1

Interview with Carol Garvey
Date: April 2, 1995
Interviewer: Fitahugh Mullan


Mullan:   This is April 2, 1995.   We're at the home of Dr. Carol
Garvey, sitting on her porch on a spring afternoon, the first day
of daylight savings, with some sun that comes and goes.    I wanted
to chat with Carol about her background in family practice, but
where I'd really like to begin is with you telling us a little
bit about you in terms of your background, where you came from,
and just a little bit of biography, starting way back when.


Garvey:   I grew up in Baltimore, went off to college [Radcliffe
College], sent there by my parents primarily for two reasons:
one, to find a husband; and the other to learn enough about
literature and art and music to entertain myself at home when I
was taking care of my future children.   I succeeded in finding a
husband, and he was not at all enthusiastic about my sitting at
home and having children.   He was the son of two physicians and
decided that I ought to go to medical school.    He decided this in
the spring of my senior year, when I was already signed up for a

master's program in teaching, because I thought I would actually
be a teacher when my children were in school.    I didn't have any
pre-med courses, having majored in English literature and taken
some art and music courses along the way, too.
     So I got a teaching job and took courses at night school and

summer school, pre-med courses, and two years after graduating
                                                                    3

     So I took geology, and that was where I met Tommy, in
December of freshman year.    I didn't take any more science
courses until my senior year, and what happened there was, I had
taken a statistics course, which I thought was good preparation
for teaching, in my junior year.     My parents happened to live
next door to a physiologist at [Johns] Hopkins [University], who
had known me much of my life and needed a statistician for the
summer.   So I worked for him between junior and senior years and
found his work fascinating.   So I actually did take a freshman
chemistry course and a freshman biology course--the biology
course was second half of senior year--figuring that they might
be useful when I was teaching.     And I thought they were great,
but it didn't occur to me to change directions, other than maybe
to use that in teaching, until March or April of senior year,
when Tommy insisted that I wasn't going to be a teacher; I was
going to be a doctor.


Mullan:   Tell me about your youth and your background and your
parents' or family's attitudes towards a young woman's education.
Were you born in Baltimore?


Garvey:   I was born in Baltimore, although my father had been
from New Jersey and his parents had been from England.    My mother
had grown up in Baltimore, and her family had been there forever.
So I went to a very traditional girls' school.
                                                                      4

Mullan:   What was the school?


Garvey:   Bryn Mawr School.   My mother had gone there, my aunt had
gone there, my grandmother had gone there, and that's where I
went to get a job after I graduated from Radcliffe, because that
way I could live at home and save money for medical school.      I
taught three classes, and actually my science came in handy.     Of

course, I hadn't had very much.     I wrote and said I would teach
math or English, and the headmistress said, "We have all the math
and English teachers we need.     Teach science."
     I said, 18Well,I haven't had much yet."
     She wrote back and said, '*Stay a day ahead of the kids,"
because they were desperate for a science teacher.


Mullan:   What had your science been like at the Bryn Mawr School?
In terms of women and science in the epoch of the fifties,
sixties, when you were in school, what kind of signals did you
get, as you recall?


Garvey:   I think the expectation, that being the fifties, was
that we were all going to grow up to be housewives.    There was a
lot of emphasis on getting into the Seven Sister colleges, but
that was really a status thing.    It wasn't to prepare us to go on
to graduate school.   It was a wonderful time to be educated as a
woman in the sense that since they couldn't threaten us by

saying, "You're not going to get into the graduate school of your
                                                                      5

choice.@@ The teachers had to make us love what we were doing,
and so I think there was much less teaching to tests than there
is now.
     If we were considered to be smart girls, we were supposed to
take lots of languages, so that really we only had one year of
high school in which we could take a science course.       We had a
choice of physics or biology, and there again, if you were a
smart girl, you took physics.     If you were a dumb girl, you took
biology.


Mullan:    That was the only option or the only year in which you
had science as a possibility?


Garvey:    That's right; senior year.   The girls who couldn't make
it in languages could take biology one year and physics another

year, but that was very rare, so most of us just graduated with
one year of high school science, and it was either biology or
physics.    There was no chemistry taught at the school.


Mullan:    How about math?


Garvey:    Yes.   I did take math all the way through, so I had had
a little bit of calculus.


Mullan:    Let's go back to your family for a moment.   What did

your parents do and what sort of expectations or what sort of
                                                                     6

launch did they give you in terms of your own professional
identity?


Garvey:    My father was an architect.   He had grown up as one of

three boys, the middle of three boys.    As I said, his parents
were English, and his mother had been educated as a pharmacist,
and her father had been a doctor, but she used her pharmacy
training only until the age of twenty-seven, when she got engaged
to my grandfather, or got married to my grandfather, and moved to
this country, where he had moved first to take an academic
position in Toronto, and then ultimately he moved to Bell Labs.
He was a physicist.    So my father had grown up with a mother who

didn't work.    She never got credentials in this country.
     My mother had grown up one of three girls and a boy.    The
boy went into the family business, which was really the only
option offered to boys in my mother's family, and that was the
woolen business, and the girls were really not expected to have
careers.    My grandmother hadn't gotten around to finishing high
school; she just didn't think it was important and her parents
didn't think it was important.   My mother had gone to a junior
college and then to a nursery training school.


Mullan:    Nursery as in--


Garvey:    Nursery school.
                                                                         7

Mullan:   Sitting amid these flowers, I wondered if there was a
horticultural streak.


Garvey:   No.      And she ended up as a kindergarten teacher.     She
worked, I think, really because architects don't earn a lot of
money, but I think if she'd had her druthers, she would have been
at home full time.       In fact, she did a lot of hand-wringing over
even the time and energy that the teaching took from her
mothering, and she really felt that mothering was the only
appropriate career for a woman, and that teaching was okay as
long as you made sure that your hours were limited to the hours
when your children were in school.       But she thought it was really
immoral for a mother not to be home when her children were home
from school, for a mother not to have the same vacations and that
kind of thing.


Mullan:   How many kids were there?


Garvey:    Four.     I was the oldest of four.   So it was never
proposed to me that I have any career other than teaching.
Teaching was kind of an allowable profession.        It might come in
handy if I also married a husband who wasn't very good at earning
money.    But that was really it.     My brother became an architect,

my first brother, and the younger one became a builder.          I think,
in retrospect, I would have loved architecture, but it just
wasn't offered as an option.
                                                                        8

Mullan:    So there were definitely different presumptions, at

least, if not signals, in terms of boys and girls.


Garvey:    Clear-cut, very explicit.   I think perhaps if I had been
part of a family that had only daughters, that possibly my father
would have been more oriented towards having his daughters end up
with professions.


Mullan:    He had no other outlet; he might have tumbled to that.


Garvey:    Right.   I certainly see that in families which have only
daughters.    But I think my mother's goal would still have been to
marry us off as soon after college as possible.


Mullan:    As you proceeded really out the other side of college,
as you headed towards sciences and towards medicine, how did they
respond?


Garvey:    My father was pretty neutral.   He never particularly
encouraged me, but he didn't say anything particularly negative,
and I suspect that he didn't want to be in conflict with my
mother.    My mother was strongly negative, and she kept preaching
to me that it was inappropriate for me to get more education,
that there were plenty of men who had college degrees, but not a
lot of men who had more than college degrees, and that a man was
not going to marry a woman with more education than he had.        So
                                                                      9

that the more education I got, the fewer men would be available
for me to marry.


Mullan:   Very pragmatic.


Garvey:   Oh, absolutely.    Tommy was not eager to get married
right after college.      He wanted to continue the relationship, but
he just wasn't feeling, I guess, grown up enough to get married,
and my mother, at least, was afraid that he never would.


Mullan: She was worried that he would never come back and pick
you if you stayed on in the sciences?


Garvey:   That's right.    Absolutely.   Absolutely.    So she was very
upset that I was pursuing this, and when I told her that I had
gotten into medical school, she burst into tears.


Mullan:   Tears of--


Garvey:   Not of joy.     She really felt that it was a very wrong-
headed thing to do.


Mullan:   I want to come back and touch on English, but let's
pursue this for a moment.     Did she come around?     What was the
evolution from that point?
                                                                   10

Garvey:   I think that she was somewhat relieved when I got
married, but then she was worried about my childbearing.      I think
she finally began to relax a little bit once I had had a child.
And then her friends, when they would say, W h a t is Carol doing?"
and mother would say, I'She's a doctor," her friends would say,
llOh,isn't that wonderful."     So eventually she began to listen to
her friends.   So I guess maybe somewhere between five and ten
years after I had graduated from medical school, she decided it
was nice that I was a doctor.    And then once I was back in this
area in ' 7 6 , having graduated from medical school in '69, she
found it handy to ask me for small prescriptions for things,
because she's very Scottish.    If she called the doctor and he
said, "Come in for an office visit," and she knew she didn't need
an office visit, but she could get a prescription from me without
having to pay for an office visit, she liked that.


Mullan:   How about your dad?   How did he take it all?


Garvey:   I have absolutely no idea how he has felt about it,
other than he also finds it handy when his seborrhea acts up, to
get a little steroid cream from me without having to track down
his dermatologist.


Mullan:   Let's go back to English for a moment.   What was
entailed in your decision to major in English and how did you
feel about it both as literature as you approached before college
                                                                     11

and in college?     Was this something that was convenient or was it
something that you really were excited by?


Garvey:   I was excited by it.    Two of my high school English
teachers had gone to Radcliffe.


Mullan:   That influenced you in picking Radcliffe?


Garvey:   To some extent.    My father had gone to Harvard.   My
mother did not want me to go to Radcliffe, because she thought
only weird people went to Radcliffe; she wanted me to go to
Wellesley, where "nice girls" went.     But my teachers encouraged
me.   I loved writing, and my teachers encouraged me there, and I
really enjoyed reading, enjoyed poetry.     I didn't particularly
like history, because that was memorizing a lot of dates.      I took
the languages because I was considered to be a smart girl, and
that's what the smart girls were supposed to do, but I really
wasn't turned on by languages.
      The only science I had was the little bit of physics, which
was okay, but not particularly exciting.     So English seemed very

logical to me and, again, something that would be a source of
entertainment throughout my life.     I think I'm very interested in
how people live, and I don't see literature as being completely
fiction; I see it as being a lot of psychology and also
representational.     I'm not a big science fiction fan, but I love
eighteenth and nineteenth century novels, because to me they
                                                                                12

present a picture of people living in other centuries.              I'm
always interested in how people live and how people think, so I
enjoyed it.


Mullan:     Have you continued reading and/or writing over the
course of your life?


Garvey:     For a long time I didn't get to do any recreational
reading, and then in 1982--I just didn't feel I had the time for
it--I joined a book club, mostly NIH [National Institutes of
Health] wives, and, being compulsive, I tend to do the assigned
reading, and it's been wonderful because it's really been an
excuse; I mean, I "have to" read this novel because it's assigned
for book club.     So in that sense, yes.        The little bit of writing
I've done has really been mostly commentary on what's going on in
medicine.     I've written just little things, editorials and things
mostly, for the county medical society bulletin.             I haven't done
any real scientific writing.


Mullan:     Has your reading, particularly in previous years, been
useful to you in your practice?         Is literature in any way
connected to how you see your work or see your patients?


Garvey:     Probably not in a direct way, although I frequently
point out in W u t h e r i n g H e i g h t s the fact that people catch colds
in W u t h e r i n g H e i g h t s and they're sick all winter because they
                                                                    13

don't have antibiotics, but they do get better, most of them,
eventually.   It's very interesting to get that perspective.    And
probably just my interest in family psychology is in some way
reinforced by the reading, but it's not a very direct connection.


Mullan:   How was the transition from being an undergraduate
English major to being a full-time student of science?    How did
you find both the transition, and then as you got into medical
school, did it go well or was it swimming against the current?


Garvey:   It was frustrating trying to get in, because in that era
the medical schools had very strict quotas for women.    Cornell
had 5 percent and most of the others had 10 percent.    So I was

really struggling against the quotas, as well as just the effort
to get in all the science and that kind of thing.    Once I got in,
I didn't really feel as though I was having to deal with any
particular sexism within the medical school teaching situations.


Mullan:   You went to Cornell?


Garvey:   No, I went to Columbia.


Mullan:   And Tom went to--


Garvey:   NYU [New York University].   The science, as I mentioned,
I really found fascinating.   I did have trouble with
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biochemistry.     I just wasn't that well grounded.   I had a summer
organic chemistry course at Hopkins, but that hadn't really
implanted itself very firmly in my mind.      But things like
anatomy, anatomy is a very visual thing, and I'm very visually
oriented.     I loved anatomy.   And physiology just made so much
sense.    It's just inherently so reasonable and rational that I
didn't have difficulty.     I just found it wonderful.   It was like
just exploring new territory.
       And then when I got to the clinical side, it was that much
better.     I mean, to some extent, obviously, the first two years
are like learning Latin, which is kind of a dreary task in just
all the rote learning that's involved, although the facts in
themselves are inherently interesting; it's just making yourself
learn things.    Then the clinical work I just loved, and I loved
the interpersonal aspect of it right from the beginning and
really just bonded very strongly with the first patient that I
ever worked up and still have two of her paintings that she gave
me.    She actually died about six months after I had first met
her.


Mullan:   What was her condition?


Garvey:   She had had rheumatic heart disease.    She had come into
the hospital in congestive failure.     She had been discharged
after that particular admission, but she was having ever more
frequent episodes of congestive failure.     So then she got a valve
                                                                    15

replacement and died of complications.     I don't think she ever
got out of the hospital after her valve replacement.


Mullan:    She was a painter?


Garvey:    She called herself a black Grandma Moses.   It was really
a recreation, and the paintings that she did were copies of
pictures in magazines that she liked or greeting cards that she
liked.    These are kind of rural scenes, the two that I have.   She
said she wanted to get the pictures framed and asked if I would
arrange for the framing for her.    And so I did, and then once I'd
gotten them framed, she gave them to me.    I didn't know she was
going to give them to me.


Mullan:   How did you like Columbia?


Garvey:   Very much.   It's a very clinically oriented school and
very rigorous.   They really exposed us to all the subspecialties,
and, of course, as a generalist now, the fact that I had two
weeks of ophthalmology and two weeks of ENT and two weeks of
dermatology and two weeks of orthopedics and two weeks of
urology, you know, at least it's not totally unfamiliar.
Obviously, I've had to boost those areas of knowledge a bit since
then, but certainly I felt that we were much better prepared than

students who had gone to schools with a lot of electives, who
really used them to explore one or two areas that they were
                                                                    16

interested in entering and just had vast areas of the human body
that they'd never touched.
     I precepted Harvard medical students when I was doing my
family practice fellowship, and they could graduate at that point
without ever doing a pelvic exam, because OB/GYN was an elective.
Medicine was required, but they weren't required to do pelvics on
medicine.


