family. An interesting combination. The two families would not probably 2 have spoken to each other had my father's family survived, but it never became an issue. It's a very interesting way to grow up. Mullan: Your mother's family is Jewish as well? Adler: No. Very Irish. My father brought this incredible Renaissance man character to everything that he did. You know, that Jewish intellectual society of between the wars culture was very interesting, and we spent every weekend at the ballet or the opera or museums. Just as an interesting snapshot of my father (he just died so I think about him a little bit more right now) when he had three months off between when he was demobilized after the Second World War and started into his practice again, and he and my mother spent that time visiting every church and every museum in New York City. That's what he did with that time. So that's sort of who they were. Mullan: What sort of practice? Adler: He was a psychoanalyst. Mullan: Trained-- Adler: In Europe. Mullan: Whereabouts? 3 Adler: Austria. Germany, France, Austria. He taught neuroanatomy in Turkey for a while. Mullan: Was he affiliated with Freuds, or the Adlers, or the Jungs? Adler: He was mostly Jungian. Mullan: Whereabouts in New York City did you live? Adler: I grew up in Springfield Gardens, which is in Queens. Mullan: You were in the City proper before that? Adler: No, that would be in the City, and then on Long Island in a town called Upper Brookville. Mullan: He was a non-physician psychoanalyst? Adler: No. He was a physician. He actually practiced in both neurology and psychiatry for a long time. Then as he got older, stopped doing neurology. During the war, he was practicing largely as a neurologist. Mullan: He was in the U.S. Army? Adler: Yes, the U.S. Army. 4 Mullan: Tell me a little bit about your youth, growing up. What were you like, what did you do, what did you think about? Adler: We did a lot of those activities that I described. What did we do? One of the most interesting things that we did was learn languages. My father spoke eight languages, and we all started by age seven taking French lessons, and then, when I was thirteen, I went on my own to France for the summer and got really good with French. Then when I was fifteen, I went to Guatemala and learned Spanish, and then later went to Germany. Both the language and that exposure, I think were very interesting experiences for us, and very politicizing experiences for me more than for my sisters. I don't have a lot of memories of who I was or what I did as a little kid, except I remember they called me a tomboy at one point, and I remember playing jump rope. We grew up in a racially mixed community. But by the time I was in ninth grade, on Long Island, I was getting kicked out of class for being a Communist. I was thrown out of my best friend's house for being a "Goddamned nigger-lover Commie Jew bastard." So I was already pretty political, obviously. The high school years, of course, people were starting to organize in the South and do voter registration stuff. That's when I remember a lot of my intellectual and political activities starting. It was in the high school years. What else about me? Mullan: Where did you go to high school? 5 Adler: On Long Island, a place called Locust Valley High School. Mullan: What role did science and medicine play in your mind at that point? Adler: I loved my science courses. I didn't like physics, but I liked the other science courses. We had aptitude tests. I remember this part very well. Each time we took aptitude tests, they said I ought to be a doctor, and every time that happened, people said, "But that's silly, because you're a girl.'' And so I was a history major, and I went to college in history, because it was silly for me to think about being a doctor, because I was a girl. That was ' 6 5 . Mullan: Where did you go to college? Adler: Cornell. Mullan: What was that like? Adler: [Laughter] It was a lot of fun. I actually loved my history courses, and I really enjoyed that. Mullan: What kind of history? Adler: American history. I was doing American cultural and intellectual history, primarily I was very involved in the anti- 6 war movement. "RYM 2". I was at Cornell when the black students took over the Student Union, remember all the famous pictures with the bandoliers. Anyway, Dan Berrigan was there. We had Seder with Dan Berrigan, all kinds. It was a very interesting time. I got my degree in American History and went to Yale to do graduate work in history and just hated it. I probably don't want to say that, but I just hated it. Mullan: Was it different than the undergraduate history you had done? Adler: Yes. It was the beginning of the women's movement in New Haven, and I was involved with that. Actually what I wanted to do was oral histories of women, especially labor women, women in the labor movement. The history department was very much Old Guard, you know? What's really important is what senators and presidents were doing, they were not interested in oral histories, people's histories at all. It was a real conflict. I left after a semester. I did some work in New Haven in community organizing stuff, and went back to Cornell for a while, and then went out to Seattle. I was doing community organizing work in Seattle and helped start the Country Doctor Clinic in Seattle. Mullan: Tell me a little more about it for the record. 7 Adler: Country Doctor was one of the first few clinics in Seattle, and it was a collective of which I was a part that did the community organizing to start it. Tommy Byers [phonetic], who is now the advisor to the mayor on health issues, Gin0 Gianola, [phonetic] who works Hutchinson Cancer Center now, Linda McVeigh, Elizabeth Nucci and there were a group of ten or so people, and we got the clinic going and built. Most of them did a lot more of that than I did but I was involved in it and also working part-time. Then another woman and I, Margie Joy and I started the prenatal clinic there. We were doing home deliveries, mostly she, and I was sort of helping and became sort of an apprentice. That's when I was "called," that was when I knew that's what I wanted to be doing, delivering babies, working with women in labor and delivering babies. That was one of the clearest things in my life, and since that time that I knew that's really where I belong. And that was wonderful. That was certainly the most focused I had ever been up to that. Mullan: The services delivered by the clinical apparatus or generally by you all were home deliveries by trained, lay, or nurse midwives? Adler: Lay midwives and a doc. There was a doc who worked with us who was usually there, not always there. We also had a women's clinic. The Country Doc had sort of a full range. They 8 had a women's clinic, they had a several general clinics, pediatric clinic, and this prenatal clinic. Mullan: Did you actually do deliveries yourself? Mer: I did. I started doing them, always with somebody else. The only one I think I ever did by myself in those days was by accident. [Laughter] Nobody else came out or got there on time. But I sort of did an apprenticeship with the midwives there and the doc there. And I loved that, but within a year, really felt that that was inadequate. I felt that I didn't want to be a part of doing what seemed like inadequate medicine to me, that if I was going to say I had some skills, I really needed to have them, and it wasn't enough to know one system in the body. You really needed to know the others. Folks would come in who were pregnant, but also had a sore throat or whatever, and it just wasn't enough to only know the reproductive system. That's when I started thinking again about going back to school. The other major and more important thing that happened during those years was that I had a baby. I had a daughter in ' 7 3 , and so, of course, was involved with raising her. There was a beginning crackdown at that point on lay midwives. I was definitely worried about supporting her and more concerned about consequences like jail once I was a parent. Mullan: Were you coupled or uncoupled? 