1

                                     JACK KIRK


                                Dr. Fitzhugh Mullan,
                                    interviewer


Mullan:     Your date of birth?



Kirk:     March 25, 1 9 4 4 .



Mullan:     We're sitting in Dr. Kirk's office in New London, New

Hampshire, the date being the sixteenth of July, 1996, and it is

a spectacular afternoon outside.



Kirk:     Indeed.



Mullan:     And it's even a nice afternoon in here.        Dr. Kirk's been

good enough to entertain me in his practice.           Why don't we start
back at the beginning and tell me, if you would, a little bit
about yourself, where you were born, where you grew up, and what
your early years were like.


Kirk:     I was born and grew up in Oak Park, Illinois, a suburb on

the west side of Chicago, a comfortable though not extravagant

suburb.     I guess I grew up very much in sort of what might be
described as ethnic Catholic enclave in that suburban area, went

to Catholic schools all my life, and was very impressed growing
                                                                     2

up with the need to serve my fellow man, I guess.   I had a bad
case of that altruism growing up, certainly, and it was always

just whether I was going to a priest or a doctor or both.    For a

long time I planned do them both.
     I didn't have any family members who were really in

medicine, didn't have any early experiences in medicine.    It was
purely and simply that it was an honest sort of serving ideal

that was always there, and certainly by the time I graduated from

high school, it was perfectly obvious that I was going to be a

pre-med major wherever I went to school, and if I didn't get

turned completely to the Dominican fatherhood, that I would be in
medicine.

     Growing up, I had one brother two years older than I, and

mostly we spent our lives with sports, an intact sort of very
supportive family group.   Anyway, the whole environment on the

West Side, in our parish, and in our subsequent high school, was
a very warm and nurturing place, and a sense where, again, you
came out of it with this sense of wanting to serve in some way
and be good to somebody else.   I was fortunate and didn't have
any pressing family or other problems.   Life was simple, as the
fifties were supposed to be.



Mullan:   What did your parents do?
                                                                      3

Kirk:     My father was a salesman who, himself, had grown up in a

small town in central Missouri.     When he got out of high school,

moved to Chicago to try to find work, basically, and never

completed his education.     My mother's family was a little closer

to Irish roots, but she grew up in Chicago.     We were always proud
that she was George Halas' executive secretary for a number of

years before she and my father met and got married relatively

late in life.     I think they were in their early thirties, and
were close to forty when they had my brother and I, which is
often used as the excuse for why we're perhaps as simple as we

are.    We were had late in life.
        But anyway, certainly, my brother and I were clearly college
ordained.     The Catholic high school we went to was a real solid

college preparatory school, that that was expected of everybody,

and there was never any question that we were going to go on to
higher education and somehow be of service.


Mullan:    The milieu of the Catholic upbringing was important to

you, in general.    Were there particular teachings or particular

figures that enforced or to which you connect this service
principle?



Kirk:     I don't know that I can name it beyond that it was very

much seemingly the nature of all of the messages working
                                                                      4

together, certainly both the home as well as from school.      At
least that was the message I heard.     I'm sure there were fellows
in the next seat who heard perhaps a different message, but that
was always the message I heard.    I don't think of any one role

model in that sense that sent me on this way.

     I think what I was most impressed with, I guess, as I think
back on it, is that the education, especially at the high school
level with the Dominicans, was very focused on logic and natural

law as the way to understand what ethical behavior was and how

one solved problems.    I'd always thought that that part of my

high school and subsequent college Dominican education at

Providence College was all very much focused on logic and on a
very careful reasoning of how one solves problems both in the
ethical sphere and the moral sphere, and just in general in l i f e .

So I think apart from the idea of service, it had a lot to do

with what I hope is still a very sort of logical problem-solving
approach to things, and what was always interesting to me about
medicine is that it is about solving problems and getting in
there and seeing if you can figure it out and solve the problem

in a logical fashion.
                                                                      *



Mullan:   Were there medical figures in your early life that

influenced your interest in medicine?
                                                                       5

Kirk:     I think not at all. Again, no one that I can recall had

any--1 suppose I shouldn't say nobody had any significant medical
problems.     My mother had colon cancer when she was in her

fifties, and had a colostomy, but that was just sort of--1 mean,

I was vaguely was aware of that, but in those days it was sort of
kept from you, and she lived well on into her life without any
further problems.      And my father had a heart attack when he was

in his mid-forties when he was away traveling.       I remember that
my grandmother from Missouri had to come and take care of my

brother and I for a couple of weeks until he was able to come
home.     But again, in general, there wasn't a lot of talk of those
things, and I didn't have any medical exposure myself.       It was
just always kind of an ideal, and something to do, and it had no
particular experience behind it.