Mullan:     How about the culture at Columbia in terms of the
institution?     How did you like it and how did you feel about your
life as a medical student versus your life as an undergraduate?


Garvey:     Well, as a medical student versus an undergraduate,
clearly a medical school is a trade school, so that I was a
little taken back that we weren't expected to think, we were only
expected to memorize in the first few years, after having spent
four years being taught to think.
     When I got to the clinical side, one of the things I found
disturbing right from the beginning was the emphasis on what was
referred to as tlfascinomas.f@The residents would call from
downstairs at three in the morning or whatever and say, ltI1ve
                                                             got
a fascinoma for you down here in the emergency room," and they
would be really thrilled if they could admit a fourteen-year-old
with acute rheumatic fever and Sydenham's chorea.    Great, yeah,
that is a fascinoma.
                                                                   17

     But one of the first patients that I had was a thirty-six-
year-old black man who had come into the emergency room with
bilateral pneumonia and a temperature of 105.    Because he wasn't
a fascinoma, he was put back in an ambulance and sent to Harlem
Hospital, and Harlem apparently said, "Look, we've got patients
in the halls.   We don't have any room," and sent him back to
Presbyterian.   He was looking pretty sick at that time, and so
Presbyterian figured, well, it probably isn't a good idea to send
him to yet another hospital, so the second time around,
Presbyterian took him.     He got better, but I was just so
horrified that they would send someone out who clearly needed to
be hospitalized merely because his disease wasn't interesting
enough for them as a teaching institution.     I think that was
really when I became interested in public health and the whole
problem of medical care access, and that aspect of Columbia I
really found despicable.


nullan:   Were there others in your class or were there faculty
who allowed you to explore or develop that broader-based
interest?   Either politically or educationally, were there people
who were supportive of that?


Garvey:   Not particularly.   There were, in our class of 120, two
of us who did not intend to go into medical specialties at the
time of graduation, and to the best of my knowledge, most of us
have gone into medical specialties.    Actually, I decided to go
                                                                     18

into public health at that point.    The two months of electives
that we were allowed in our senior year, I spent really kind of
dabbling in a whole range of public health things.     I went to
Sinai's Department of Community Medicine, which was, I think,
about the only community medicine in New York at that time.


Mullan:   Was Kurt Deuschle there?


Garvey:   Yes.   With two students from the University of Vermont,
who were also doing electives, we did a little research project
on parasitic diseases.    I don't really even remember the details,
but we met with a health officer in Harlem and got data.     I just
don't even remember what the thrust of the little study was.
     But I ended up also going up to Montefiore's Social Medicine
Program and Martin Luther King [Jr.] Community Health Center and
getting to know those people a little bit.     I went to a wonderful
post-hospital nursing unit that Montefiore had and talked to the
nurse who had set that up, and that was revolutionary.     I mean,
there wasn't really anything between hospitals and home or
permanent nursing homes, but this was kind of a post-hospital
rehabilitation center.    And ended up immunizing people against
the flu, because there was a flu epidemic during that period of
time, and I did that in a health center.     Went on restaurant
inspections, talked to the director of maternal and child health
programs for the city, and just really kind of explored.
                                                                    19

Mullan:   Did you craft this yourself or was there somebody at
Columbia who was a mentor?


Garvey:   I had gone to Harold Brown, who was the head of the
Public Health Department at Columbia and who taught us our first-
year course in parasitology, and I guess he may have been the one
who sent me to Sinai.   I don't really remember.   Sinai provided
some focus, but then I think I kind of bounced around and heard
about this person and that person.    I don't think that there was
one guiding person behind it.


Mullan:   As you approached the end of your undergraduate medical
education, how had you begun to see the future?    What was your

vision of what kind of doctor you were going to be?


Garvey:   My vision was that I was going to go into public health.



Mullan:   What did that mean in your mind at that time?


Garvey:   I wasn't sure, other than I wanted my goal to be to work
on access to care.   In fact, when I talked to Dr. Brown, he was
the one who pointed me towards getting generalist training.      He
said, ''Don't just go get an M.P.H.   Get yourself fully trained in
some branch of medicine, because youlll have a lot more
credibility if you're board-certified in something."
                                                                   20

     That was 1969 that I was graduating.    Family practice was
just becoming a certifiable specialty, but there were no family
practice residencies in the Washington area.    We were coming down
to NIH for Tommy.


Mullan:   He had finished his--


Garvey:   He finished two years before, because I was studying,
getting my pre-med courses his first two years in medical school.


Mullan:   So he had done two years of internal medicine?



Garvey:   Right, at Roosevelt.    So I went to the Hospital Center,
which had--


Mullan:   Which is the Washington Hospital Center.


Garvey:   Right.   The thing is that their internal medicine
program, you could do straight internal medicine or mixed
internal medicine.    I did mixed internal medicine, which allowed
me to do eight months of medicine, two months of pediatrics at
Children's, and two months of OB/GYN.    Then following that, I did
a year of regular internal medicine and then took a couple of
years working at Group Health.    But when I was doing my internal
medicine, I actually did it in a year and a half, because I cut
                                                                  21

back my schedule a little bit--well, fifteen months--because I
had Tommy right after my internship.
     But I'd been very upset by the way they had the clinic
system arranged at the Hospital Center.    What they had was block
rotations, and each intern took a one-month block rotation to
medical clinic.    I don't remember what point in my internship I
hit the outpatient department, but what I saw was that a
patient's lldijll
                level tended to be changed every month, depending
on whether the intern of the month thought that the level was too
high or too low.   This was before you could draw a dij level, so
it had to be done clinically.    And the diuretics might be changed
because one intern might be more comfortable with one than with
another, and I thought that the care was absolutely horrendous.
     So I went to the chairman of the Department of Medicine, Jim

Curtin [phonetic], who was extremely approachable, and said,
would like to see the outpatient department changed, and I would
like to see interns assigned an afternoon every week and follow
the same patients through their entire internship year and also
do that as a resident."   I think the residents had block
rotations, too, in the clinic.
     So my year of internal medicine residency, my second
postgraduate year, I had three months off with the kid, and then
nine months in the outpatient department and six months
inpatient.   He said in those nine months, that if I could
reorganize the schedules, meet with all the specialty attendings,
get them to agree to have all the specialty clinics held in the
                                                                         22

morning, because they were kind of random, some were in the
morning, some were in the afternoon, and you couldn't have the
intern's continuity clinics in the morning, because mornings were
when they made their rounds.          So I had to make sure all the
specialties would be in the morning and the general medicine be
in the afternoon.        But he said if I could do that, he would let
me rearrange the entire medical clinic system.


Mullan:     Could you?     Did you?


Garvey:     And I could and I did, because I figured that would
improve the quality of the care for the patients.


Mullan:     And established a continuity of rotation.


Garvey:     That's right.    I also had picked up some of my own
patients, and one of the things when you do that block rotation,
you would go through the specialty clinics, too, so that you
would do pulmonary and oncology and whatever.         What I found was
that oncology had the greatest continuity because of the fact
that most of the patients came back every week instead of once a
month.    So in my one-month rotation, I got to know a bunch of
patients.
     So then I had also asked for permission to go to oncology
clinic even before I finished my internship so I could see what
happened to these patients, and ended up, after my three months
                                                                        23

off with the kid, continuing to follow the oncology patients and
go to oncology clinic for the rest of the time I was there.           And
then the last six months were just straight ICU and general
medicine, regular medical rotations.


Mullan:   What do you have in your mind at this point?        Where did
you see yourself headed?


Garvey:   I wanted to get an M . P . H .   and I wanted to finish a
residency.   By that time, there were more residencies available.


Mullan:   In family medicine?


Garvey:   In family medicine.


Mullan:   Did you have in your mind family medicine?


Garvey:   Yes.


Mullan:   You appreciated it was a coming thing and you wanted to
connect with it?


Garvey:   We had also vacationed in the Caribbean, and part of our
vacation consisted of going to hospitals and seeing what
hospitals were like on these small backwards islands.         We were
going to little islands; we weren't going to the big resort
                                                                     24

islands.    We would see congenital heart disease untreated.    We
saw osteogenesis imperfecta and reproved LA baby [phonetic] and
all kinds of things.    We saw a tetanus case, things that we
hadn't seen in our New York City or Washington, D.C. settings.
We were very interested in going back to a tiny island and maybe

practicing for a few years, so I wanted generalist training
because we would have been the only doctors on that island and
would have had to deal with everything.
        Also, I figured that if I were going to be a health officer
or something, that I really needed to know about children and
obstetrics and adults and just needed the whole range of primary
care.     So it was really, again, with the idea that I was going to
go into public health, that I wanted to do family practice.       That
just seemed like the most logical preparation.


Mullan:     How did you head for Group Health and what was that
like?


Garvey:     One of my attendings at the Hospital Center, Nelson
Goodman, who's still practicing in the area, practicing in Bowie,
was working for Group Health at that time.     I was looking for
part-time work, because I had been doing the regular inpatient
rotations for the last six months at the residency and not seeing
too much of my child, so I wanted to spend more time with him.
so Nelson suggested I look for a part-time job at Group Health
and knew that they had some part-time positions available.      So I
                                                                    25

worked in their walk-in clinic three days a week, which was a
perfect schedule because it got me out into the real world three
days a week, but gave me the majority of my time at home with
little Tommy.


Mullan:   And keep your medical practice on a predictable basis.


Garvey:   Right, absolutely.   I went in and worked my eight hours
and went home, and that was it.   I did that for a year and a
half, and then I wanted to get back and finish my training.     I
figured my options were University of Maryland for the family
practice and Hopkins for the M.P.H. or Harvard for both.   Again,
Tommy decided to direct me, and he thought it would be much
better to go up to Harvard and get the M.P.H. and finish my
family practice training.   So I went into Harvard's family
practice fellowship program and did that and finished that.


Mullan:   They had one at this relatively early date?


Garvey:   Well, you know, Harvard always has its nose up for
money, and I think it might have been Robert Wood Johnson was
then funding family practice training.


Mullan:   That was, what, about 1975?
                                                                    26

Garvey:     This was '73, and so then '73, '74 I got my family
practice.     At that point, the board did not require that you do
two years.     They would allow me to count the two years of
internal medicine with the family practice fellowship to qualify
for the boards.     Now you've got to do it at least two years in
one place in family practice.


Mullan:     So this was a year of the fellowship and then a year of
M.P.H.    subsequently?


Garvey:     Yes, and then I got the M.P.H. in the next year.   When I
was getting my M.P.H.,    I also worked in a neighborhood health
center, a regular Section 330 neighborhood health center in a
Title X program doing family planning.    I did that through that
M.P.H.    year, I think a couple of evenings a week or something
like that and then through the next year, and I think we expanded
from two sessions to three sessions as the health center had
grown.    Then I worked half time at Boston City Hospital in their
so-called primary care center, which was in fact as crummy a
medical clinic as any city hospital might have.    There was
nothing primary care about it.    They had no evening hours, and it
was not particularly patient-friendly.    It was just a regular old
medical clinic with a fancy name.


Mullan:    A word about the Harvard training program, because I'm
not aware that they have family practice at Harvard today at all.
                                                                   27

Garvey:   They don't, and the year there convinced me that getting
family practice training or generalist training in a specialty-
oriented institution is not a good idea.


Mullan:   Where did they even have it and who would have taught
it?


Garvey:   They had it in a little building that was kind of
equidistant from Brigham and from Children's, and Beth Israel and
Boston Line In [phonetic] were another block further.   So it was
well located, and when our adult patients got sick, we admitted
them to the Brigham and worked them up as regular residents.
When they were admitted to Children's, we worked them up.     We
didn't do deliveries.   We did some prenatal care at the health
center, and we had some instruction from the attendings at the
Brigham and we learned to put in IUDs and fit diaphragms and that
kind of thing.   We could take electives, and I took weekly
dermatology at Beth Israel, which was terrific.   And I took some
time, I think a month or something, in the emergency room at Mass
Eye and Ear.
      So you had access to things, but what I didn't like about it
was that at both the Brigham and Children's, we were made to feel
like second-class citizens.   We weren't really part of the real
pediatrics program or the real internal medicine program.
      The teachers were an internist who had trained at the
Brigham, who was kind of young and idealistic; a pediatrician who
                                                                      20

had trained at Children's and who has subsequently gone into
straight family practice; and a so-called family practitioner who
had been recruited from the hills of New Hampshire and who didn't
seem to know a whole lot.     In fact, I ended up during my M.P.H.
year going up to New Hampshire to do a rural health project, and

I found myself in the community in which this person practiced.
I didn't know he was from there, but when I interviewed people
who then asked me where I'd come from, what I had done, and heard
that I had been in the program with this guy, they said, "Oh,
boy, he was a menace.     We were so glad to get him out of town.''
He was doing laminectomies and cholecystectomies with no surgical
training.     Our impression was that he was not terribly
knowledgeable.     He didn't think that trichomonas was a sexually
transmitted disease; he thought it was a woman's problem and that
men didn't need to be treated if their wives had it and that kind
of thing.     But because he was the only one who had practiced as a
generalist, he seemed to have great credibility with the
institution.


Mullan:     So the program, as far as you know, lasted for a while

Johnson funded it and then it faded out.


Garvey:     It lost its accreditation.   I think there were so many
other better programs coming along.      And at that point, Robert
Wood Johnson started funding primary internal medicine and
                                                                    29

primary pediatrics, and so Harvard jumped on that bandwagon and I
think no longer had any real interest in promoting--


[Begin Tape 1, Side 2 1


Mullan:    This is side two of Carol Garvey on the first tape,
continued.


Garvey:    They really didn't have a lot of people around who were
interested or enthusiastic about teaching the course or teaching
in the fellowship.    We did have some input from Mass Mental
Health, too, which was good, but it's better to teach primary
care in a primary care setting.


Mullan:    How was [unclear]?