9 Mer: I was alone. Well, we were in a variety of different collectives at various times, but I did not have a partner. So I was single-parenting. I'm trying to decide how much of this side you want to know. The next thing that happened was that a very good friend of mine from college got in touch. His wife died of breast cancer, and he had three young children, and he was back in Ithaca, and I went back to Ithaca to take care of those kids for a while, while he sort of pulled himself together. Mullan: With your child? Adler: With my child. That provided sort of a break in terms of my being able to then say, "Okay, now I'm on the East Coast. Here I am. What do I want to do?" And I went back and forth between thinking about doing some kind of PhD program in public health or an MPH program in public health, between becoming a nurse midwife and going to medical school, and finally decided, "What the hey? I might as well try to go to medical school. I don't know if I can do it, but I'll try." So by that time I had moved to Boston. I was working as a secretary, took my pre-med courses at night. Mullan: You've not done any of them in college? Adler: No. It's just a major. I didn't take any science in college. So I took all my pre-med courses at night and proved to 10 myself--1 got all As--1 proved to myself I could do that, and applied to medical school. Mullan: Before we depart on medical school, the theme of women's health, both the work at Yale and the drift towards midwifery, that would have seemed to have been a theme. Is that an important element for you? Tell me a little about that. Adler: Absolutely. It absolutely was and still is. The sixties, early seventies, of course, were a time when the women's movement was really just taking off. I was a middle-class kid and I hadn't suffered any horrible economic discriminations. But I knew from my own life and experiences the unequal position of women and the violence against us. I felt a lot of kinship certainly with other women and with doing organizing around women's issues. I had already been involved in some anti- violence issues, violence against women, the abortion issue, too. During that time, and I can't remember what year it was anymore, but Washington had finally legalized abortion. So women's health was certainly, yes, a big part of why I went to medical school and what I was interested in doing. While I was thinking about doing public health policy health or something like that, women's health was certainly a focus of what I was thinking about doing. Mullan: You describe in your youth a fairly high amount of activism, I think would be a generic term for it. Where did that come from? 11 Adler: I don't know. Mullan: Were your parents political? Adler: No. They were Democrats, not terribly political. I remember this feeling of justice being an overwhelmingly important concept from very young. Then, of course, there certainly were things that promoted that. We grew up in a racially very mixed neighborhood in Queens, which, of course, felt completely normal to me as a kid, because that's where I grew up. Certainly, later, I found that people didn't think that that was normal. When I was in Guatemala, a lot of that really came to a head, because, of course, seeing the incredible poverty next to the incredible wealth in Guatemala. Guatemala is a place where there's 95 percent illiteracy, 5 percent of the people own 90 percent of the land. Everybody was talking about how the CIA had killed the only freely elected president they ever had. It was a tremendous eye-opener for me. I was sixteen. While I had been political before that, that was a very politicizing experience. Mullan: You're describing your saga of language acquisition. Was it your idea to go to Guatemala or your parents'? Adler: It was my idea to learn Spanish, along with theirs, and Guatemala just happened to be where I was assigned as an exchange student, but it was a very pivotal experience. 12 Mullan: In developing your sense of justice and activism, did religion play a role at all? What was the religious environment of the family? Adler: No. Virtually nonexistent. My parents were very ecumenical. If we wanted to go to any kind of church or synagogue, we could, and if we didn't, that was okay, too. Mullan: Had your mother been raised Catholic? Adler: No. Her family was originally Catholic, but her mother wasn't (I don't know the details). Anyhow, she was raised as Methodist. My older sister, interestingly enough, has become an Episcopal priest. Mullan: Tell me more about your sibs. Are they activists as well? Adler: No. My older sister's an Episcopal priest in Alexandria, Virginia. My younger sister is doing some free-lance consulting at the moment. She worked for a long time for an insurance company and finally decided that she hated it. She's sort of trying to figure out exactly what she wants to do. Mullan: There are only three of you? Adler: Yes. 13 Mullan: So you took your pre-med courses in Boston. Did you like them? Adler: Yes. Actually, I did. I liked chemistry. A lot of physics I could still do without. Mostly what I did was convince myself that I could do science and also do school again. Mullan: How long had it been? Give me the dates. Adler: Almost ten years. Mullan: You graduated from Cornell? Adler: Cornell in '69 and I started medical school in '79. I was working during the day and on weekends. I was sitting on the beach with my three-year-old so she could play in the water while I learned organic chemistry. I had another friend that I was living with and she was in medical school, and I was taking care of her three-year-old. [Laughter] So it was challenging, but I proved to myself that I could do it. Mullan: And you applied? Adler: And I applied and g o t in. Mullan: Tell me about it. 14 Adler: School? Mullan: Yes. Adler: School was a riot. The first few weeks I wasn't sure I was going to hang in there, not because of school, but because--. Mullan: This was Tufts? Adler: This was Tufts. I was ten years older than almost everybody. The very first day I remember sitting next to this kid who looked like a kid. I said something about my daughter, and he said, "Oh, what does your husband do?" And I said, ''I'm not married." And he said, "But I thought you said you had a daughter." I sort of felt like I had to explain to him that those two were not necessarily related, anyhow it was interesting. I met Mike Rowland, who is now my husband, in the first few weeks of medical school, and that actually helped quite a lot. We had each other to get through medical school. Mullan: He was a classmate? Adler: He was a classmate. He was also an older student. He was five years older than most. He's five years younger than I am. He had been out teaching in Vermont in an alternative school. He had done that after high school, teaching in an alternative school in Vermont and on the coast of Maine. Every 15 day in Vermont he would pass the sign that said, "This town needs doctors." Finally he said, "Well, okay, rural America needs doctors." He went to Yale, went back to school, did his college years, and then went to medical school. He is the one who started first talking to me about family practice, which was a concept I hadn't really heard much about before. Then, of course, we heard about it in medical school. Mullan: He went back to Yale. He was teaching without a bachelor's degree? Adler: Right. It was sort of this hippie alternative school. He was right out of high school. Mullan: So he had to do eight years. He had to do all of undergraduate? Adler: Well, he only did seven. He got into medical school after three years at Yale. He skipped out after three years of Yale, but, yes, he did Yale, and then went to Tufts. Mullan: And you got married-- Adler: The spring of our third year in medical school. Mullan: That made it easier? Obviously the friendship made it easier? 