Mullan:     So Providence was the college.



Kirk:     Providence was the college.



Mullan:     I was going to say, a distinctly non-Catholic but, of

course, Providence is.



Kirk:     Right.   They really twisted my arm.   I was going to stay

in Chicago and go to Loyola or someplace where my brother had
                                                                      6

gone, and the Dominican fathers at Fenwick wanted me very much to
stay within the fold, partially because they were convinced that

I was cut out to be someone in a white robe.     I was all right
with that, but I think going to Providence was a good idea

anyway, because certainly the focus at Providence was a very nice
environment that certainly broadened my, at that time, very
parochial horizons, which I think was undoubtedly a very good

idea, and provided a real good preparation, as it turns out, for

medical school.


Mullan:     You were committed at that point to medicine?   You did a

pre-med course?



Kirk:     Yes, still with no more logic behind it than this general

idea of service, the whole idea of what kind of a doctor I used

to think I was going to be.    I was impressed as a child,    I

remember,    reading somewhere along the road about the Shriners
hospitals, and it seemed like being a pediatric orthopedic
surgeon sounded about right as the ultimate in service.      It was
never more reason than that, and I'm about as far away from being
a pediatric orthopedic surgeon as I could be.



Mullan:    What did your brother do?
                                                                       7

Kirk:     Bill was two years older than I and actually was accepted

to medical school after his four years at Loyola, and declined
the offer and has a Ph.D. in biology, and is a vice president for

environmental affairs for Commonwealth Edison in New York.      He's

an industrial biologist, so to speak, working in environmental
affairs.


Mullan:    As you went through college, did the notion of the

priesthood stay neutral or fade?     Presumably it ultimately fell

by the wayside.     How did that come about?



Kirk:     Yes, I think probably the height of it was probably in

high school, and probably in college as I got more interested in
what I was doing, and certainly in biology, I had, I guess, less

interest in that.    Certainly, at least, it never heated up any

further.     It was during my college years, also, that I met my
wife, and our relationship developed the last two years of
college.    I think somewhere in the midst of all of that it was

clear that I was going to go on to medical school and not enter a
seminary.    I think probably about midway through college, there
was not even any thought anymore that I would do that.    I just
threatened her now that if she gets tired of this whole thing and

leaves me, I still have the priesthood to go to.    But otherwise,

it doesn't occur to me anymore.
                                                                       8

Mullan:     Then you chose Cornell for medical school.   What

prompted you and how was that experience?



Kirk:     Well, by then, certainly, I had more or less opted to stay

in the East, partly and largely probably because of my

relationship with my wife-to-be.     So I looked seriously at that
point at Eastern medical schools, and I guess there was also a
sense that those were the ones that were "the best."      I'd been a
very high achiever at Providence, and Providence, though it had a

small program, had been capable of getting a few people into very
good what were considered to be the finest Eastern medical
schools.    So those were where I applied.    I probably applied to
Harvard--I know I did.    I think Cornell was probably second. My
wife was from New York, and I figured if I didn't get into
Harvard, although I didn't know anything about Boston, but that
was just, once again, that was sort of an ideal, that that's

where you went.    You couldn't not give it a try.    So I didn't get

into there, and I got into Cornell, and that was a good choice,
because my wife was from there, and so our relationship would be
fostered by that if she returned home to finish college and then
we would be able to stay together.    But we subsequently got

married halfway through medical school.      That was a part of our

plan.   So Cornell was obviously, as I was led to believe at that
                                                                     9

point, a very good school and, in fact, I think it was, and it
was sort of the right place for us geographically at that time.



Mullan:    Going into medical school, were you still entertaining

the orthopedic surgeon notion, or what were you thinking at the

time?



Kirk:     I don't think I formally had that idea anymore, but I

don't think I had replaced it with anything very concrete at that
point.    I'm always amazed when I think back at how it was like
having blinders on.    I was just a very focused person on studies

and on doing certain things, and I could do them well and shut

out the rest of the world.    If you told me to study biochemistry,
I'd study biochemistry, and I didn't necessarily ask the
question, "Why do I have to know that?    I'm not sure what I want

to be yet."    so it probably came from my Catholic school
upbringing.    Point me at it and turn me loose, and I'll get an A
in it.