Garvey:    It was interesting.   I think the instruction was of high
quality.     I loved the health care administration, which had kind
of a mini-course on economics, which, of course, had never
occurred to me as something I should have taken in college.       But
again, like gross anatomy, it was like another language.     It was
entering new spheres that had been totally mysterious to me
before then.
     But it was a funny place.     The building, I think, was a
metaphor for the school itself.     It was a new building and it had
great big windows overlooking the Harvard Medical School quad and
                                                                   30

little teeny windows facing up towards Mission Hill and Roxbury,
where the community lived.   There was no orientation towards
Boston or Massachusetts or medicine in the United States.
     One thing I'd seen at the Hospital Center was lots and lots
of tuberculosis.   I saw tuberculomas of the brain, I saw
tuberculous peritonitis, I saw Pott's disease, I saw tuberculosis
affecting the kidneys, and there were, to me, a lot of issues
that came up about case-finding, about isolation procedures, and
all those kinds of things, and I couldn't find any course work
that was relevant to that.
     There was a course that dealt with tuberculosis in the Third
World, and so I went to the teacher of that course, and he said,
no, he didn't know anything about tuberculosis in the United
States and he really couldn't help out.     I was also concerned
about hepatitis and how we dealt with that epidemiologically or
how you dealt with patients and their families and the hospital
staff and all of those things.
     So I and a couple of other M.P.H.    students who had been
practicing physicians went to the administration and said, "We
want to know something about infectious diseases in the United
States."   The school was very accommodating and put together a
spring course once a week, and they brought up someone from the
CDC [Centers for Disease Control] to talk to us about
tuberculosis, because there just wasn't anybody who could talk to
us about that.   But it was a good course and it also dealt with

vaginal organisms and the outcome of pregnancy, which was totally
                                                                      31

new to me.   It, I think, was relatively new as a consideration
for pregnancy outcomes, other than gonorrhea and syphilis, which
people knew about.   But strep infections and things like that was
new territory.   So they were very responsive in that sense.
      I also went to Alonzo Yerby [phonetic], who headed the
Health Services Administration at that time, and said, ''Hey, how
about something about public health in this area?"    We had a
five-day elective between first and second semester, which they
encouraged us to use to become computer-literate.    Then they had
a five-day intensive computer course.   But he offered to put
together a five-day course for us in public health in the area,
and that consisted of lectures in the morning and field trips in
the afternoon.   So Julius Richmond came and talked to us about
community health centers, and then in the afternoon we went to
the D- Community Health Center and saw that.      We did get a
chance to go to the Region 1 regional office in Boston and also
to the Boston Health Department.   So it was kind of a little bit

of redoing what I had done in medical school, in terms of getting
around to see things.


Mullan:   So it was useful, but it wasn't a great experience, the

M.P.H.?


Garvey:   It was an enjoyable experience.   The other thing,    I'd
gone in as a straight Health Services Administration person, but
then I'd gotten so interested in the aspects of the Title X
                                                                  32

program, because I was working part time in the Community Health
Center in a Title X program--


Mullan:   Then being family planning.


Garvey:   Family planning, right.   So I started taking population
science courses and ended up doing a project, and I don't even
remember what it was, but it was a family planning thing, met
other people in the population department and ended up getting a
part-time job doing site visits to Title X clinics throughout
Massachusetts for the state Department of Health.   So I really

enjoyed that, too.


Mullan:   What happened next?   We're up to 1975.


Garvey:   Tommy was at Mass General and wanted to do another year
there.


Mullan:   He was doing gastroenterology?


Garvey:   Right, he was doing research in gastroenterology as a
G.I. fellow.   So that was why I put together the half-time job at

Boston City.


Mullan:   That was the year following.
                                                                          33

Garvey:     Right, and continued at the family planning clinic.


Mullan:     Had you now taken your family practice boards?


Garvey:     Yes.     I took the family practice boards in ' 7 4 ,   as soon
as I finished the training.


Mullan:     You were now a certified family doc in search of an
outlet.


Garvey:     Right.     So we came down here in '76, because Tommy went
back to NIH.       What I really wanted to do was work in a Section
330 in a neighborhood health center community health setting, in

which I figured I might be able to do kind of medical director
and a practitioner kinds of things, where I could kind of combine
some administrative work with primary care, because a thing that
had happened to me along the way was, I got addicted to patient
care.     So I had seen myself as going into public health, because

I thought that one could do so much more by looking at the forest
than by looking at the trees, but there's a lot of personal
gratification in taking care of patients, so that I really wasn't
ready to step back and say, "Okay, I've had it with patients.
Now I'm going to go get an administrative job.''
        I came down and interviewed with Montgomery County
[Maryland] Health Department.         There were, of course, a few
health centers in downtown D.C.,        but Tommy IV was still very
                                                                      34

young.    I didn't want to do heavy-duty commuting.    I wanted to
live in Montgomery County and work in Montgomery County.
     The health department was very welcoming, and they said with
my background I could work in the well baby clinics.      I said,
W h a t happens if the baby comes in with a strep throat or fever?"
     '*Oh, then we send them to the emergency room.    We don't take
care of sick children here."    That didn't sound very rewarding.
     I could work in the T.B. clinic.     I said, W h a t if a patient
has something in addition to T.B.?"
     "We only take care of the T.B.     They have to go somewhere
else if there's something else going on with them.     But in a few
years there's going to be Shady Grove Hospital, and we think
we'll have a health department primary care clinic there."      But
until then, the health department didn't seem very appealing
because there really was no patient continuity experience
available, no comprehensive continuity experience.
     So I went back to Group Health and said, ttCouldI work for

you part time?"   They said fine.   They always had part-time
positions.   So I ended up working a day and a half for them,
while looking for something else, and went first to Bureau of
Community Health Services, because that certainly seemed the most
in line with all the things that I was interested in.


Mullan:   This was Public Health Service?
                                                                     35

Garvey:   Right, which had the Title X and Section 330, which were
really my great interests, where I turned in my r6sum6 and was
completely ignored.   So I went to others.     I went to I think it
was the Bureau of Health Professions at that time.


Mullan:   Bureau of Health Manpower.


Garvey:   Health Manpower, yes.   Bob Graham was the director of
that program at that point.   He was very pleasant, but it didn't
sound very interesting.   I interviewed with various other people,
but the bureau still sounded like the most interesting.
     And then T o m y met a woman in an elevator, an nephrologist
at NIH, who lived next door to Jordan Popkin, and somehow the
fact that he had a wife who was a doctor and who was looking for
a job, and she was a woman doctor and was kind of interested in
helping women doctors, she said, "1'11 call Jordan and see if
there's something in HSA that would be of interest."
     And so Jordan Popkin interviewed me and got me an interview
with John Marshall, and, I think, Phil Killam [phonetic], too.
But in any case, when they actually looked at my rgsume, they
said, "This is real-live person who's actually worked in a health
center.   That would be unique in the bureau to have a doctor who
actually practiced in one our clinics.''     So I got a job there.
                                                                       36

Mullan:    What was the definition of the job?    I remember we
interacted at that point a number of times.      How many years was
that, which years?


Garvey:    They told me in October of '76 that I had a job.       It
took until the end of January actually to be brought on board.
They said, "You've got the job.     Just fill out the papers, and
we'll call you when everything's processed."      They still hadn't
called me by the first of December, so I started calling and I
badgered Phil Killam.     Finally, I said, "1 can't afford not to be
working.    I have to be on board by the end of January or I just
can't work here.     I'll have to go get another job."   So they

brought me on board January 31st of 1977.


Mullan:    So this period is January of '77 through--



Garvey:    October of '81.   I came on board as a medical officer.
There was a division that was supposed to kind of function across
the divisions.     It was doing quality assurance, but it turned out
it was mostly MCH.     I was really working directly under Mary Egan
[phonetic] and Vince Hutchins.
     That was an interesting experience, because when I got there
I was told that the health centers and the health departments
needed a quality assurance document for quality assurance
standards, what to do, immunizations, and that kind of thing.          I
said, @'Okay, when do you want it?''
                                                                     37

      They said, IIOne month.   We want it by February 1st.Il
      I said, IIHow do I get it?"
      Well, you write to AAP and you get their standards, and

then you figure out how to do the quality assurance."
      So I went to the library and I read up on quality assurance
structure process, outcome, and all that kind of stuff, and I got
the AAP standards and I put together guides to pediatric
services.   I guess I was supposed to do obstetrical, too.      So
that was January 31st I came on board.     February 28th, I handed
them the guidance, and they said, "What?      You did it in a month!"
      I said, "Yeah, you told me to do it in a month.Il    Apparently
nothing in the government got done in a month.
      But then I had done it, and it seemed pretty
straightforward, because all I had done was basically transcribe
the academy standards from ACOG and AAP, and then put together
chart forms that they could use and self-assessment things that
they could do for chart reviews.     I said, ttWell,it's ready to
go.
      They said, IIOh, no, it can't go out.   It's got to be
circulated first.   First we circulate it among the bureau, and
then you revise it, and then we circulate it to the regional
offices, and then you revise it again."


Mullan:   Government.


Garvey:   That's right.
                                                                   38

Mullan:   Why don't you give me a summary of those years, because
I'm anxious to move forward to the primary care practice years.


Garvey:   In those years, I was in that--1 think it was Division
of Clinical Services, but then I moved over towards the end of
that year as a medical officer for Community Health Services.
And then Marty Wassermann came in as the chief medical officer
and was there for about a year.   But then when Marty left, they
decided that even though I was only half time, I could be the
chief medical officer.   So after Marty left, I was chief medical

officer for the community health, migrant health, whatever, all
those programs, wrote the internal quality assessment PCRR, which
is just going out the door now, I understand, being replaced with
some new form data set deal.
     Then in '80 or maybe early '81, I moved over to be deputy
director of the Office for Planning under Bill White.    I loved
the 3 3 0 programs, but I also had a lot of connection to the Title
X, so I was very happy to move over there.


Mullan:   You were doing all this half time?


Garvey:   I was doing that half time.   And then when little Tommy
got sick, he was diagnosed September 25, and he was just going to
need so much.


Mullan:   Of 1981?
                                                                          39

Garvey:     Of '81, right.   So I quit as of October 1, because
clearly he was going to need heavy-duty chemotherapy.         He was
needing a lot of surgery and radiation.
     What I had done meantime at Group Health, I had come there
' 7 6 , fall of ' 7 6 , and in the spring of ' 7 8 , a couple of things

had happened.     A patient of mine who I had seen a lot, she'd had
a lot of things, she'd had complications after gall bladder
surgery, so I got to know her pretty well, and I got to know her
husband because he would bring her in, and they were both forty-
seven years old.     One Saturday the husband called because he was
having pain in his left shoulder, and he was told not to come in,
because it was 11:30 on a Saturday morning and the doc could
leave at twelve if he didn't have any patients.         In any case, he
called later and asked to come in downtown, and they also told
him he didn't need to come in, that he probably had
osteoarthritis of the neck, and to take analgesics, and he died
at home with a cardiac arrest.
     I was very upset with my colleagues for being too lazy to
see somebody in distress.     I was upset with the system which
discouraged care by offering the doctors no incentives for seeing
patients.     I mean, there was a disincentive to see patients.        The
more patients you saw, the harder you worked, but you didn't get
anything extra for doing it.      So it just seemed like a patient-

unfriendly system of care.
     One of the doctors, the second doctor who turned this guy

away, then decided that Group Health needed to pay more for
                                                                    40

malpractice insurance, that the Group Health physicians should
have increased liability coverage.     They were covered to the same
extent that the doctors in the community were, but this guy felt
all of a sudden that he needed more than that, and he probably
did if he were to practice medicine that way.
        And then there was another issue, which was that at Group
Health we only had to be on call once a month or something like
that.     They wanted to be able to moonlight, and this was a
consumer-run cooperative which was set up so that the doctors
would be well rested.    Patients wanted to be taken care of by
doctors who hadn't been up all night.     So the patients who ran it

said, no, you can't have outside employment if you're a full-time
Group Health employee.
        So the doctors went on strike, because even though those who
were paid for full time wanted to moonlight elsewhere, and they
also wanted more liability coverage.     I thought it was a very
selfish strike and worked to the detriment of patients.     So I was
a scab; I worked downtown.    I did pediatrics, I did surgical
follow-ups, and I did internal medicine until the strike was
over, and then I decided that was it for Group Health.     I really
didn't want to work there anymore.
     T o m y had been doing a little bit of practice one night a
week with an old NIH friend of his, so I asked whether I could
see patients several times a week in his office, and he said,
"Sure."    So I started seeing patients and had gone from three
                                                                    41

sessions, as I started off in '78, up to pretty heavy-duty half
time by the time I left the bureau in '81.


Mullan:    This was at Group Health?


Garvey:    No, in private practice.    I entered private practice in
'78.



Mullan:    So the Group Health experiences you described culminated
in '78.


Garvey:    Right.   I left in the spring of '78, took the summer off
from practice to spend a little more time with my kid, but I was
still working half time at the bureau, and then in the fall of
'78 started private practice.    And actually, at open season some
of my Group Health patients left Group Health and came to see me
in the private practice.
       That was interesting, going back to something you said early
on.    The person that I went with, Tommy's old friend, took me
right over to the medical society and said, "Register with their
patient advocacy referral service, because that's the way to
build a practice.    If people call up asking for doctors, the
medical society will refer them."
       I started getting lots and lots of referrals, and a lot of
the practice started with high school girls, because it was a
time of feminism in the high schools and girls would get to the
                                                                      42

point where they were having periods, they didn't want to go to
the pediatrician, and their mothers would say, I'You can come to

our doctor. I'
      They'd say, "NO, your doctor's a man.    I want a woman
doctor. It
      So the mothers would call the medical society, desperate,
and say, "I don't know any women doctors.     Do you know any woman

doctor who can see my daughter?"
      Eventually I was getting so many new patients that the
person that we were associated with--he'd sent me over there in
the first place--got very angry with me and felt that I must be
diverting patients from him, that I must have told the medical
society that since I was the new person in the practice that I
should get all the referrals and that he didn't need any.        Of

course I'd done nothing of the sort, but I was upset at his
accusation.
      So I want and talked to the lady who ran the referral

service, and she said, well, no, this Peter Bent Brigham-trained
internist, who had been chief resident at the Brigham, had never
gotten around to taking his boards.     She said, "First of all, the
consumers are now asking for board-certified physicians.        Second

of all, family practice is much more popular than internal
medicine.     They'd much rather have family practitioners.     And
third of all, we have so many people calling and asking for
women.
                                                                     43

     So the fact that I was a board-certified woman family
practitioner meant that I was getting five referrals for every
one that this non-board certified, but extremely well-trained and
qualified internist male was getting.       So the practice really
grew very quickly, and eventually I really had to start turning
down referrals from anybody, because I just had enough patients.


Mullan:   About when was that?


Garvey:   In   '86,   we were joined by another woman, an internist.


Mullan:   When you say          who is that?


Garvey:   Actually, at the point the original person that we had
joined with had died.


Mullan:   The Peter Bent Brigham-trained?