16 Adler: The friendship made it easier, yeah, by a lot. I had another good friend, Michael, a friend of mine from Seattle, who came and lived with us our third year to take care of my older daughter, because third year was such a nightmare--you probably remember your third year of medical school--and that really helped. So friends have been wonderfully helpful and supportive in this whole journey. Mike and I had a second daughter our last year in school, which was challenging. Mullan: As you progressed through school, you mentioned Mike raised the issue of family practice. What were you thinking? Mer: When I started, I assumed I was going to do OB/GYN. That was my assumption. The people that I had been working with before that (my day job had been as a secretary for the Infectious Disease Department) thought I ought to do Infectious Diseases. They would go so far as to say I could do GYN infectious diseases. [Laughter] Then it was in medical school that really shifted, for a variety of reasons. One was that I got much more interested, even while learning all the science of medicine, I got much more interested in how the art of medicine happens, and how really being with people makes a difference in their health, as well as knowing the right drugs and all of that, and I felt that primary care was the way to do that. Being there for the family as a unit was the way that you really can be there for people, and also help steer people in positive directions. 17 Mullan: Was there anyone teaching that at Tufts or you just intuited that? Adler: No. There was nobody teaching that at Tufts. In fact, both Mike and I got a lot of flak from people at Tufts about doing primary care. It was a very specialist-oriented kind of a place. Mullan: This being now the class of '83? Adler: '83, exactly. There were some people there pushing primary care. Mort Maddox was there, and there was an official Primary Care Department, and we had, I think, like three lectures on primary care. But then once you got out into all of the rotations, people kept saying things like, "Why do you want to be a family doctor? You're a smart person. You could do something really interesting," and things like that, so the messages were clearly against it. But it became just clearer and clearer to me that kind of unifying of care made a lot of sense. When I did OB, I felt that way even more. I love OB. It is still the thing that I love most in medicine. There are things that I love doing with my family more, but in terms of medicine, it's really what I love doing. There's something very special about that interaction of several hours of labor and coaching and birthing that's very wonderful, but it's a lot more wonderful when it's somebody that you've seen before, you see later, you 18 see those kids grow up, you interact with that person throughout her life cycle, or throughout the child-raising years. The first thing that became clear to me was that I wanted to work with women and children. I wanted to take care of that unit. Then I just fell in love with doing geriatrics. The more I did medicine, the farther I got into medical school, the clearer it became to me that it's a healthier approach to health, to be able to take care of the whole life cycle. [Telephone interruption.] At the time, I knew that I hadn't put into words exactly a lot of what I was feeling. Then at graduation I got the award given for the excellence in the art as well as the science of medicine. I went, "Oh, that's what it is I'm doing!'' It was wonderful, and somebody else had figured that out. It was very nice. Mullan: That's great. Were there others besides you and your husband in the class that were primary care oriented? Adler: There were about five of us who became family docs. That was it. Mullan: Out of a class of? Adler: A hundred and fifty. There were other people, of course, who did internal medicine, pediatrics, you know, other primary care, but not family practice. It was pretty pooh-poohed. 19 We had one interesting experience. We had gone out to western Massachusetts for our third year, to get out of Boston, to try and do a slightly more rural, kind of practice, a medical school where there weren't ten residents fighting over every patient. Boston gets pretty crowded. We went to Bay State Medical Center in western Massachusetts in Springfield. It was also an opportunity to get our older daughter in a wonderful school there. Smith College has a school on campus where they train their teachers. It was wonderful. So she was at Smith College in second grade, and we were in Springfield. Then we really wanted to stay for our fourth year because it had been great. We had a lot of one-on-one work with the attendings. We'd have one resident taking care of a patient, instead of six different layers. We really got to do a lot more as medical students in Springfield than we could in Boston, so we wanted to stay there for our fourth year as well, and we also didn't want to disrupt our daughter's education again. When we went to set it up, I remember meeting with our advisor, and he said, "Well, we don't let people do that. You need to be in Boston. What are you going into anyway?" We said, "Family practice. He said, "Oh, well, then I guess it doesn't matter where you go, does it?" So he let us stay there. [Laughter] So it was great because we got to do a lot. Mullan: How did you finance your medical education? 20 Adler: National Health Service. We were both scholarship recipients. Mullan: From which year? Adler: All four years. Right from the beginning. Mullan: How do you come to the conclusion that you needed it, and you were willing to take that risk or that tradeoff? This is the National Health Service Corps? Adler: Right. For Mike, he was independent, and he had planned on doing rural practice. So it was up the right alley. For me, similarly, I was independent with a child, and had to find some way to support her. I really did not want having big debts to influence how I wanted to practice afterwards, because I wanted to do shortage area medicine. I felt like pretty much no matter where I went with the National Health Service, I'd be doing shortage area medicine. I never wanted to do suburban practice. I wanted to be where I was needed. Mullan: This was 1979, 1980, so there was still a fair amount of scholarships available? Adler: That's right. 