Mullan:    This was a whole period of political ferment on the

campuses in general, not particularly Providence or Cornel1 Med.

Were you tempted or involved in any civil rights, anti-war, or

any kinds of movement kind of activities?
                                                                        10

Kirk:    That's interesting, because that comes on the heels of

this, as I look back, about how focused and narrow that focus
was.     I, frankly, would have said, "I don't have a political
position."     I was shocked that anybody would really think that
the government in a vague way kind of wouldn't do right, or at

least they'd be honest even if they were wrong.

        I wasn't actively anti-demonstration,   I kind of wondered
how people had time to do that, because I was up to my ears in
very focused things.    So   I was kind of apolitical.    I was just
kind of the war went on and I was doing my thing.        I think if I

had ever thought in a larger way, even though Cornel1 provided a

wonderful education and I enjoyed my years there, as I look back
on it, it was in a social setting that if I looked at it today
would be very uncomfortable to me.     I was in sort of an ultimate

one of the ultimate Ivory Tower kind of institutions with a

certain of that kind of arrogance; it never occurred to me to
even begin to sort of list places with regard to things like
that.    I was studying that biochemistry.   So,   yes, I was kind of
indifferent to social causes.
       We had grown up very simply. Actually, I mean, probably the
most intimate awareness I have now is that this western suburb of
Oak Park was quite comfortably well off, and the parish school

and all that I went to, we lived like at the very periphery of

the parish, and I was the only person that I knew who lived in a
                                                                       11

two-flat sort of house.      Never knew anybody else who didn't have
a big house with a professional father.      So I always kind of

socially felt uncomfortable.      I don't ever think that I
determined that I was going to work hard to make up for that, I
just did.     Sort of what I dealt in then, since I didn't reckon I
could compete in those social areas, was I did good at things,

whether it was sports or school.      I mean, if you said, "Let's go
do that," I was determined to do it and do it real well.

        Life was simple.   We were sort of the least well off, though
never in any way that was discomforting, and always had what we
wanted.    And other than having this general idea of service and
altruism, it was not focused on anything in particular.       It was

probably focused one by one by one in terms of my interactions

with people, but it wasn't aimed at larger social sort of things.


Mullan:    You then went back to Chicago and you made a choice for

medicine.    Why was that?


Kirk:     I know very well the experiences at Cornel1 that made a

difference.    One was that it was the beginning of third year
when--maybe it was the end of second year--that we had a public
health seminar course, and Walsh McDermott     himself, beloved and

revered Walsh McDermott, lead that series of seminars, or at

least was my group leader, and the world opened as it had never
                                                                      12

had before.     I always remember having a discussion about air

pollution.     I didn't care anything about air pollution and the
physics of air pollution didn't interest me, but it was like

suddenly there were a whole bunch of sort of social decisions in
a way that had to be made.       It was called, "Yeah, it's nice to
clean up the air, but if you do, you're going to put somebody out
of business over here, in the company that's polluting the air,"
and that there were issues suddenly that were very bigger than

what I'd looked at before.       So I actually found that these other

issues for the first time kind of made a difference, and that it
was hard to just focus narrowly on what was in front of you.
        We also spent time--gee, I did a project in the Bedford

Styvesant part of Brooklyn on tuberculosis follow-up.       Certainly,
that was the first experience that I had had really experiencing
minority populations and the problems that people have, and some

of those kinds of challenges. Again, though somewhat challenged
economically myself by comparison to my peers, I had never really
thought much about the specific problems that people had.       So

that was a very awakening experience.


Mullan:    Your Chicago West Side community was all white?



Kirk:     Oh, indeed.   Yes.   Mostly Irish and Italian Catholics.

That's all that were allowed into the community as far as I could
                                                                    13

tell, at least as far as my vision saw it.     Yes, it was a very
sheltered--it wasn't the North Shore kind of wealth, but it was a

very middle class and somewhat upper and a little cross-section

of middle class.     Nothing challenging about it.



Mullan:     So Walsh McDermott and Bed Styvesant were both eye-

openers for you.