Garvey:   Yes.   He had pulmonary fibrosis and died at the age of
forty-seven. But a friend of ours had bought his practice in '83
and was in practice with us, and Tommy again was doing a little
bit of practice, a couple of mornings a week.


Mullan:   When you left the bureau and for a while when Tommy, the
younger, was so sick--
                                                                             44

Garvey:   Basically, big Tommy also quit working.      He was
splitting his time between NIH and FDA [Food and Drug
Administration].    He left the federal government at the same time
and started consulting to the pharmaceutical industry from home.
He would go in to the practice two days a week, I'd go in three
days a week, and he'd be doing his consulting from home.
     But what happened was that since the practice was really
growing, even though it had been relatively small at that point
in '81--I mean, it was a half-time practice--as the time was
available, new patients filled it.      So really, by the time little

Tommy was finished his treatment, it had expanded into pretty
much a full-time practice.     And that would have been '83, or
really ' 8 4 , early ' 8 4 , he was really out of the woods.    In ' 8 6 ,
we took on another partner, and we took on a female because the
demand for females was high.


Mullan:   Was she a family physician?


Garvey:   She was an internist.    There weren't many family
practitioners around in this area.     There's a lot of room for
them, lot of demand, still, but there's just not many of them.
But I found that she was not getting new referrals because she
was an unknown person.    I had become known in the community, so I
was getting referrals.    I would be so busy with new patients that
if my patients would call up sick, she'd end up seeing them
because she had all this time.     So my patients weren't getting
                                                                   45

continuity, and she wasn't getting new patients.      So I guess
after she'd been with us for about six months, I told the medical
society to stop sending me new patients, so that she could get
all the new referrals, and then I really had to start turning
down colleagues, too, except for family members of people who
were already in the practice.     So from I 8 7 on, I would sometimes
see patients, if things weren't too hectic, referred by
colleagues or referred by friends of patients or referred by
other patients, but for the most part it was just family members
of people who were already in the practice.


Mullan:   Did you have hospitalizations?


Garvey:   Oh, sure, yes.


Mullan:   At various hospitals?


Garvey:   We had joined staff with Suburban when we went into
private practice in '78, we joined the staff of Shady Grove when
they opened in ' 8 0 , and then I had also joined the staff of Holy
Cross, because I occasionally had patients there, but an even
bigger factor was that Tommy was getting a lot of his
chemotherapy there, and on the staff I was able to park in the
doctor's lot.   Parking there was almost impossible for patients.
[Laughter] So I could park there.
                                                                   46

        But it was really not a good use of time, to spend time
driving among the various hospitals, and the problem is that
there's so much paperwork that every time you'd for a patient,
you'd end up going back just as often just to sign something that
had been overlooked.     If you call in a phone order in the middle
of the night, then you had to go in, even if the patient is long
gone.     And since we were covering for other people, we really

just found that it was too much of a burden.     Patients we hadn't
admitted, we'd call in an insulin order at 3 a.m., and then we'd
have to go in the hospital just to sign the insulin order.     So we
ended up cutting back after a while just to Suburban, and that
really did make more sense, although now that I'm with GW [George
Washington University Health Plan], we're on the staff at Holy
Cross and Shady Grove, because that's where the GW program goes.


Mullan:    What I'd like to explore next is your recollections and
observations about being a family practitioner in a populated,
generally well-to-do community that is well stocked with
specialists, how that has been both from the point of view of
professional identity with your fellow physicians and others and
what it's been like in terms of clinical work and how patients
respond to you and how it's been for in terms of satisfaction,
identity, etc.     So why don't you just associate what it's like to
be a family doc in Montgomery County, Maryland.
                                                                    47

Garvey:   Professionally, I would say it's a slightly awkward
situation.    At Shady Grove, they have obstetrics, which, of
course, they don't at Suburban, but they're a little
uncomfortable with the idea of family practitioners doing
obstetrics.     I don't want to do obstetrics, so that's not an
issue, but you know before you even ask the question that there's
a little hostility about family practitioners doing this.
     At Suburban, because I was covering with a bunch of
internists, I always got notices for the internal medicine
meetings.     1 never got any notices on family practice meetings,

even though all my credentials said family practice.     I didn't
even realize, until I'd been on the staff for a number of years,
that they had a family practice department.     I thought that

family practice and internal medicine was treated as one
department there, and by the time I found it out, I was used to
going to the internal medicine meetings and liked them fine, and
it was a chance to see my husband, who also went to the internal
medicine meetings, and often it was the only time we'd see each
other in a busy day.     So that I would say professionally it left

me a little bit without an identity.


Mullan:     Who are the family docs at Suburban or in Montgomery
County?     Are they old GPs [general practitioners]?


Garvey:     At Suburban, a lot of them at that point were older GPs
or people who may have had a variety of training in other
                                                                    40

countries, but couldn't get certified as specialists in anything
here.    At Shady Grove now, I think Shady Grove has become a focus
for some of the people trained in family practice who have
settled in Montgomery County, so they currently have, I think, a
growing and vibrant department.     The department was just quite
small at Suburban.
        And, of course, the useful thing about being in the
internist meetings was that the internal medicine subspecialties
were there, and certainly as a generalist I very much depend on
the specialists when I put people in the hospital.     If I'm going
to admit a heart failure patient every two years, it might be a
little more often than that, but a lot can happen in terms of
therapeutics in that period of time, and I'm going to ask for the
help of a cardiologist.    The same thing with acute respiratory
failure, which might only happen every five or six years in my
practice; I'm going to call a pulmonologist.     So it was useful to

be part of the internal medicine department, because I did get to
know all the subspecialists, and I think it was actually easier
dealing with them and using them and finding ones that I liked
than it would have been if I had just gone to family practice
meetings and hadn't met all these other people.
        In terms of patients, as I mentioned the Medical Society
Referral Service found a great demand for board-certified family
practitioners.     It's a very popular idea with patients.    One of
the other ways in which my practice grew was that although the
teenagers who had come to me because they wouldn't see the
                                                                   49

parents' doctors grew up, went off to college, married and
settled in many parts of the country, many of them, it began to
occur to their mothers that the only doctor they had was an
OB/GYN.   They hadn't had a child in fifteen or twenty years.
They were beginning to have some complaints that the obstetrician
couldn't deal with, especially if it were high blood pressure or
something like that.    So that what I ended up with as a much
bigger part of my practice than teenage girls was the mothers of
the teenage girls.
     Then I've also had a lot of that generation then start
bringing me their parents.     That, to me, has been one of the
nicest things about family practice, to see three generations of
a family, and there are a couple of families in which I've had
four generations.    I've got one fourth generation on the way,
too, because one of the teenage boys in my practice is about to
become a father and says I will take care of his baby.    But it's
got a very high rate of acceptability among patients, and I feel
that's really the heart of the satisfaction.


Mullan:   How would you characterize your practice, or can you
quantify it?   Is it predominantly women as opposed to men,
predominantly one age group as opposed to another?    How has it
developed?


Garvey:   I would say the largest plurality is women within five
years of my age, up or down.    I would say I probably have three-
                                                                         50

quarters female, one-quarter male, and certainly I go completely
across the age span.    I don't have a lot of young children in the
practice, because my coverage was internists, so I didn't take
children under the age of six until I joined the GW plan, where
I'm with other family practitioners.      Now 1'11 take them from
newborn on, but I haven't accumulated very many at this point.
     I certainly have many fewer elderly patients than a regular
internist does.    I've always kind of wondered at the idea of
making geriatrics a separate specialty of internal medicine,
because one of the things I did when I was at the Hospital Center
was kept track of the ages of my patients, and the average age
was seventy-two.   So as far as I was concerned, internal medicine
   geriatrics training.   But I have a lot of middle-aged
patients, and at GW I'm getting more young adults, too.


Mullan:   Maybe we should pick up and just do the GW chapter,
because we stopped short of that, and then I want to come back
and ask more of the big-picture questions.      Recently you have
moved from your semi-independent private practice into an
arrangement with George Washington University Health Plan.         How
did that come about and how does it work?


Garvey:   I've always enjoyed teaching.     I feel as though I'm
teaching the patients a great deal of the time, too.      I really
did want to become a teacher.   I started teaching Georgetown
[University] students, gee, I guess probably ten years ago in my
                                                                  51

practice, precepting them in my practice, and then doing some
classroom teaching downtown for the first-year students at
Georgetown.   GW approached me and asked me about precepting in my
office, which I also did.
     But then I understood that George Washington was going to
start a family practice residency in the county, and I thought
that teaching in a residency program had a great deal of appeal.
So I started talking with Rusty Kallenberg [phonetic], who's head
of the Family Practice Division at George Washington, and said,
''When this comes about, I'd be interested in precepting some
residents and maybe coming up there for an afternoon a week or
something like that."   So I just kind of kept in touch with them.

     The September before last, I was really just kind of
touching base with them and saying, "1 know your residency is
coming up in less than two years, and I just want you to know
that I'm still interested.t'
                    still interested in you, too.
     He said, llWetre                                  Why don't you
just move your practice up and join us in Rockvi1le.I'
     I said, "Oh, no.   I love my office.    I love my staff."
     They said, l1Well, we'll take your staff, too."
     I originally said no.     Then I sat down and started thinking
about it, and one of the things that's happening to, I think,
everybody in private practice in the last few years, it wasn't
happening until maybe the last three years or so, is every
January 1st or so we'd get a bunch of requests for record
transfers, and often with sad notes, "My employee has changed me
                                                                      52

to MDIPA or some other health plan, and I'm sorry I can't be your
patient anymore.     Please send my records to Dr. So-and-so."   To
me, that was a loss to lose the patients.     I didn't have a lot of
trouble replacing them, but you lose the relationship with the
patients.
       Meanwhile, the OSHA regulations had been passed, which had
all kinds of Mickey Mouse requirements.     The only, I think,
useful part of the OSHA regulations was that all your staff
should be immunized against Hepatitis B, which my staff already
was.    The CLIA regulations had come in.


Mullan:     OSHA being the Occupational Safety and Health
Administration regulations relating to--is it medical practice
personnel?


Garvey:     It's blood-borne pathogens, to protect the staff.


Mullan:     CLIA is the Clinical Laboratories--


Garvey:     Laboratories Improvement Amendments of 1988, which
weren't implemented until '92, I think.     But the state of
Maryland, anticipating CLIA, since our Senator Barbara Mikulski
had introduced CLIA, had in ' 8 6 implemented rules that were
pretty similar to C&IA's, and they would come around every year
and do a twenty-six-page survey of our laboratory and require
that the only person who works in the laboratory recorded every
                                                                      53

night that she had disinfected the counter tops, that she had
recorded every day that she had checked the temperature in the

refrigerator and the temperature in the incubator.


Mullan:   This made for very cumbersome stuff.


Garvey:   You bet.     That she had not only done controls, but then
had graphed the controls.      She couldn't just record them; she had
to graph them.    And so she was spending six hours a week, in
addition to her forty hours of lab work, doing paperwork, first
for the state and then for the state and the feds, which was
making the lab very expensive to run.      I was getting to the point
where my prices were having to go up almost every year, and I
felt that there were plenty of people who were willing to keep
paying those prices, but that there were also people who
couldn't, and I didn't want to lose them as patients.      I don't
want a practice which is socioeconomically uniform.


Mullan:   So you accepted the GW offer.


Garvey:   So I accepted the GW offer.     That seemed to get me out
of all the administrative hassles of running a practice.      The
prices dropped.      They charged less than I was charging, and I
would have had to increase my prices.      It also did offer me the
opportunity to practice with other family practitioners so that I
                                                                     54

could take younger children, and, of course, the opportunity to
participate in building up the residency program.


Mullan:     And most of your patients came with you?


Garvey:     Yes, most of them have come.   Of course, a couple months
ago we got the usual raft of changes.      And basically what GW has
done, which has been terrific for me, is that they have said,
"Your patients can remain fee-for-service."      And they hired my
bookkeeper to teach the GW people how to manage fee-for-service
patients.     They hired my nurses.   So that worked out well.
Actually, with the open season, a lot of my patients decided to
change to GW.


Mullan:     To come back.


Garvey:     That's right, where they could come and see me at much
less under GW than fee-for-service.


Mullan:     Let's go back to the big picture.   I'm very interested
in learning your experiences, as I say, with colleagues and with
patients, and let me just push on a little bit.        Family
practitioners are often seen in the world of specialties as less
competent or less able, so that sophisticated patients would
rather go to more highly credentialed and more highly specialized
individuals, both because of the competencies or the alleged
                                                                     55

competencies, as well as the fact that these "sophisticated
patients" can make a determination if they need to see a
gynecologist or an internist or a surgeon for a given thing.
What is your experience with that?


Garvey:    GW patients don't have a choice; they have to go through
us.   The non-GW patients will often call an orthopedist directly.
For a lot of the other things, for the medical subspecialties,
they may ask to see a subspecialist, but they want my referral,
because then they have somebody that they know that I trust.
      And then the other side of that, which I think   is one of the
most important aspects of being a family practitioner, is that I
become the patient's advocate in the subspecialty system.      I also

become basically an interpreter, a translator, because the
specialist may not speak in terms which are as accessible to the
patient.    So the patient my go to a specialist and the specialist
may tell the patient what he thinks is going on and what the
treatment should be, but the patient will then call me and say,
W h a t did the specialist say to you?   What do you think I ought
to do?"


Mullan:    Sort of the upside of gatekeeping, the positive side of
gatekeeping, where you can be ombudsman.


Garvey:    Right.   Certainly when I do put a patient in the
hospital, I know that I have to call and ask specialists
                                                                    56

elementary questions that people with a large hospital practice
wouldn't be asking, but on the other hand, it's usually very
important to the patient that I'm still involved in their care,
and even for the kind of simple-minded things.    Simple-minded to
the doctors are not simple-minded to the patients, things like
getting the kind of diet that they want or like, getting
something for sleep that agrees with them, getting something for
constipation, the things that are routine, that don't really take
an M.D.   to do, but you still need somebody to write the orders.
It may be just harder getting the best supportive care from
someone who just doesn't know you.    So I feel as though I have a
real function in the hospital, even--


[Begin Tape 2, Side 13


Mullan:   What are the prospects for the growth of family practice
in a community like this?   If one could argue that you've been
doing it for more than a decade and you're, at least until very
recently, one of the few people, to my knowledge, who is doing
that, that is, a recently trained family physician in general
practice in this tally.   First of all, I guess, is that true; and
secondly, why have more not come and will more come in the
future?