21 Mullan: You graduated headed towards family medicine with a National Health Service Corps obligation. What happened next? Adler: We went to residency, and we came to the Maine-Dartmouth residency in Augusta. We got them to agree to let us do it in four years instead of three, because by then we had a new baby. I had a baby during fourth year of medical school. Another experience. So what we did was split our internship year. We alternated months, one month at home, one month at work. So each did internship year over two years, and then went full-time with our second and third year. So we did residency over four years instead of three. There it absolutely reinforced everything. I loved it. [Tape recorder turned off] Mullan: We paused for about fifteen minutes to bring one more child into the world, Dr. Adler having done the ministerings. The baby and mother are reported to be in good shape, and Dr. Adler in her scrubs is back to resume her story. So you went to Augusta and did three years in four. Why did you choose the Maine-Dartmouth program? Adler: We looked at a lot of programs. We only looked at family practice programs. We looked at programs that were sensitive enough to the needs of families in family practice to consider letting us do this "special situation." That actually didn't end up being as difficult as we thought it might be. We thought we'd get a lot of grief about that. People certainly were nervous 22 about it, but we were both great candidates, so folks ended up wanting to bend over backwards to take us. They had reservations about taking a married couple, as did everybody, but it worked out well. We ended up coming here because of the people we met in Maine especially Alex McPhedran. Mullan: You ended up coming to the program? Adler: Because of the people that we met, Alex McPhedran stood out as a prince among men, in terms of people we met while we interviewing in various places. It was the only place we found where people could be openly gay in residency, where women were valued for who they were. You really felt that in the residency program. Their commitment to training physicians for rural areas was very clear. So we felt very comfortable with them politically and socially and in every way. It just really stood out for us as different, feeling very different from other places. Mullan: How did you feel about Maine and about rural medicine? Were those things you were comfortable with? Adler: Yes. Especially I have to say that Mike was. That was clearly where he was headed all along, so partly I was going along for the ride. Mullan: It's a long way from Queens. 23 Adler: It's a long way from Queens, but my commitment was to do shortage area medicine. I had been thinking about doing Third World medicine for quite a long time, which is a lot more rural than Maine. My commitment was shortage area medicine, which more or less translates, into inner-city or rural medicine in this country. Yes, I felt very comfortable with it. Mullan: So the residency after the first year which you shared was full-time residency with a young child and a not-so-young child. How did that work? Adler: Right. An eighth and ninth-grader and a toddler. It was hard, but it was wonderful. We got our schedule down. The first two years worked nicely, but even the second two years worked with a babysitter and day care. It was interesting. I'm sure it was hard going through it, but when I think about it, that's not the part that I remember. I remember the conversations with people. I learned so much. One person who really shaped my thinking a lot was Karen Gershman, who came to the program just about the time that we did, and who is to geriatrics what midwives are to obstetrics. She is a family doctor/geriatrician who loves old people in a very beautiful and special way. I learned an enormous amount from her and was very encouraged in doing family practice by my experiences. I did a lot of family counseling. My practice has always been a lot of women. I'm a woman physician. Women want to come to a woman physician. I did more deliveries during my 24 residency than anyone had ever done in residency there before. People came to me and I sought it out, and some of the doctors, the obstetricians really came to trust me and my experience a lot, so I did a lot. I did C-sections. OB was always a focus, but I loved every part of it. I did a lot of work with family counseling with kids, family counseling with the families of children who were diabetic, and teaching and learning how to cope with their chronic illness. It was a wonderful time. Mullan: So when you got done, you had a National Health Service Corps commitment. How did that play out? Adler: Well, Mike and I had planned on doing that in Maine. That was the plan, but by 1987, the sites had been closed down. It was really limited choices. There were no two-person practices in Maine, and the closest the Health Corps would let us be was about five hundred miles apart. So we decided that was not a good option, and started looking around the country for a two-person option. And those were pretty limited, too. It came down to the Navajo Reservation and Zuni, and there was one site in Texas and one in the Northwest. And so we looked at all of these. We liked the Zuni reservation a lot, but we ended up going to Moses Lake, Washington, which was a migrant farm worker site in eastern Washington, and again, was an enriching experience. 25 Mullan: What sort of community, what sort of clinic? Adler: It was about 70 percent migrant farmworker, 30 percent indigent people from the area. Moses Lake is a town of about fifteen to twenty-five thousand, depending on how big an area you count. We were the only two docs in the clinic when we got there, there was one PA, and it was a very busy practice. Mullan: Had the practice been functioning before with another National Health Service Corps docs? Adler: Exactly. Yes. Mullan: They rotated out when you rotated in? Mer: Exactly. They waved goodbye as we rode into town. [Laughter] Mullan: Two of them? Adler: Two, no overlap. There we were. It was very busy. The clinic was wonderful. The people who staffed the clinic are still very close friends and are fabulous people, very committed. It was great because we spoke Spanish half or more of every day, and we are both fluent in Spanish. So that part was great. Of course, a very busy obstetrical practice and a lot of peds. The first year was like a fellowship in perinatology. We had a lot 26 of high risk OB, a lot of very sick babies, a lot of congenital hearts kids and kids in congestive heart failure. Mullan: Clinic? Adler: We had a clinic and there was a hospital in town where we did deliveries and hospitalizations. It was a fifty-bed hospital. Mullan: You were the only docs? Adler: No. There was a medical staff of about twenty-five. The others were all in private practice. So we took care of everybody who didn't have any money, and they took care of people who did. [Laughter] When they had to, they'd take care of our patients. So the specialists supported us. The internists were very good about seeing patients when we needed them to. But we did almost everything for everybody. The early pediatricians were not very good about taking other people, and so we took care of some very sick kids. I had eight hemophiliacs in my practice, and, in fact, ended up being sort of the hemophilia expert in eastern Washington. It was very interesting. I learned an enormous amount there, too. We had quite a few older people in the practice, the whole range of medical problems. I had several families where I was taking care of four generations of people. It was very rewarding. 27 Mullan: How long were you there? Adler: Five years. We had a four-year commitment, and we stayed an extra year, which was unheard of in the National Health Service there. [Laughter] But we liked it, and we liked the clinic and the people. Mullan: What was the living like? Mer: Strange. It's a very, very conservative town. I was the only woman that I knew who had kept my maiden name, and people would give me a lot of grief about that. It was an atmosphere that was stuck in the fifties. People mostly identified by their church, and that's how people socialized, was by church group. So we were almost never asked out because we didn't belong to any of the local churches. There was a large Mormon community. The Hispanic community was very open and we went to lots of balls and quincineras and parties with our patients and staff at the clinic. But the Anglo community was not all that open to us. It was interesting. So it was very isolating socially, in terms of that. I still had friends in Seattle and I would do the three- hour drive to Seattle once a month just to connect with people and politics. Mullan: How about schooling for your kids? 28 Adler: The grade school was great for our younger daughter. She was in grade school by then. The high school was a trial for our older daughter. It's interesting because of the primary reason we had gone there instead of the reservation was for high school. We weren't ready to send her away somewhere, and high school on the reservation is problematic. She didn't fit in very well in Moses Lake either, but she ended up doing a lot of independent study courses. I remember her first week of school coming home in tears going, "They have mandatory pep rally here." [Laughter] So there was some culture shock, but she got over it, and immediately, when she graduated, headed for New York City, and she went to Columbia. She wanted to be as far culturally from Moses Lake as she could get. Mullan: Her family genes expressed themselves. Adler: That's right. She just graduated from Columbia, actually, and is doing molecular genetics and protein synthesis stuff. She's doing great. Mullan: Her education wasn't retarded entirely by the Moses Lake experience. Adler: No. She's doing very well. 29 Mullan: What was your experience like with the National Health Service Corps in terms of how they treated you, how the program worked, what you think about it? Adler: It was mixed. The first several years worked well. We had an executive director, Myron Cowals, who was tremendously supportive. Mike and I work hard. One of the things we knew was that our only hope for getting anything other than every-other- night calls was to build the clinic, The first two years we were every-other-night call with each other which was ghastly. We never saw each other. It was pretty bad. Basically, the way to change that was to build a clinic so we could hire somebody else, and we did. We were seeing lots of patients, we were very busy, we took all comers, built up the clinic, and hired somebody new. Our director was very supportive in terms of doing that, and so late in our second year we went to every third night, which was glorious. He gave us a lot of support to do that. Historically every two years the doctors att the clinic had changed. Our stability there (5 years), the fact that we worked so well in the community made the clinic grew. But also the reputation for the clinic in the community grew so that the other docs were more accepting. The whole thing just worked better. So the clinic grew tremendously while we were there. By the time we left, there were four docs and two PAS. We had a new building. It all worked well. The fourth year we were there, there was a change of administrator, and it became terrible. He was awful. I don't 30 know how to put that politely, but he was terrible. We were part of two clinics. There were two clinics together called Central Washington Migrant Health Project and the other was in Wenatchee. Anyhow, after he became director of the two of them, and after a while when we saw this was not working, we tried to separate. The the Health Service didn't want us to do that. It became a very ugly scene for about six months until the Health Corps people actually came out to a public meeting where it became so clear that our whole community was supporting us and separation from this other group, that they finally gave in and let us go. The clinic has continued to take off, and he eventually got canned, when the other clinic discovered he was a jerk, too, but it took them longer. Mullan: Moses Lake has had another generation of NHSC docs? Adler: Yes, and some who aren't NHSC. Mullan: And it's functioning? Adler: It's going great guns. We were just there. It's flourishing. Mullan: You had an extra year. Did that mean you were considering staying long term, or what did it mean? 31 Adler: Yes. We considered it. The social isolation was difficult. The deciding factor was that Mike's plans solidified. His plan since he was seventeen or eighteen was to sail to Ireland to Skellig Michael, [phonetic] which is a rock off the west coast of Ireland where the Monks kept civilization alive during the Dark Ages doing the illuminated manuscripts and everything. You can't sail from the desert in eastern Washington. [Laughter] So we came back to Maine, and he got an old boat and fixed it up and sailed to Ireland. Mullan: From Maine? Adler: Yep. Mullan: That was not what the monks did. Adler: No. That was not what the monks did. He sailed from Maine to Newfoundland, to Ireland, and then to Spain, left the boat there over the winter, and then Bermuda and then back home. Mullan: On his own? Adler: No. He had two friends with him. Mullan: That's exciting. Which years did he do that? 32 Adler: Last summer and the summer before. So we needed to be back on the East Coast for that dream. So here we are. Mullan: How did that come about? How did you end up in Farmington? Adler: Originally, we came East to be in Maine. We definitely wanted to be back in Maine, we still have a lot of friends here and wanted to be doing rural shortage area medicine. For a while I thought about teaching in the residency in Waterville. [Begin Tape 1 Side 21 Mullan: Connie Adler, Tape one, side two. Adler: We chose Farmington because it's an excellent school system for our younger daughter, with a lot of emphasis on music, which is her interest. I found this wonderful opportunity to do just what I wanted to do, when is I found two obstetricians who were willing to let me do family practice and as much OB as I wanted to, which was unique. We had certainly looked at a lot of communities where there were clearly turf battles where the obstetricians didn't like family docs, etc., etc. I started working with these two obstetricians. I do primary care, but the three of us share call. I work as an OB/GYN in terms of all of that. I do my own C-sections, I do my own tubals, all my D and Cs, and I share call with the obstetricians, and I share call 33 with the pediatricians. I do all of the pediatrics that I want to. It's been great. Mullan: You're based physically with the obstetricians? Adler: Yep. We share one building, but I have my own office in that, one end of it that's mine, and I have a nurse practitioner working with me, who also does family practice. So what we do is family practice for women. We don't have any adult male patients, and we do a lot of adolescent medicine. We see a lot of kids. Mullan: So it's a maternal-child health practice. Adler: Essentially, yes, although we take all ages of women, so we do a lot of work with menopausal women as well. Mullan: It's a unique cut. What do you call yourself? Adler: Just me. [Laughter] People talk about a women's health care specialist, there is no such thing at the time, but I guess that's what I am, except I do a lot of pediatrics as well. There are internists who try to do what they call women's health care, but they don't really know a lot about obstetrics. OB/GYNs don't know a lot about diabetes and congestive heart failure and all of those things. I think this is perfect. I love it. With my partners, I have a great give and take. Then they can ask me for 34 information on