Garvey:   Well, it's not so true, because I think that the GPs are
retiring, but because there are more and more family practice
                                                                   57

programs available all the time, there are more and more family
practitioners available for all parts of the country, including
this.     So I think that younger family practitioners, a few of
them, are coming back to this area, probably not in as great
numbers as specialists.     I think the specialists end up coming,
say, to work at NIH, and then they decide to stay in the area.
There's nothing to draw the family practitioners back to this
area.
        I think that the market for family practitioners is very
good, and the managed care programs are actively seeking family
practitioners and basically primary care internists and
pediatricians, and they don't feel that there are enough of them
around.    The specialists, on the other hand, people are
suggesting that they go get retrained so they can become
generalists.     Some of the obstetricians at Shady Grove are
interested in working kind of a trade with our family practice
residency program in that, yes, they will precept them in OB/GYN,
but they'd like a little CME in generalist things, because they
would like to be able to offer primary care to women patients.
        I think that Montgomery County will clearly have more family
practitioners just by virtue of graduating family practitioners
from the GW program, because I think it's very common to stay in
an area where you've trained.    A lot of our applicants are from

local medical schools, from Maryland, Georgetown, GW, and Howard,
or people who have grown up in this area and want to come back.
So I suspect that the vast majority of people who go through this
                                                                    58

family practice residency, and that will turn out six people a
year, will choose to settle in the county and practice right in
this area.


Mullan:   That's exciting.


Garvey: Yes.


Mullan:   Back to the question I asked a little bit before, are
there patients, in your judgment and experience, who are
generalist-inclined and others less so?     Clearly, particularly
when you are a rare bird, there's a lot of self-selection that
goes on in those who found their way to you.     But in your
experience practicing both with them and observing the community
in general, are there people who are disinclined to generalist
care and are anxious to have the cutting edge that were available
at every visit?


Garvey:   Of course, the people who really don't want to see
family practitioners never cross the threshold, so I don't know
who they are.     But my sense is that almost everybody wants a
family doctor, and there certainly are plenty of sophisticated
people who want to see a left great toe specialist when the left
great toe hurts, but they still want to come back and process it
with their family doctor.
                                                                   59

     I have patients whose self-referrals I really can't control,
but who will come back and say, "I saw my rheumatologist last
week and my allergist the week before and my ophthalmologist
before that, and my ophthalmologist doesn't want me to take
aspirin, but my rheumatologist does.   What do you think I ought
to do?"   So wanting a subspecialist on the cutting edge doesn't
seem to preclude also wanting the family doctor to process the
recommendations with.


Mullan:   We touched this a little bit before, too, the attitude
towards generalists in general or family physicians in particular
among your colleagues.   You, I believe, have been very active in
the county medical society.   Tell us a little bit about that and
how you are seen in that community as an unusual entity, a family
practitioner.


Garvey:   I actually, I think, became visible in the medical
society because of my interest in public health.   I joined the
Public Health Committee of the medical society, and then I became
chairman of the Public Health Committee, which put me on the
executive board of the medical society.   While I was chair of the
Public Health Committee, I founded something called the Primary
Care Coalition of Montgomery County, which is an organization
which the health department and the medical society and
representatives of the five hospitals, now GW and other
interested parties--community ministries, United Way--participate
                                                                     60

in community clinics, mobile medical care.     So I think it was

actually more as a public-health-oriented person than as a family
practitioner, per se, that I became visible.
     The people who are president of the medical society are

people who just become visible, and specialty seems to be
irrelevant.     The current president is a dermatologist.   He was
preceded by a plastic surgeon, preceded by me, preceded by a
cardiologist, preceded by an orthopedist, preceded by a
neurosurgeon.     The specialty doesn't seem to have too much
relevance.
     It does have some relevance when the medical society is
trying to form committees.    The state medical society, which I am
now treasurer and a member of the board of trustees, formed a
committee last year to look at the idea of a medical society-
sponsored HMO or PPO, and because Maryland in general is so laden
with specialists.     I think there are three ophthalmologists on
our board of trustees for the state medical society.     They wanted
me on that board because I was one of the rare family
practitioners that they could find that they knew and that they
could put on the board, because clearly, family practice is
important.
     I think for a lot of the physician hospital organizations
that are forming now--every hospital is trying to form them--
again, the family practitioners are in great demand.     Everybody
wants family practitioners there at the core, because that's what
the employers want to buy.    They want to buy access to family
                                                                    61

practitioners.     They don't want to keep paying for access to

specialists.
     So I don't think it was a big benefit or detriment in terms

of becoming active or becoming a part of the hierarchy of the
medical society.


Mullan:   In terms of another kind of colleague, the non-physician
provider--the nurse practitioner, the physician assistant, nurse
midwife--how have you seen that developing in this area, and what
are the relationships, particularly between generalists either in
your practice or you observe, and nurse practitioners or other
non-physician providers?


Garvey:   That's really an interesting area, and it's an area that
is a concern to me.    I worked a lot with nurse practitioners in
Boston, because there were some nurse practitioners at Boston
City Hospital, and I worked very closely with the nurse
practitioner at the community health center, and we had a very
well-functioning collaborative practice in which I was there for
my three sessions.    There was an internist who did internal
medicine for two or three sessions a week.
     When the doctors were there, the nurse practitioner
functioned as a nurse.    She'd do the vital signs, she'd take a
little initial history, but we did the examination and the
treatment.   When we were not in the clinic--she was there full
time--she would do the follow-up.    She would check diaphragms for
                                                                        62

fit, she would do things like blood pressure follow-ups, and
she'd also do some primary acute care.     So if a patient of mine
or the internist came in with, say, a urinary tract infection,
Pat would order the urine, evaluate the results, and usually call
me or call Betty, depending on whose patient it was, and say,
ItI've examined the patient, I've looked at the urine, and these
are the findings.     What do you want to do?"     So that she really
functioned as a practitioner when we weren't in the clinic, and
there were some things that she could do under protocol, and she
functioned as a nurse when we were there.        So that we knew her
very well.     We knew what her skills were, and she got an
opportunity to work both with us and also semi-independently,
doing her own evaluations.
     When you look at the cost of medical care and you look at

the functions that a generalist performs and you see that, say, I
might be doing a bunch of camp physicals in the spring and in the
fall I'm doing a lot of sports physicals, school physicals, that
doesn't take a whole lot of heavy-duty smarts.       It's pretty
straightforward, and, gee, do you really need somebody with all
this training and a hospital-based residency to do a camp
physical?     No, you don't need a hospital-based residency to do a
camp physical.     Do I want to turn it over to a nurse
practitioner?    Absolutely not, because that's when I get to know
these kids.
     If you first see a patient with a temperature of 103, who's
writhing in pain and you're trying to figure out what to do with
                                                                   63

the kid, but you have no rapport and no knowledge of that kid, I
think taking care of his acute problem, you might as well be an

emergency room doc.    So I've never been really tempted by the
idea of sharing my practice with a nurse practitioner or a PA.
Although I have the greatest respect for their abilities, I'd be
jealous.    I don't want to give up the contact with the healthy
patient.
     I also do feel that my ability to care for a very sick
patient is to some extent improved by knowing the patient when he
or she is healthy.    I want as much knowledge of that patient.    I
ask them what they eat for breakfast and what they eat for lunch
and what they eat for dinner and what they snack on and what
their hobbies are and what their husbands do for a living and are
there any health problems in the family, do they    have any pets.
All these things, I feel, give me a context for treating the
patient.    So if I turned over the routine stuff to somebody else,
I don't think I could be as good a doctor.


Mullan:    There are those who argue that the future is non-
physician providers and specialists, and that the generalist's
role can be relegated to the non-physician provider and at a
lower level of training and a lower level of recompense, and
where you really need to pay your high-cost training and your
high-cost care is with a fleet of specialists that will work
directly with non-physician providers.   Can you talk about that?
                                                                  64

Garvey:   It is a hypothesis which strikes fear in the heart of
every family practitioner, and I disagree with the premise.
Going way back to 1975, ' 7 6 , when I was doing the site visits for
the Massachusetts Department of Public Welfare and the Title X
program, what I noticed very clearly, going around to the
different sites, and these were basically sites just like the one
that I was in, where there would be a doctor who came in for a
few sessions a week and a nurse who basically ran the clinic and
was really responsible for anybody who called or came in between,
this was really before nurse practitioners were widely available
and it was before the training was at all standardized, so you
could go off for a six-month program and all kinds of things.
And there were people who were not nurse practitioners, also, who
were basically in charge of some of these programs.
     The difference in the charting and the quality of the
program varied greatly, and the top being a nurse, who I don't
think was a nurse practitioner, but she had been an intensive
care unit nurse before she'd been a Title X clinic nurse.     so if
a hematocrit of 22 came back, she'd know, "Gee, this could be a
problem, I'd better do something about it,'' whereas some of the
people who had just gone from nursing school into outpatient
nursing, they get back an abnormal lab result, they would record
it and ignore it, because they didn't have any kind of a context.
     I think that when you've seen and had to deal with serious
illnesses, that something which might not be very striking, but
                                                                    65

which could in fact be an indication of something very dangerous,
would have a lot more impact.
     I had a patient who probably would not have been cared for,
even in the future would not be cared for by a non-physician.       It
was a woman who had been treated for a cancer several years
before.   She had come in for a routine physical, and she had a
small nodule in her navel, which she had noticed but she hadn't
worried about.    It was about the size of a pea.   But knowing that
she had had an intra-abdominal malignancy a few years before, I
sent her to the surgeon right away.     I mean, this was not some
little umbilical hernia.     Even over the course of ten days it
took to get her under the knife, she had developed huge palpable
metastases in her abdomen.     I think it's the kind of thing which
a relatively minor physical finding could give someone without
more training a false sense of security.     He might say, I1Letms
check that in a couple of weeks,I' or something like that.


Mullan:   So your feeling is that the assurance of the quality of
care and the vigilance in the hands of lesser trained people will
not be as good?


Garvey:   I don't think it can be as good.   There's always a
balance between how recently you've acquired your skills and your
book learning and how many years you've had to observe things,
and certainly a nurse practitioner or something will over the
decades acquire more experience and be perhaps much more astute
                                                                  66

than somebody who comes out of a hospital-based residency and has

only been in practice a couple of years.     But I still think that
hospital-based training does give you some experience that you
can't get purely in an outpatient setting.
     I think if you took somebody and said, "You have a nursing
degree, but I'm still going to put you through a medical
internship and residency," perhaps you can be just as skilled a
practitioner in that situation, but I don't think that with
lesser training you can have the same level of knowledge.


Mullan:   Managed care is obviously a big part of the picture now
and presumably in the foreseeable future.     You've talked a little
bit about it in terms of your own patient perturbations that it's
caused with your practice.   How do you see it as a structural
element of the system?   You observed at least a version of
managed care all the way back in-the seventies.    Are you for
managed care or against managed care?   What would your wisdom be
on managed care?


Garvey:   I consider managed care in general to be %-Mart
medicine."   I was very idealistic when I started to work at Group
Health, and I really liked the concept of an HMO which did not
penalize a patient for being sick, where supposedly it was
revenue-neutral whether you came in healthy or sick.    What I
found was that a system which supposedly has the door always open
has to find a way actually to keep the door closed a great deal
                                                                    67

of the time.    So I would find that very pushy people could send
in a seventeen-year-old child because the child had a bigger
pimple than usual, whereas a very unaggressive person, like the
husband of my gall bladder patient, could die at home without
care because it was not easy to talk their way in.
     You had to talk your way into the place.     They had something
like an intentional six- to eight-week waiting period for
physical exams at Group Health, and sometimes even for regular
appointments.   In fact, the director was quoted in the Washington
Post shortly after I left as saying that he really thought that
most acute-care appointments should have a long waiting period,
because most acute problems would go away by themselves, and then
the patient wouldn't need the appointment.
     I don't know what the balance is, because clearly it's not
just the doctor-driven incentive to bring patients in for all
kinds of things.   Patients are absolutely unlimited in their
ability to demand care, as long as somebody else is paying for

it, and you certainly notice this when you're prescribing
something and you say, tlYouhave bronchitis, and I think
doxycycline will work very well for you, and I think you'll like
it because it's under twenty dollars for the whole prescription.'#
     And they say, "Oh, yeah, but sipro [phonetic] worked really
well for me last time, DOC.'#
     I say, "Yeah, but that's seventy dollars."
                                                                     68

     '*Oh, yeah, but my insurance pays for it.''     They want the
latest and the most expensive if their insurance is going to pay
for it.
     I think that something like a medical savings account, in
which the first dollar is paid for by the patient and there was
some incentive not to spend, but always the backup of insurance
if your expenditures exceed a certain amount, would be a far more
sensible thing, but it's obviously much more difficult to
administer.    So I don't know what the answer is.
     But managed care, I'm not convinced it saved money.      What
it's become now is one of the most profitable sections of the
stock market, because the various business people have found that
managed care, which I think started off as Blue Cross/Blue
Shield, asking for second opinions and things like that, they
figured if you can ratchet down the doctor's pay and you can
ratchet down the patient's access and still rake in the kinds of
dollars that the insurance companies were raking in, then you can
pay a lot of money to stockholders, and that's what they're
doing.    If managed care were something in which all the dollars
went to patient care, I think it would be a much less vicious
system of care than it is now.   But now it's a profit-driven,
anti-patient, anti-physician system, and it is %-Mart      medicine."


Mullan:   Given the trends in the system, which include managed
care, it includes more primary care, it includes more non-
physician providers, and a host of other potential changes, how
                                                                    69

do you see the future if we look down the road twenty years,
particularly from the point of view of someone who's dedicated
her career to generalism, to the generalist approach to patients?
How do you see it faring with the perturbations of the
foreseeable future?