ears, noses, throats, lungs, diabetes, heart disease. Then, of course, there are always GYN issues that I want to talk to them about. I don't do GYN surgeries, except as an assist. I do a lot of surgery. I do my own C-sections, but also I assist on all of the cases that my patients go for. So if they have a cholecystectomy, I do it with them. That's a piece that a lot of family doctors loose, is the OR stuff, as they do more and more internal medicine. So I do a little less internal medicine and geriatrics then I used to, though some. Of course, I've been involved in taking care of my geriatric parents these last few years, too. But it's a wonderful kind of family practice. Mullan: Is Mike out of practice now? Adler: Mike has actually been working in the emergency room. It was too difficult to do family practice. You can't take a family practice and then take off for six months to sail across the ocean. So he was working in the ER until after that, and he still hasn't quite decided where he's going to settle in, but he's the director of the ER here. Mullan: You like the community? Adler: Love it. 35 Mullan: Demographically, ethnically, financially, what sort of practice is yours? Adler: It's a private practice. In terms of demographics, it's an interesting community because we do have a college here, University of Maine at Farmington, so there's some element of college professors and students. We have a lot of farmers and people who work in the woods. Maine is a poor rural state, folks who have nothing. There's a big ski area nearby and there are yuppies who work at the ski area. [Laughter] It's a very interesting cultural mix. Almost everybody's white with only really a handful of non-whites in the community. I do miss the cultural mix, especially not being able to speak Spanish very much. Of course, every Mexican-American in Maine, I think, knows that I'm here, so I have four Mexican-American patients, because they come to see me because I can speak Spanish. There aren't very many of those. Mullan: How is it now that you have your own practice? How do you feel about that versus your previous experiences? Adler: I hate private practice. The only part of it I like is being able to make decisions about my schedule. I can say I'm taking a week off, and I take a week off. That kind of thing I like about it, but I think it's a dumb way to do medicine. If there had been a way to do this through the rural clinics or through some kind of other public sector, I would have been much 36 happier doing that. I hate doing the business part of private practice. I'm good at it, I'm doing fine, but I think that it's stupid, and I hate having to think about insurance companies and reimbursement, all that stuff. I would much rather be working in a community clinic. Mullan: How are you doing financially? Mer: Fine. Mullan: Is this community able to support, and how do you handle the folks who don't have insurance? Adler: You just write it o f f . In OB, a lot of people become eligible for Medicaid, so the OB part tends to pay for itself. Then the folks who I see in the office, if they can't pay for it, we end up writing off lots. It all works out. We have some people who will pay over time, pay with services, and we try and do whatever we can to work that out. I'm making a perfectly good living, got my kid through college. That's all I care about. [Laughter] Mullan: In terms of the dynamics in this community, what is the role of the generalist versus the specialist? How are the specialists in Farmington, and how do you relate to them here or elsewhere? 37 Adler: There are a few. It's largely family practice, internal medicine, pediatrics, with the largest group being family practice. Then there are general surgeons, who are sort of specialists in a way. There are three OB/GYNs, there's a urologist and an ENT and an ophthalmologist, and three orthopods because of all the skiing accidents and sports injuries. It's a high orthopedic trauma town. I have an interesting place in the medical staff. Right now I'm chief of staff, so that's interesting, too, but I'm the only one who actually goes to all three services: adult medicine, maternal-child health, and surgery, because I'm the only one who really overlaps those three. That's been good. I get along with most of the specialists. People have idiosyncrasies, God knows, but there is not a lot of turf-fighting here. Certainly, the obstetricians are the ones who mostly would be an issue. They're my partners, so that's not an issue. The pediatrics went through a very tough time for a while when we were down to only two pediatricians, and during that time I did a lot of pediatrics. I picked up a lot of pediatric call and helped them through all that. I have been able to be the pinch-hitter in the community, which is what it's all about. You go where you're needed and you do what's needed to be done. That's worked out quite well. There have been more family docs and internists who are comfortable doing internal medicine, so I have done less of that. Mullan: What impact do you feel from the perturbations and the system as a whole? Is managed care affecting you? Is the 38 increased number of doctors available having impact here? Is the shift toward primary care having impact here? How do you feel about all of that? Adler: Maine is way behind the curve, in terms of much of that, and managed care in a serious way is just really hitting here. We're probably ten years behind California, I think. So a lot of it here is just speculation. I have a group of managed-care patients in my practice. I have learned how to use that system and do the gatekeeper role and that kind of stuff. We have just formed a PHO in the hospital, and so over the next year, I really will be able to say a lot more about how I think that's going to affect us. I think that what it's going to mean is that we have to learn how to talk to each other better and manage patients on a community basis a whole lot better than we have in the past. There are few specialists who do inappropriate things, and we have to learn how to control that as a medical community. That's going to be a big issue. Medicaid is going to be managed care here in another six months. That's going to have a tremendous impact, and we don't know exactly how well that will affect us. Rural hospitals in Maine are closing. I don't think that's going to happen here, but there's a larger hospital south of here that could gobble us up. Mullan: Where is that? 39 Adler: Lewiston. They could take virtually all the specialty care down there. Hard to imagine taking obstetrics down there. Mullan: What's the driving time? Adler: Well it's forty-five minutes from here, but we have folks in our service area coming all the way from the Canadian border. There are folks who drive two hours to get here. That would be adding on almost an extra hour for them. Our service area is larger than Rhode Island. Mullan: Any other hospital around you? You've got Lewiston to the south. Adler: Waterville, Skowhegen to the northeast and nothing to the west or north. It goes all the way up to the border. There are people who drive incredible distances to get here for appointments, have babies, etc. Mullan: So managed care has not really hit yet, but it's coming. Adler: It hasn't. We do a lot of thinking and talking about it, but reality hasn't really sunk in. Mullan: What about the appropriateness of the level of physician staff in the area? Is it about right now? 40 Adler: It was short when we came. We've gotten two more pediatricians and two more family docs since Mike and I came here. Mullan: When you came it was 199- Adler: '92, and two internists. We're pretty good right now. Statistically, we're absolutely appropriate for non-managed care levels. For managed care levels, we're slightly oversupplied. So probably there will be some atrophy in the next couple of years, I presume, of specialists. The other interesting thing about this community has been that there are a bunch of primary care docs who don't do hospital practice, who just do out-patient practice, which has been a lifestyle choice of theirs. Also, some of them are from way out north and it's too far to do hospital practice, which has meant a lot more hospital practice for those of us who are still here. I do pediatric admissions for a lot of docs because they don't admit to the hospital. That has put a strain on the medical staff. That's been the biggest ongoing struggle in the medical staff because there are resentments about that. Nobody likes to be up at two o'clock in the morning. Mullan: Is that both against the folks who are at a distance as well as those who are close by and just don't do in-patient? Adler: Both, although more against the latter than the former. 