Garvey:     It's hard to say.   I can only imagine that as far as the
payment mechanism goes, the pendulum is going to swing far enough
that people are going to become outraged enough that we will
dismantle the insurance system.     I was terribly disappointed that
the Clintons didn't succeed in doing something with health care.
I think they got too ambitious and they tried to accomplish too
much.     I think if they had taken kind of a Lyndon Johnson
approach and said to Congress, "See, the country wants this and
the country wants that.     They want universal access, they want
noncancelability, they want no pre-existing condition exclusions,
figure out how to do it,@' that maybe we could have gotten
something that allowed the states some flexibility and still
provided those features, because even the system as it was five
years ago needed to be overhauled, and I think we need to get the
insurance companies out of it.
        Even though I rail against the inanities of Medicare, I
think, in fact, a single-pair system is where we should be, and I
can't imagine our not being there eventually, if not in twenty
years, than twenty-five years, hopefully in five years.
                                                                    70

        I think the idea of having a primary care provider for every
patient is so inherently sensible that regardless of how it's
funded, that we'll continue to go in that direction.      Whether
those primary care people are going to be physicians or non-

physicians, I can't imagine that we're going to change
completely.     Even in Group Health, when I was working there,
actually I worked with nurse practitioners there.     We had
doctor/nurse practitioner teams, but we really functioned side by
side.    The doctor had his or her own patients, the nurse
practitioner had her own patients, but the doctor was available
to the nurse practitioner if her patients came up with something
that was beyond her ability.     And, of course, the doctor did the
hospitalizations of the patients if the nurse practitioner's
patients needed to be hospitalized.
        I think that there are enough people alive who are used to
going to doctors and who would like to continue going to doctors
that there will certainly be a demand for the foreseeable future.
But I also think that more and more people are getting accustomed
to seeing non-physicians and that that will have increasing
acceptability, also.
        So I don't know.   I can't imagine the primary care physician
disappearing completely, because I think there are people like me
who like to deliver that kind of care.      In fact, there are
specialists now who deliver primary care, simply because they
treat a patient for something that's serious.     Say a
rheumatologist or a gastroenterologist may end up so involved
                                                                   71

with a patient around a serious problem that that specialist will
end up seeing the patient for the minor problems, too, that it
would just seem beside the point to go off to somebody totally
new who doesn't know the patient.     If your first problem in a new
town is serious and you off start with a subspecialist, you may

never establish yourself with a primary care doc.     And there are

some specialists who really get a lot of satisfaction out of
having patients they consider to be their own patients and for
whom they provide all levels of care.


Mullan:    I think that trying to scope out the future, with all
the changes going on, is very, very difficult, and I agree with
you.    I'm concerned about the notion of generalism, even as it
gains credence, which I think it is in this epoch, will also be
routinized in a way that will make it easier to devalue in the
sense of moving it down the hierarchy of skills and saying that
lower-skilled people can do it.     Even as it arrives at a point of
prominence, it's also liable to simplification or devaluation.
That's a real challenge.
       Let's go back to the big picture, back out of the trees to
the forest.    I was interested and I was asking about your
original majoring in English, because in talking to a number of
people about their interest in primary care, it often comes up
that people who have either started in directions that were not
headed towards medicine, or even as they went into medicine their
interests were other than traditionally scientific, who seem to
                                                                  72

enter into the tunnel or into the chute of medical training,
scientific training, and out the other side select a broader
discipline rather than a narrower discipline.
     A s you look back at your own career, I realize you had some

strong influence along the way that said, "Go down this path,"
but as you total up all that you've been through, your enjoyment
to practice as a generalist and your vision of the world as a
generalist, how does that relate to your earlier experiences in
life?     Do you have any thoughts about what contribution your
youth and your pre-medical training has made to that?


Garvey:     I think coming from a non-medical family, other than my
great-grandfather in England, who, of course, I never knew, I
didn't have perhaps some of the snobbery that comes along with
being in a medical milieu from the beginning, so that being a
doctor is kind of good enough without having to prove myself by
becoming a sub-sub-subspecialist; whereas I think perhaps people
who come from medical backgrounds, like my husband, or people who
have gone through the sciences, where you seem to get the most
credit for knowing the most about the least thing--I mean, you
pick one little area and you know everything about this gene or
this chemical or whatever, and you become an expert--1 think that
not having grown up in a scientific or medical milieu, that kind
of expertise had no particular social value for me.
    Also, not seeing myself as the primary breadwinner gave me
the option to really just kind of follow my own preference and
                                                                    73

not think, "Gee, as a cardiac surgeon, I could earn a lot better
living than I could as a generalist."    I wasn't even worried
about having to support myself as a teacher.    The financial
aspects have never been part of the consideration, and I think
that they are.    If you had gotten married in the first year of
medical school and have three children by the time you finish
your residency and you think you're going to have to support them
all, and you're married to somebody who doesn't work, who's been
at home with the three children, that factors into your choice of
specialty, and for an extra year or two of training to be able to
have three or four times the income of a generalist, may seem to
be attractive or to be worth it.
     Also, though, I was a generalist because I felt that it was
the best training for public health, which is really still a
great interest.    One of the advantages of the GW program, it's
not just a straight family practice residency; it's a community-
oriented family practice residency, and there will be an effort
made to probably have the residents work in a community.    There
is something called Community Clinics, which is not a Section 330
center, but it is very similar in its concept, to have them do
various projects with the health department and that kind of
thing.    So it will be very much integrated with my own interests.



Mullan:    In terms of things we haven't touched on, and we've
touched on a great deal, is there anything else that's occurred
to you that you'd like to add to the story?
                                                          74

Garvey:   No, I think we've touched on a lot of things.


Mullan:   Good.   Terrific.   Thanks.


[End of interview]
                                                              75

                              Index


Boston City Hospital 26, 32, 61
Boston Health Department 31
Brigham Hospital 27
Brother, older 7
Brother, younger 7
Brown, Harold 19
Bryn M a w School 4
Bureau of Health Manpower 35
Centers for Disease Control 3 0
Children's Hospital 20, 27, 28
Clinical Laboratories Improvement Amendments (CLIA) 52
Clinton, Bill 69
Clinton, Hillary Rodham 69
Columbia University 13, 15-17, 19
Community Clinics 73
Cornell University 13
Curtin, Jim 21
Deuschle, Kurt     18

Egan, Mary    36

Father 3, 6, 8, 10, 11
Food and Drug Administration (FDA) 44
Garvey, Tom  [husband] 1, 3, 9, 13, 20, 25, 32, 33, 35, 40,
          43, 44, 47, 72
Garvey, Tom IV [son] 21, 25, 38, 41, 44, 45
Georgetown University 50, 57
Goodman, Nelson 24
Graham, Bob 35    .
Group Health 24, 34, 39-41, 66, 67, 70
G W Health Plan 46, 50, 51, 53-55, 57, 73
Harvard University 2, 11, 25-27, 29
Holy Cross Hospital 45
Howard University 57
Hutchins, Vince 36
Johns Hopkins University 3, 14
Johnson, Lyndon B. 69
Johnson, Robert Wood 25, 28
Kallenberg, Rusty 51
Killam, Phil 35, 36
                                                              76

Marshall, John 35
Martin Luther King [Jr.] Community Health Center 18
Massachusetts Department of Public Welfare 64
Massachusetts General Hospital 32
Massachusetts Mental Health 29
Medical Society Referral Service 48
Medicare 69
MHC 30, 50
Mikulski, Barbara 52
Montefiore Hospital 18
Montgomery County [Maryland] County Health Department    33
Mother 3, 6-11
Mount Sinai Department of Community Medicine 18
Mount Sinai Hospital 18, 19
New York University 13
National Institutes of health (NIH) 20, 33, 35, 44, 57
Occupational Safety and Health Administration (OSHA)    52
Popkin, Jordon 35
Primary Care Coalition of Montgomery County 59
Public Health Department (Columbia University) 19
Public Health Service (PHS) 34
Radcliffe College 1, 2, 4, 5, 11
Richmond, Julius 31
Section 330 Program 26, 33, 35, 38
Shady Grove Hospital 45, 47, 48, 57
Suburban Hospital 45, 47
Title X   26, 31, 32, 35, 38, 64
United Way 59
University of Maryland 57
University of Vermont 18
Washington Hospital Center   20, 21
Washington Post 67
Wassermann, Marty 3 8
White, Bill 38
Yerby, Alonzo   31
                                                                   1

                          CAROL GARVEY

                         Fitzhugh Mullan
                           Interviewer



Mullan:   Would you give me your name and spell it?



Garvey:   Carol Garvey--C-a-r-0-1 G-a-r-v-e-y.



Mullan:   It is the 5th of January 1997 and we once again are in

Dr. Garvey's house for a catch-up interview.   It will be short
and to the point but I wanted to come back and ask a little bit
more about your experience with your son's illness which we
touched on several times in our earlier interview but we really
didn't talk too much about either what happened or how it
affected you both as a physician and as a person.   So maybe we'll
start just describe a little bit about how it came about, what it
was, and what happened medically.


Garvey:   It was of course totally horrifying. Also I think it

was extremely educational in learning what patients go through.
Tommy went off to camp, a rather rotund child who had been teased
by his classmates. He came back--


Mullan:   How old?
                                                                         2

Garvey:      Eleven. .He came back from camp--


Mullan:      This would have been 197--



Garvey:      1981.   --he'd gone o f f , I guess, weighing about 100

pounds and he came back weighing 86 pounds.       So he had lost 14

pounds in four weeks.      He (unclear) just looked like a different
person.     We said ''Tommy, you lost so much weight.    How did that
happen?"     He said, "Well, I was very active and the food wasn't
as good as your cooking."      He was thrilled because he had been
called "Fatty" at school and he didn't like being fat.        We took
off the day after he returned for Cape Cod for a vacation
together and the first night he woke up and said I
                                                 '        have an
earache."    We didn't have any instruments with us because we were
on vacation so we had no way to deal with it so we gave him some
aspirin and got up and the next day he was fine.        His ear didn't
bother him during the day.      Over the next few nights he got
earaches at night not during the day.       We went over to visit a
friend of ours on Martha's Vineyard and told him--we planned to
visit him anyway--but told him that Tommy had ear pain.        We
actually went to an emergency room because Michael didnrt keep
his stuff at home, looked in his ears, couldn't see anything that
looked unusual but decided, well, we'd treat him for (unclear)
externus so we gave him cortisone drops which didn't make much
                                                                      3

difference.   Then over the next few weeks after he got home he
began to get a really stuffy nose.    So   we figured maybe it's
pressure on the eustachian tube that was giving the problem but a
really stuffy nose wasn't unusual because T-three has such
terrible allergies.   So,   okay, the kid's developing allergies.
Not wanting to get deep into treatment of a family member we took
him to an ENT person who said, "Oh, yeah, he's got bad allergies''
and put him on Tavis-D.     Then he developed purulent discharge
from his nose and so we figured maybe he had a sinus infection.
We took him to his pediatrician who said, "Yes, he's got a sinus
infection" and put him on Bactrum (phonetic). After a few days
he developed a rash--we obviously couldn't stay on Bactrum--we
called the pediatrician back and he said, "Well, take him to
Bruce Feldman" who was a somewhat more eminent ENT person in a
kind of friendly neighborhood. The ENT person we had taken him
to originally. Bruce Feldman tried to irrigate his sinuses and
could not get water through his nasal pharynx.      He tried to be
very low key but said, "You know, why don't we get a CT scan.
Try to set one up next week."    This was a Friday.    We obviously
weren't up to waiting until next week and we called up Suburban
and got him on the schedule for nine o'clock that night.
Actually an acquaintance of T-threes from NIH was on duty at
Suburban in radiology and saw a large nasopharyngeal mass which
he said could be a benign vascular tumor of preadolescent boys--1
                                                                        4

forget the name of it--that was bothersome but not malignant.          So

we pinned our hopes on it being that.      We tried to reach Dr.
Feldman, called his answering service repeatedly throughout the
weekend, never got a return call. Monday morning I took Tommy to
school, called Dr. Feldman from the school to find out whether I
needed to come and pick him up early to take him to see Dr.
Feldman again to discuss the CT scan and he said, "Did you give
him breakfast?"     I said, "Yes."   He said, 'Well,   then, I can't
operate on him today."     Oh, that was my first experience with how
awful weekends are for patients especially if answering services
and doctors don't respond.     He said, 'Take   him right over to
Children's and we'll do a narcoriogram (phonetic) today."        We
did.     He then had his biopsy the next day and we got the
diagnosis the day after that.


Mullan:      The diagnosis being?



Garvey:     Rabdomyocin sarcoma (phonetic). I had tended to be

optimistic--I'm just always optimistic--and my husband is just
the opposite.    He always wants to anticipate the worst so that he
can't be disappointed. We got the diagnosis and then, I guess,
about five o'clock on Wednesday night, and then I guess really
benefitted AT&T by calling everybody we knew up and down the East
Coast.     I guess David Nathan (phonetic) who was up in Boston
                                                                       5

(unclear) Harbor, called NIH people and then a friend of ours put
us in touch with a guy named Paul Peebles who was a pediatric on
call locally.    Paul came by at about ten o'clock Wednesday night.
He sat down with us and went over everything and said that he
actually thought that Hopkins was preferable to either Children's
or NIH.    At Children's the technology was such that he would have
had to had his palate split in order to get at the base of the
tumor and do a definitive procedure as opposed to the biopsy that
he had had.    Whereas it could be done endoscopically at Hopkins
and that was new technology.    Only Hopkins and (unclear) had it
at that time.    They didn't have that surgery at all at NIH so he
could have gotten Chemo but he couldn't have gotten surgery.       I
think he could have gotten radiation at Children's.    He could
have gotten surgery and Chemo but he would have gone to GW for
radiation.    They don't have pediatric radiation oncology at GW
just kind of general.   At Hopkins he could have gotten surgery,

radiation and Chemo.    We took Paul's advice and went up to
                                                           -

Hopkins.   Of course, T-three and I were just absolutely
devastated and Paul said, "Well, you know, we really have to be
honest with Tommy. We have to tell him what's going on."       And he
said, "Now, you can do it or I can do it.   However you want to do
it."   Well, T-three said, "You do it, you do it.   I couldn't
possibly tell him."    I wouldn't have minded telling him but T-
three kind of assigned it to Paul.   We went in and Paul
                                                                          6

introduced himself to Tommy and sat down very earnestly and was
straightforward telling Tommy, "You have a tumor and it's going
to require a lot of treatment" and kind of went through some of
the things that Tommy could expect in terms of the work-up and
everything.    '1   want you to feel you can ask me any question at
any time.    So,    do you have any questions now?"    Tommy looks at
him and noticed that he had one finger missing.         He said, "Yeah,
I have a question--What happened to your finger?"         Paul had cut
it off as a child in some accident.       Interestingly, even though
Paul thought he had told Tommy everything, we--it took us a few
days after his discharge from Children's to get everything set up
at Hopkins and then we had to go back down to Children's to pick
up his X-rays and Tommy was very--getting kind of impatient with
all of the rushing and bustling and he said, "What is all this
about?"    I said, "Well, you know Sweetie, it's really important
to do all this stuff as quickly as possible when you have Cancer
so you can get started on the treatment."      He said, "Cancer!
Nobody said I had Cancer.      Why didn't you tell me I had Cancer?"
So   tumor he saw as an unacceptable euphemism.       We went up to
Hopkins and there he had bone marrow biopsies and LPS and all
kinds of stuff and ultimately, actually, several, a big
diagnostic surgical procedure. A definitive surgical procedure.


Mullan:     All those were separate or just he had one surgical
                                                                     7

procedure that was   --

Garvey:    He's had--he had two separate procedures up there.

guess one--the first one--was 16 or 17 biopsies.      They went into
every saw (phonetic) in his cavity and did multiple biopsies in
every sinus cavity.       I guess that was the first one because they
wanted to know whether it had gone beyond the nasopharynx
(phonetic) because the thing is it was all in the back of the
throat and it had put so much pressure on the sinuses that all
the tissues were all distorted so that they really couldn't tell
what was tumor and what wasn't.      So the tumor had been kind of

amputated at Children's as part of the--you know it was an
amputation biopsy but there hadn't been any attempt to go deep
into the underlying tissues.      So it was the first procedure he
had.   That showed no extension beyond the original bed of the
tumor.    The second procedure he had was removal of the tumor base
which had invaded the outer but not the inner table of the skull.
They removed that. Actually, when we decided to go up to Hopkins
it turns out we knew the Chairman of Pediatric Oncology, Bridget
Levanthal and the Chief of Pediatric Surgery whose name I don't
remember, was quite well known and had been written up a short
time before for having done some wonderful throat cancer surgeqq
procedure on some child. We called Bridget and said, "You know,
Bridget, should we go to Dr. S o and So for the surgery?" and she
                                                                       8

said, 'Oh,    no, he's a lower pharynx man, you need an upper
pharynx man."       And so she steered us to Michael Holiday, who is
an upper pharynx man.      Actually, between the time he was at
Children's and the time he went up to Hopkins and there was only
like a week's difference, he developed numbness of the right side
of his upper lip.      We were really concerned about an involvement
of facial nerves.       Holiday is just renowned for being able to
pick tumor off of nerves.      Luckily it hadn't invaded the facial
nerves but it was certainly compressing various nerves.      He was
really able to remove it completely and alleviate all the
pressure.


Mullan:      And did he get radiation and Chemo?



Garvey:      Yes.   He had 4500 rads of radiation which ordinarily

would have been six weeks but because of Christmas and New Year's
ended up going somewhat longer which was just as well because at
the same time they started his Chemotherapy they had him on 24
cycles of intravenous therapy with Actomyocin (phonetic) D,
Cytoxin (phonetic), Pristine (unclear), and that was at four week
intervals and then they had him on 12 cycles at six week
intervals of Intratracheal (phonetic) treatment with
Methotrexate, Dexamethasone, and a third agent, I don't remember
what it was.    And the intrathecals (phonetic) just horrifying--
                                                                     9

you know, they put right into the spinal canal because of the
fact that it had invaded the outer table and basically they treat
head and neck rabdos (phonetic) pretty much the way they treat
leukemias (unclear) the   C&S.




Mullan:   His radiation was limited?



Garvey:   The radiation, what they did, the protocol, he was

randomized into an NIH protocol which--where the difference in
treatment was between Actomyocin (phonetic) D which he was in or
Abemycin (phonetic). The other thing was that the protocol
included whole brain radiation which we were very upset about
because it does tend to stop some of the maturation of the brain
and result in significant detriment in IQ.    As it happened, Paul
Peebles had a child one year older and a child one year younger;
Bridget Levanthal had five kids, one of whom was close to Tommy's
age and I think that they kind of thought about it and thought we
                                                          -


wouldn't want our kids to have six weeks, 4500 rads of whole
brain radiation.   The pediatric radiation oncologist was Moody
who had been in Matthew's South, Tommy's freshman dorm and Moody
has a daughter two year's younger than Tommy.    So I think all
these people with children around the same age said, "We wouldrgt
do this to our kid, we're not going to do it to yours."       They
didn't quite put it that way but that was--
                                                                      10

Mullan:      So that was the protocol?



Garvey:      So much for the protocol.   What they did was, they did

what they call shrinking field.       They started with a large field
but then rapidly shrunk down to just the area around the tumor.
Which, of course, unfortunately includes the pituitary gland.         I
mean there was no way the pituitary gland could avoid the 4500
rads.     The Actomyocin D (phonetic) acts to amplify the effects of
radiation so that this being head and neck--with head and neck
tumors there's a lot of oral mucosa (phonetic) damage.      You know,
temporary damage.    Not necessarily permanent.    They also with the
radiation they made molds of his teeth and they had him do
fluoride treatments in these molds throughout the period of the
radiation so that he had some way to protect his teeth from
radiation.


Mullan:     How did he handle all of these therapies?



Garvey:     He was such a good kid.    He was--he really understood

the people trying to help him.    He had small things, they were
difficult to stick but two of our friends Mike Jacobs who had
been an intern when I was a medical student at P & S and who
practices on the Vineyard, in fact he was the one who took us to
the emergency room so we could look into Tommy's ear and Debbie
                                                                   11

Goldberg who was a class behind us in college and practices
locally here.   Both worked on him to teach him self-hypnosis. He
would leave his hand behind for people to stick and the rest of
him would go to Colorado back to camp.    He really knew the self-
hypnosis to kind of enable them to stick him without yanking his
hand away--it was his instinct initially. Another problem was
that he had really a catharsis (phonetic) kind of kinetic
(phonetic) reactions with all of the anti-emetics (phonetic) but
he was very, very sensitive to the emesis (phonetic) producing
effects of all the Chemotherapy agents.   And as long as you
didn't distract him, he would hypnotize himself to try to control
his nausea.   But if you'd come and say, "Tommy, how are you?"
that would break his concentration and he'd barf all over the
place.   He generally lost 10 pounds every time he had
Chemotherapy. His weight actually ended up shortly after the
radiation at 65 pounds down from 100.    The radiation was terrible
because it caused so many oral sores.    He couldn't eat and he
also was nauseated from the radiation as well as from the Chemo.
Once he got--maybe a month or so out beyond the radiation, when
the effects of it wore off, they were very tenacious (phonetic).
I mean in the beginning it was like nothing and then as he had
more and more radiation it wasn't just the oral sores but
complete lassitude (phonetic) and he wasn't in school that whole
year although he had home tutoring.   I guess around February he
                                                                   12

was still--he was on the tail end of his radiation, he had a
seizure which I think was just the cumulative effect of the
radiation and the intrathecal (phonetic) and all the other stuff.


Mullan:     When did you have a sense that he was out of the woods?



Garvey:     The problem with the Chemo was that we could never feel

he was out of the woods.    The data--when he was diagnosed we were
told that for his stage, of course, medical school we heard 80
percent of the kids with rabdos (phonetic) died.    We were
devastated. We were assured by Paul that 66 percent were
surviving at this point.   Actually, by the end of the two years
the data was showing that 75 percent were surviving.    So they

were making strides even as Tommy was getting the treatment. But
the problem was that he--the further he got into treatment the
longer it would take his bone marrow to bounce back.    The second
year of treatment was actually in a way more horrifying than the
first.    We put him back in school the second year which meant
that he got exposed to everybody's germs.     He would have five
days of Chemo when he couldn't go to school, he'd barf and he'd
be losing all this weight and then he would really work hard to
start eating when he got his appetite back.    Then the third week
he'd hit his nadir with his white count and pick something up and
he--the last year of therapy he was usually in the hospital twice
                                                                     13

a month.    Once for the first three days of Chemo because they
were afraid that with his vomiting he needed round-the-clock
hydration to avoid the cytox (phonetic) and damage to the
bladder.    Then once later in the month because with his nadir
he'd get a fever and he'd go in and get triple antibiotic therapy
which is horrifying, too, because No. 1 the infections themselves
could have been lethal; No. 2, you know he was getting tobramycin
(phonetic) which could wipe out his kidneys or deafen him, you
know, just really heavy-duty antibiotics.     So the whole thing was
just an exercise in (unclear) to the very last treatment.        The 24
cycles didn't actually finish until 27 months.      They actually
stored it because he'd get white count was too low, or he'd be
too sick, or whatever so we would have to postpone the Chemo.


Mullan:     How was his classmates with him having l o s s of hair and

loss of weight?    How did--


Garvey:     Actually when he went back to school the first day he

came home from school crying, not because of his classmates, but
when he left school he was in the 98th percentile for height.
When he went back a year later he was in the 50th percentile for
height.    And so all these kids that he had towered over were nois
towering over him.    He was very upset by that.   Most of his
classmates were very protective and very concerned.      There was
                                                                     14

one kind of bad apple who was not a nice kid anyway who gave him
a hard time but generally they were very protective.     Bizarrely,
three weeks after he was diagnosed the brother of a classmate of
his was diagnosed with acute leukemia.     The school was kind of
freaked out--they had these two kids diagnosed within three weeks
of each other and I think his class in particular because Tommy
plus this classmate's brother.     Then, of course, you've got them
all thinking about the Kennedy kid who'd been about 10 years
before.


Mullan:     This was at St. Alban's?



Garvey:     Yeah.   Yeah.   He had osteogenic sarcoma (phonetic).

The year that he was back in school they had a school trip to
King's Dominion and there were some kids there who were kind of
saying, 'Hey,   what's that funny looking kid doing?   Why are you
bald?"    You know, really kind of giving him a hard time and his
classmates very much came to his defense.     We actually were told
at the beginning of treatment to take him to "Amy of Denmark" who
has a wig shop in Wheaton across from Wheaton Plaza and NIH sends
all of their patients there. And we were told to go to "Amy of
Denmark" before he got far into the Chemo because Amy would work
with--you know, look and see how his hair looked and then give
him a wig that would look like his own hair.     That was fine, we
                                                                     15

went off and did that and it was kind of (unclear), he lost his
hair all over one weekend.     He wore the wig for maybe a week or
two and then he found it was kind of hot and scratchy and he
really wasn't interested in wearing it and he wore wool caps in
the winter time just to keep his head warm but he really wasn't
interested in the wig.   What he did do with it was he'd go down
to the end of Garry (phonetic) Road, stand on River Road with his
wig on and then when cars went by he doff his wig the way a
person would doff his hat (laughter).


Mullan:   His father's sense of humor.



Garvey:   Right.


Mullan:   Tell me about you.    How was it for you?



Garvey:   It was, as you can imagine, incredibly stressful and

actually at that point I was still working for the Bureau of
Community Health Services.     T-three was working for FDA and both
of us decided with the schedule that we had that there was no way
that we could continue working for somebody else.     Tommy had
talked about doing consulting from home or doing consulting--he\
hadn't really thought about having an office at home--he thought
about just (unclear) an office--but leaving the FDA and doing
                                                                   16

some consulting eventually anyway but this kind of hustled that
process along.    I'd been half time at the Bureau and half time in
practice.   Well, actually a little bit less, I think it was
pretty much 80 percent time with the Bureau at that point.     What
we did was we kept the practice going and one or the other of us
would go in for part of every day.    That meant that one or the
other was usually here.     Tommy did very well, I mean he had
several clients right away which was very lucky.   One of the
things that Paul said to us in the beginning was that it was
going to be very stressful and that he wanted us to go into
family therapy and he found us a wonderful person that we started
going to.    I think that--in addition there was a kid who was two
classes ahead of Tommy and was diagnosed three weeks later, a
year after Tommy was diagnosed a neighbor with an 18 year old
daughter, we knew because she had been counselor at the
elementary school day camp that Tommy had gone to, was also
diagnosed with rabdo and--


Mullan:     (Unclear)


Garvey:     It was back more, well it wasn't really nasal

pharyngeal (phonetic) it was retro-orbital (phonetic) I believe.
Her parents ended up splitting. She died and I think that put
even more stress on the relationship but I think that Paul as a
                                                                  17

pediatric oncologist had seen the stresses that were put on a
marriage. Actually, even in spite of the therapy, which we did
for a year but then with Tommy being in the hospital twice a
month, it became difficult really to even be available for family
therapy, so we stopped the second year and ended up then going
back a little bit after it was all over--after Tommy's treatment
was completed.    I nearly ended up going back and doing some very
intensive work with her because I tend not to be very vocal in my
expression and of course, as you know, T-Three (phonetic) is.
What happened, I think that the dynamics were that he fretted
about everything, he, you know, after Tommy's radiation treatment
you say, 'Well,   there go a few more IQ points" he couldn't attend
the intrathecal (phonetic) treatments, he just found the first
one so horrifying that I had to take T-Four to all the subsequent
ones.    Because of that he got a lot of emotional support from
everybody because everybody said, "Oh, yeah, poor Tommy's falling
apart.   Oh, Carol is so strong" and so I wasn't getting -any
emotional support because everybody thought well I was just
handling it so well.    I would see things that would worry me but
I felt that I couldn't discuss them with Tommy because it would
send him off the deep end and felt that I really couldn't turn to
him for any support.    It ended up being very resentful, very
angry at him and really feeling as though I had kind of had to go
through this ordeal alone where he had gotten both support from
                                                                        18

me and support from everybody else.        Of course, you know, he said
'Well,    if you had ever said you needed support, I would have been
happy to give it."       No, I wasn't falling apart, I was just
expressing myself.       You know, I think things were just so tense
in those circumstances and there was just--1 mean, there were so
many scary episodes--we were vacationing on the Cape and Tommy
got a fever and Paul had told us whenever he has a fever, he's
got to get a white count.       So   we called some random lab in
Hyannis and said, "Can we bring our child by for a white count?"
We did it and then they could call back in an hour and give you
the results.    And I called back and asked what the white count
was--the total count was pretty low, 1100, 1500, something like
that--and so she started reading off so many lymphs, so many
monocyte (phonetic), what about neutrophils (phonetic)? None.
This just kind of struck terror in your heart so we called Paul
and he said, "Take him into Children's right away."        We did and
then they--


Mullan:     Children's in Boston?


Garvey:     In Boston.    And they had a whole unit for pediatric

oncology.    Then they put him in a four-bed ward and the kid
across from him had aspergillosis (phonetic)pneumonia and so we
weren't too happy with a zero neutrophil kid in the room with
                                                                      19

somebody with aspergillosis pneumonia.     He went off on a camping
trip with St. Alban's when he went back to school in the Fall and
they were out in the middle of nowhere when he developed a fever
and so luckily there were several teachers.      One teacher and a
group of six boys had to trek back to civilization, find a motel,
call us from the motel, of course the five other boys were
thrilled because apparently the first night had been cold and
wet--so they got to sleep in a motel for a night.      You know, we
had to drive two or three hours out across Virginia and pick him
up and took him directly into Holy Cross.      I don't know--then
there was the time that we thought he had appendicitis and we
didn't have a functioning car (laughter)--we'd get him anywhere
and ice storms when we were taking him to radiation--just one
disaster after another.


Mullan:   As a pediatrician, I've always wondered what it would

be like to have one of my kids, sick different from being sick
myself and then what effect it would have on my practice or my
attitude towards practice.    What did it do to you?