41 There are two other projects, two other things that I've been most excited about the last couple of years. Two years ago I was asked to be part of a national task force to put together training for nurse midwives in domestic violence. I've worked with shelters and domestic violence issues forever. The midwives realized that they did not include in their training anything about domestic violence, so they pulled together this task force. I represented rural women. We pulled folks from all over the country and put together a syllabus that is now incorporated into all of the nurse midwifery training programs in the country regarding domestic violence, and a CME journal that comes out this fall for people who are already out in practice, on domestic violence. So that's been exciting and it was very exciting participating in those meetings and working with the organizing. Mullan: What's the task force for? Adler: It's Task Force on Domestic Violence for the American College of Nurse Midwives. This year I was asked to be the medical consultant to the Breast and Cervical Health Program, which is the Maine piece of the CDC Program on Breast and Cervical Cancer Prevention. I don't know if you know the program. The CDC is now in thirty-five states and nine tribes, I think. The CDC supplies money to do screening for breast cancer and cervical cancer for indigent women. So we're providing cancer screenings, Pap smears through colposcopy, through cryo, and breast self-exam, and clinical breast exam and mammography, 42 and biopsy for low-income women and women of color all over the country. I'm the medical consultant for the Maine section on that. That's been wonderful. I've been meeting folks all over the state and working on this whole other set of women's health care issues. It's been great. Mu1 lan : It's your policy side. Adler: Yeah. Well, I find that as much as I love my day-to-day encounters with patients, I need to also be able to feel like I'm doing something in a bigger arena. In Moses Lake, I did that with various committees on teen pregnancy. I was very active with the teen pregnancy prevention group and domestic violence, and here I've done it with these two. I need to feel like I'm doing something bigger than this community, as well as all of the day-to-day care of patients. Mullan: Tell me about your interest in the teen mother. Adler: I love working with adolescents. I think they're a tremendous challenge, both trying to be so mature with this wonderful linking of maturity and magical thinking. [Laughter] It makes them a delight. The story that I like to tell is of a fifteen-year-old who I took care of who delivered a baby at twenty-eight weeks, who had terrible problems with bronchopulmonary dysplasia. I had to admit that baby, I think, six times in his first year of life. He was a terribly hard 43 child. The mom had to learn how to do all kinds of nebulizer treatments and chest PT and all of this, and she was very, very good with him, never called inappropriately, always was right on top of everything with him. She kept going to class through all of this, graduated second or third in her class in high school and is in college, just got married. It was wonderful. I sent her a big graduation present. I was so proud of her. She did so well. Mullan: That's, I would presume, an atypical story? Adler: Well, it's not entirely atypical. Yes, it's atypical mostly because of the extreme, but I remember another similar kind of story with a girl that I delivered in Moses Lake who was sixteen. She came in at like thirty-six weeks' gestation because she had been afraid to tell anybody she was pregnant. I found out about her and we got her in. I told her mother with her there, because she was afraid to tell her mother. Mullan: She was not showing at thirty-six weeks? Adler: Well, you know, kids, big tops, they get away with it sometimes. Anyhow, she became very preeclamptic. She came very close to death during labor; I mean, she was very sick. We got her through that, none of which she remembered, of course. Then I continued to see her. She married the father of the baby, and I saw her for her next pregnancy a couple of years later. I 44 delivered three children of theirs in my five years there. They were both working, had a lovely house, wonderful kids, and they, too, just really pulled it together. Yes, there are a lot of kids who don't pull it together, absolutely. I don't know, I guess the good stories stick in my mind better. There have also been teenagers who I have helped who clearly were not ready to parent, and I've had terrible reservations about sending the kids home, and one or two who have had their kids taken away. But it's such a growth time, and if you take them seriously and with a sense of humor, it's a wonderful time to be involved in their lives, and it's so nice to see them figure it out. You watch them sort of put it together and come out the other side. It's very exciting. Mullan: Your attitude is so different from many people who talk about teen pregnancy. It's a definitional downer. You embrace it. Adler: I wish they weren't pregnant, and I do everything I can to keep them from getting pregnant, and talk to them about options and adoption and all of that stuff, and I did the teen pregnancy program in Moses Lake largely to have an impact, and love to talk in schools about pregnancy prevention. I wish they weren't pregnant, but once they are, I think you use the opportunity to help them make it a positive experience for themselves and for their babies and to help them grow with it 45 emotionally, physically, spiritually, in every way. And sometimes it works. Mullan: Let me go back and touch on a topic we brushed by or we departed from. The quality of your colleges, and particularly of the generalists, there are still practicing in some parts of the state GPs from the days before family medicine training became a reality. And although they're mostly at the end of their careers, I imagine you have encountered them in various ways. What are they like and what are their practices like? And how do you as a younger, more rigorously trained family practitioner relate to them? Adler: It's a real struggle. In this community, most of the practitioners are younger. There are a small handful who fit into that category, but it was an issue we also faced in Moses Lake. There was particularly one very sad occurrence where there was a doc who had been the first doc there, and he did everything for everybody and was wonderful and had become totally