Garvey:   As I mentioned earlier, it really made me aware of how

terrible weekends are for patients.     The first weekend after
Tommy was discharged--1 guess he was discharged on a Friday--and
around 7 : O O or 7 : 3 0 on Saturday night Paul Peebles called and he
                                                                        20

said, \'I'm just calling to find out how things are."      It was
about half an hour after T-Four had said, "You know, my lip is
numb" which had sent us both into a panic.       We didn't figure

there was anything to be done so we didn't call anybody, we
weren't sure what we should do, but just to have him call right
after this horrible (unclear) was so incredibly comforting. The
thing was, he had been discharged from Children's on Friday, he
was supposed to go into Hopkins on Monday and so I wanted the
treatment to start yesterday--1 didn't want to wait for a couple
of more days before we could get anything going.       You know, when
you do a biopsy you've got to wait two working days usually
before you can get a result.     If you get biopsed on a Thursday or
Friday, Heaven help you--you've got to live through the whole
weekend without having results.        I think it's made me extremely
conscious of how terrible weekends are.       One thing that I try to
do is harass pathologists to the extent that I can to get results
before a weekend and then, of course, once you get results you
have to at least figure out some kind of a plan of action.       If I
can't, at least to keep in touch with patients over the weekend.


Mullan:     Do you tell patients that you've had a child who's

sick?     I mean, do you share that?


Garvey:     Yes, and I actually--1 still have a lot of patients in
                                                                  21

the practice who were patients at that time and because our
schedule was so much dominated by what was going on with him,
they really had to know--1 mean, if he went into the hospital
unexpectedly, the patient might get called and rescheduled--so
really the patients were very much aware of it.


Mullan:    For the record, just to tie off the story, just tell me

a quick word about what Tommy has gone on to do.


Garvey:    Well, in spite of his cranial radiation, he went to

Harvard.   We, I guess Tommy-Three blamed Moody Wearham"s
radiation for the choice of law school rather than medical
school. Various other things along the way but--after college he
did a year of travel and then he actually ended up working at
Dana Farber (phonetic) Cancer Center for two years.   He was very,
very interested in cancer but I think what kept him away were two
things: No. 1, he felt that, as a political activist, he- could
probably accomplish more with a legal degree than a medical
degree in terms of helping people and he also had a little bit of
paranoia--I mean living, working at Dana Farber, wearing the
radiation badges, and being aware both of organisms and radiation
exposure, he was a little skittish about putting himself in
contact with potential carcinogens.
                                                                     22

Mullan:      So he chose law school?



Garvey:      So he chose law school.



Mullan:     And he's currently a second-year student at Georgetown?


Garvey:     Right.   Half way through and has now decided to go to

medical school anyway.


Mullan:     Well let's if we could, shift gears.   When we talked

last you were in full-time teaching practice and moved your
practice to the GW Health Clinic but the--and you had evinced
interest all along in public health and becoming more active as a
public health practitioner.    Since then that's happened.   I'd be
very interested in knowing how that came about--how you became
the Montgomery County Health Officer and what it's like--how it
conforms to what you thought it might be.


Garvey:     It was really a fantastic development from my point of

view.     I had tried to stay in touch with public health while in
practice--I'd been on the Public Health Committee of the State
and County Medical Societies and actually had headed the one
Public Health Committee of the local medical society.    I'd been
on various task forces for the Health Department, had done a
                                                                   23

breast clinic every Friday afternoon for the Health Department as
a volunteer and after having had the Federal Public Health
experience was really very interested in doing local public
health where you're really not just kind of setting the global
parameters but actually getting down and getting things done.
When Duncan came in--


Mullan:   Duncan being?



Garvey:   The County Executive of Montgomery County--



Mullan:   First name?



Garvey:   Doug--Douglas--he--



Mullan:   Which was when?


Garvey:   In--must have been '94 he was elected--so he would have

come in January of '95. He really wanted to streamline
government.   He's a fiscally conservative Democrat and he felt
that the country government had become too large.   In fact, the
Health Department was very administratively top-heavy. The
Health Department had expanded some of its activities during the
80s and then had been forced to cut back.   They had felt that the
                                                                   24

cut-backs were only temporary. The way they dealt with it was
they maintained their entire administrative staff while cutting
back the clinical services on the theory that they'd need
everybody in place once their clinical services were again
funded.    They really didn't see the handwriting on the wall that
the clinical services were gone for good.   Duncan's team decided
to really clean out deadwood throughout the government not just
in health and to combine health and social services into the
County Health and Human Services Department under somebody named
Chuck Short who had been doing, I guess, some aspect of social
services prior to that.   The other thing that was true of
Montgomery County is that while the administrative personnel were
pretty stable year-to-year, the health officer is a political
appointment and so that with County Executive comes a new health
officer.   Health officer may not be the most important
appointment in the eyes of the County Executive and therefore,
there was often a considerable delay or a prolonged appointment
process or review process so that the Health Department could go
a year or so without a health officer and yet they obviously had
to keep functioning.   The administrative staff was actually
capable of carrying out the administrative functions in the
absence of a physician to guide them.   They then recognized the
fact that what they needed the position for was medical policy--
that while the physician was the chief administrator that the
                                                                       25

kinds of things like dealing with the (unclear), working on the
budget, that kind of thing had to go on whether there was a
health officer or not.       They figured if they didn't depend on the
health officer to do these things, they could with a half-time
health officer. A retired internist named Bud Bernton who worked
with me on the Primary Care Coalition which was something that--


Mullan:     B-u-r-t--



Garvey:     B-e-r-n-t-o-n.    Horace Bernton, actually. When I was

in the Medical Society--when I was Medical Society Public Health
Committee Chairman I had gotten something going called the
Primary Care Coalition which involved the five hospitals in the
county and the two agencies that were serving--private agencies
non-profit--serving low-income people (unclear) in community
clinic.    We'd gotten various other people in.    But Bernton had
really picked up on the idea after he retired and had really
gotten the thing off the ground. He suggested my name as the
half-time health officer and called me and asked if I would do
it.      I said, "Oh, I couldn't possibly do it because I had this
new job--relatively new job--still with GW."       I mentioned it to
Tommy.    He said, 'Of course you can do it.    That's what you've
always wanted to do."    So   after about 15 minutes thought I called
back and said, "Well, yes, I ' l l do it." And it really has been
                                                                         26

just what I've been wanting to do and get back and grapple with
the local issues.


Mullan:   What do you spend time on?      What's your focus--



Garvey:   It's an incredibly diverse job.         It's a Smorgasbord--1

mean just everything--you know, Salmonella outbreaks--


Mullan:   This is Carol Garvey   -    Side 2.    Tell me again what it

is that you do on a day-to-day basis.       It's a Smorgasbord.


Garvey:   Right.    Mercury poisoning, Salmonella outbreaks, sick

building syndrome, all kinds of things.         The two things that I've
felt was most important were assuring primary care services for
young children who are medically indigent. And addressing the
whole issue of substance abuse, especially in young people.         I
think that by focusing on these two areas these are really where
we will not only realize the greatest financial savings, which I
Bhink are very, very important, but also the greatest reductions
in, you know, human suffering.       I think that they are even in
some way related because I think if you take a child and you fail
to do say hearing, vision, and language screening prior to school
entry and a child enters school with significant impairments that
will interfere with learning, that child's self-esteem is going
                                                                     27

to be poor, the child is going to find much less meaning in
school, is going to be more susceptible to substance abuse and
acting act and basically doing counterproductive things.     I
really see early childhood primary care and preventive care as
having huge implications, not just for keeping children physical
healthy, but emotionally healthy, successful in school and ready
to become functioning, productive, citizens as adults able to
work and less susceptible to things such as substance abuse.


Mullan:    One thinks of Montgomery County as a wealthy County.

It is perhaps one of the most wealthy in the United States,
population of 600,O O O ?


Garvey:    No, somewhere upwards of 810,000.



Mullan:    When you talk about the public health issues you're

dealing with, Salmonella, kids without primary care, the
immediate thing that comes to mind is "Oh, Montgomery County
doesn't have that."     How do you deal with that, it doesn't mean

those problems aren't there--


Garvey:    Well, Salmonella cuts across all kinds of socioeconomlc

groups and becomes an issue in day care where you've got children
being diapered, multiple children being diapered by the same
                                                                      28

caretaker and that kind of thing.      It is estimated that there are
80,000 uninsured Montgomery County residents.      The majority of
whom are not uninsured by choice but are medically indigent.
They're working in jobs that pay by the hour, by the day, don't
have benefits, a lot of the service industry jobs, a lot of the
housecleaning jobs, a lot of construction jobs, landscaping jobs-
-so that these are people who are above the Medicaid level--

Medicaid is obviously a form of insurance--but really well below
the point at which they can afford individual insurance and work
in jobs where either insurance is not offered or the co-pay is
significant enough that it can't be handled on an income of
$15,000   or $20,000 or whatever.    Probably 25 or more percent of
those 80,000 are children--between 20,000 and 25,000 children are
medically indigent, uninsured.      Where I think we've tended to be
myopic and where I think we cannot be myopic is that we've made
statements like ''90 percent of the children who come to us for
care are fully immunized by the age of 2."      But we are serving at
best 10 percent of the medically indigent children which means
that 90 percent of the medically indigent children may be under-
immunized at the age of 2.   I think we have to take a more global
view of things and say, "All medically indigent children are our
responsibility."   Not that we can necessarily pay for it out of
County funds but I think as Health Officer and as a Health Agency
the County has to take some responsibility for trying to assure
                                                                    29

that mechanisms are in place for addressing this problem.
Glendening just announced about a month ago--


Mullan:     Glendening being the Governor?

Garvey:     Governor Glendening, right.   --a program thriving by
three which he's proposing to the State Legislature and I surely
hope it passes.    That will guarantee medical care for pregnant
women who are medically indigent and for children up to the
(unclear) grade.    If he's able to do that then I think No. 1: our
job is still going to be "Okay, these benefits are available,
let's make sure they're utilized."     Actually, the State estimates
that of the benefits that are available that only 30 percent of
people who are eligible actually take advantage of them.


Mu1 1an :   That's medical benefits.



Garvey:     Medical benefits.   There's a program called, "Kids

Count" w A c h is not as comprehensive as what he's proposing-- t
takes care of children one to five up to, I think, 185 percent of
poverty.    He wants to do conception to up to 250 percent of
poverty.    But the "Kids Count" program is only 30 percent
utilized.


Mullan:     What's it like with your rich background in the
                                                                    30

provision of individual's primary care services now moving to the
population level responsibility? How do you find that
transition? And you walk back and forth between it day-to-day.


Garvey:      That's right.   I think it makes me maybe more

realistic in trying to plan interventions than someone who hasn't
been in the private sector.    There's a lot of perception that
private practitioners should do this, should do that, that they
should provide free care or reduced cost care without
understanding the real administrative difficulties of say
providing care to people who don't have cars.     If your office is
not within walking distance and people are relying on public
transportation there is no telling when they're going to get to
your office and if you're set up to see people on an appointment
schedule, you don't want someone coming in 45 minutes late.     You
also don't want them coming early and bringing their three
children because they don't have day care.    A lot of the should
become a lot less powerful when you know what people are really
up against in an office practice.


Garvey:     Are you able to teach about that? Are you able to

translate your public office into your residency (unclear)
training?
                                                                     31

Garvey:   Yes.   That's actually, I think, been very useful

because Montgomery County has some wonderful things in the Health
Department.   They have a Crisis Center which is actually Social
Services, Mental Health, not so much semantic (phonetic) health
but certainly very much a mental health unit which is open 24
hours a day, 365 days a year.   I think most people don't know it
exists but anybody can walk in off of the street with an acute
emotional problem and get immediate care and whatever follow-up
is appropriate. They also triage to the State Hospital, for
people who need it they have a holding area--they can people for
several days if they need to without actually considering it an
admission, they're not considered an overnight facility but they
do have beds where people sleep at night.     The County has nurse
case managers which as part of GW, I've actually been able to
call upon and say, "This Spanish-speaking mother doesn't seem to
understand, doesn't seem to be giving, you know, bringing the
child in for appropriate follow-up, isn't giving the medications
                                                        -


as prescribed" and the County will send a nurse into that home
and help instruct the mother.   I think that's also very good for
the residents because then they begin to understand what
resources are available in the County.   The County has a
wonderful substance abuse program--just a terrific substance
abuse program but if you don't know about it, the patients don't
have the advantage of being able to use it.
                                                                    32

Mullan:   A last question.   As we've talked about, throughout

your career you've been interested in public health side effects
even though until recently you weren't devoting major parts of
your time to it.   Now you're doing it.   How does it square with
what your interests would be?


Garvey:   I find it endlessly interesting because of the fact
that I've been pretty close to the Health Department all along.
There are not a lot of big surprises in terms of what it's like
and it's a particularly exciting time to come in because of the
fact that Duncan has worked so hard to restructure things. A lot
of people who were very committed to the old system have decided
to retire because they're not comfortable with the changes but
that makes it a lot easier to implement the changes.   Basically
what the County has done is privatize the things that we do pay
for--like we pay for family planning but instead of hiring docs
to do it, we have Planned Parenthood doing it.   Planned
Parenthood has tremendous buying power--they get birth control
pills at a much lower rate than anybody else can get them for--
they have terrific experience--just a very, very high quality
organization. Would--1 would have done things a little different
from what the County had done before then was say to Planned
Parenthood, "Look we have all this real estate, all the clinics
where we've been serving people, our clients are used to coming
                                                                      33

to them, wouldn't you like to give your services within our
health center?"    In some health centers they have said, "Sure,
we'll come and do services there on site" which I think is much
easier for the patients and it also means we don't have to worry
about getting the records copied and sent over because the
records are already in the Health Department.


Mullan:   How do you feel about it?     You, Carol Garvey?



Garvey:    I'm loving it.    It's really, you know, I think life is

a series of random events and private practice was the random
event for me.   It was not ever something that I had intended to
do.   It was very nice to do.    I loved having one-on-one
relationships with patients which, of course, you don't get out
of primary care.     It is piecework.   It's the trees, not the
forest.   I've always really felt that the real challenge and the
real chance to do something unique was to do public health.
                                                        -         I
think that if a private practitioner isn't there, there are
plenty of others and we have a glut of doctors, especially in
Montgomery County.    We don't have a glut of people in public
health and I think an individual can do a whole lot more in
public health and accomplish a lot more.     Do more good basically.


Mullan:   So it's met your expectations?
                                                                                  34

Garvey:    Yes.



Mullan:    Good.   Maybe w e should s t o p a t t h a t .   I ' v e g o t one e y e

on t h e clock--