and woefully out of tune with medicine. His HcPs were awful, his practice was awful, his surgery was terrible, and it was heartbreaking to have to get him to stop. Here it hasn't been quite so much of an issue. Mullan: How did you? 46 Adler: The hospital medical staff finally just kept confronting him on it and nicely asked him to retire. When that didn't work, they forced him into retirement because his patient care really was inadequate. It hasn't been as much of an issue here, though there is that tension with people. And of course, it's an issue you raise it for yourself, too. When do you start getting rusty? When are you not thinking well? And even at forty-eight, you think about, am I out of residency too long? You really work at trying to keep up and making sure that what you're doing is appropriate. I think one of the big issues is that those of us who come along later, hopefully have internalized that this is an ongoing learning process and you learn from each other, and the days of "I'm a doctor, right next to God, I'm always right" stuff is really gone. So we can talk to each other, and we can criticize each other, and we can suggest things to each other. I'm never afraid to say, "1 don't know this. Tell me how to do it," and to call somebody. I think that that's what makes it work. That's what makes family practice work. You have to be able to say, "This is something I don't know," and figure out where to get help, because you can't know everything. You just can't. In terms of people who have trouble with that, I think that folks deserve a lot of credit for what they've done in their past, but that doesn't excuse bad medicine. So somehow you have to draw that line and encourage people to do what they do know how to do, but insist that they ask for help when it's something that they don't. 47 Mullan: Where are you going to be ten years from now? Mer: I'll be here for ten years. At that point, my kids will be out of college, and at that point, I think I want to do some more Third World medicine. I now have wonderful skills for Third World medicine, because I do a lot of surgery, too, which is something everybody always needs in Third World countries, and I have a lot of pediatric and OB experience. I'm not very dependent on having the latest cardiac meds. That's what I think now. In ten years I'll still be here, and then when the kids are out of college and launched, I think that I'd like to do Third World medicine. I suppose that could change, but I really feel it's important to be of service. This is hard work. I couldn't do it unless I felt like I was doing it in a place where it was needed. One of the interesting things about being here, in addition to it being a rural area, is that since I'm the only woman physician doing women's health really at all here (the obstetricians are all men and most of the family docs are men) there is that special need. I have an enormous amount of patients who are incest survivors, cult survivors, domestic violence survivors and victims, adolescent women, women who have very special needs, a lot of people with multiple personalities from childhood abuse, and who really want to be seeing a woman, not just a doctor, but a doctor/mom. It's a very special need. It's a broad range. These are people of all ages, but that's 48 been this niche that I fill in this community, which is good. It's important to be of service. Mullan: This sense of being of service, this sense of activism, as you l o o k back now across your elongating career, where do you think it comes from and what sustains it? Adler: I don't know where it comes from. I know that it's a very essential piece of me. It's a need and just part of my essence. It doesn't make sense to be in the world without being of service to the world. I heard an African-American woman say something one day about "Service is the rent you pay for being here." This works f o r me in a whole lot of ways. I have lots of energy and a lot to give. I get enormous amounts back from my patients, some days, not every day. Some days it feels like all outgo, no input. But there are some very special moments and times with people, with their babies, with people who are dying, with people who are teenagers taking on these new tasks and figuring them out, that are very rejuvenating, that give you as much energy as you put into them. So it's very renewing. Not every day. There are days when you drag yourself around because youlve been up all night and you can't figure out which end is up. But overall, it's tremendously rewarding. There's nothing that I would rather be doing, and it enriches me and my family. Mullan: Final question. On the big picture, you talk about where you see yourself going, where do you see the system going? 49 You see here lots of middle-aged and older docs today grousing about the system and, III wouldn't have my kids going into it," etc. How do you feel about its future? Adler: I think that practicing medicine is rewarding, and I would never discourage people from doing it. I think it is a unique opportunity to be involved in people's lives and to be of help in people's lives. Right now I think we're going from point A to point B, Point A being this non-system of independent practice, B being managed care in some form. It's hard to get very excited about point B, but I think there's a point C. Point C will be a lot more involved in patient concerns (which have gotten lost in managed care) and involved in public health but incorporate a lot of the savings and organization of managed care. I think that I won't be able to be involved in getting point C if I'm not involved in getting to point B. While I have mixed feelings about the managed care models that I see right now, it makes sense to organize and to contain costs. I see that as part of the process to get to point C which will be more interested in access to care and appropriateness of care, which have gotten lost in all of the discussions. I'm excited about that. I don't exactly see what the ultimate product is going to look like yet. I had assumed it would be a single-party payer organized system. I was very excited about the Clinton health plan and working toward some kind of rational health care system. I don't know what it's going to look like, but I think the 50 process is going to be interesting. I think it'll come out positive. Mullan: That's a positive, up-beat view coming out of a physician. Adler: Managed care can't be the end. There's still all of the uninsured and there are so many issues, and we haven't dealt with all of the kinds of issues about "rationing" and the appropriate care of the elderly. But you can't be a part of that dialogue unless you're a part of this one. So that's okay. Mullan: Anything else you'd like to add before we close? Adler: No. I'm going to be real interested in seeing what comes of all this. Obviously my life has had some twists and turns that other people's haven't, but I don't think that as a practitioner it's probably all that different from what other people do, but it sure is fun. Mullan: Thanks. [End of Interview] 51 Index Byers, Tommy 5 Central Washingtor Migrant Health Project 22 Clinton Health Plan 35 Cornel1 University 4, 5, 10 Country Doc Clinic (Seattle, Washington) 5, 6 Cowals, Myron 21 Domestic Violence 29 Family Practice 11, 12, 14-17, 23-25 Farmington, Maine 23, 25, 27 Gershman, Karen 17 Gianola, Gina 5 Joy, Margie 5 Maddox, Mort 13 Maine-Dartmouth Program 15, 16 Managed Care 27, 28, 35 McPhedran, Alex 16 Medicaid 26, 28 Moses Lake, Washington 18-22, 30-32 National Health Service Corps 14, 15, 18, 20-22 Tufts University 10-13 Yale University 5, 7, 11