Kirk:     Real eye-openers.   Then there was an elective in tropical

medicine.     For a brief period of time, all of us wanted to be Ben

Kean, who was a professor of parasitology in the Department of
Public Health at Cornell, who was a most charismatic and

Runyanesque figure, somewhat deformed by an old Bells Palsy, with
a stump of a cigar hanging out of his mouth all the time, and
he'd spent his life--we all knew that he had dated Joan Crawford,
and that he had this social life in New York that was really kind
of exciting, and he spent half his time traveling the world and
looking at schistosomiasis in places.
        There was an elective in Brazil in the north part of Brazil,
in a poor part where schistosomiasis and CHAGAS' disease were
very much prevalent.    My wife and I, at that time, spent four

months there.    Again, a very exciting sort of experience where I

guess I remember that I was as excited by being out in a Jeep

trying to figure out how to get the snails out of the watershed,
                                                                      14

as I was truly more interested in that than in the surgeon's
problem of removing a hugely enlarged spleen from a patient with

schistosomiasis. So that the kind of geographic, these other

elements, including the social elements of life that surrounding

disease were by then--


Mullan:     Population health.



Kirk:     --were clearly--1 mean, I guess the skills that I thought

I had which were not purely scientific.      I was much more
interested in these sort of peripheral science areas than I was
in playing with tools and calculations that had to do with
technology related to patient care.      I always reckoned I could

get an A in calculus if I had to, in order to get the job done,

but none of that stuff ever was of interest in and of itself to

me.


Mullan:     So the Brazilian experience, the tropical medicine

course or teachings and Walsh McDermott were things that stand
out as beginning to shape your thinking in a somewhat different
way?.



Kirk:     Right.   And I certainly have to add that Ken Johnson was

one of the other professors of public health at Cornel1 with Dr.
                                                                     15

McDermott, with whom I had a lot of experiences.     Some of these
experiences were with him as part of these seminars and writing
the paper on TB in Bedford Styvesant, and subsequently, again,

that's how I ended up coming back here.
      Dartmouth was another step.    I guess after medical school,
somewhere in the midst of all that, it was clear that medicine
was my choice.   I don't remember ever having a one time when that
was clearly made or when I sat down with my internship advisor

and they said, "So what are you going to do?"     I mean, certainly
by my clinical years, I think that surgery just didn't interest
me.   I didn't enjoy the thought of spending time doing that, and

the technology surrounding that was not of interest.    So medicine
was clearly what I had opted for, although I wasn't sure where in

medicine I would go.     I wasn't interested in pediatrics as such,
and I don't know why, but it was going to be medicine, not
surgery, and vaguely after the Brazilian experience and the other
experiences, I frankly kind of wondered about whether some kind
of a public health career at that point might be mixed with some
kind of clinical work.    But I knew I wanted to do clinical work.


Mullan:   The University of Chicago is a pretty traditional

choice.
                                                                     16

Kirk:     Yes.   I had decided then it was a simple thing, because by

then my parents were a good deal older and both were having

significant medical problems and were very much alone at that

point, and it was very much a conscious decision to go back to

Chicago after being away from them for about eight years.        I was
feeling obliged to be back and participate in their life.
        We looked at three or four places in Chicago, and I guess I

was most impressed at that point with the academic challenges at

the University of Chicago.     I remember looking at Northwestern
and thinking that the internship was a little too easy.     I was
still pretty much kind of hard-core focused and reckoned that I
would flagellate myself with as difficult a program as I could
find, and that wasn't the Northwestern hospitals.

        My wife Jane and I were looking at the intern housing at the
West Side Medical Center at Pres-St. Luke's, and at that

internship, and an elevated train went by about four inches
outside the window of the apartment that we were looking in.
Although Jane didn't grow up in wealthy surroundings either, that
would have been a difficult setting.     So we ended up at the

University of Chicago, with that choice for several reasons, and
living out of the West Side of Oak Park near where my parents

were with me commuting to the University of Chicago.



Mullan:    How was it?
                                                                      17

Kirk:     The experience was indeed challenging academically.



Mullan:     A1 Tarlov, chairman?



Kirk:     Yes.   Right, indeed. Mark Siegler, who's the ethicist,

was our chief resident then.       There were a couple of things.    One

thing that I was disappointed in, I know, was that most of the

rest of the interns and residents were clearly much more

interested in academic medicine than in caring for patients, as I

saw it.     I was very proud of the fact that I spent a good deal
more time at the patients' bedsides.      I always reckoned that I
may not have been the quickest to figure out the problem, and I

may not have studied all the literature quite as well as some of

my peers, but I would be up at night, and I would be there, and I

wouldn't give up until I had the problem solved.      I always felt
that that sort of dogged determination and stick-to-it-iveness,
and spending time with patients and figuring it out was what I
was good at.
        I didn't really get a sense of a great deal of support for
that part of what I was doing from the rest of the people that I
worked with.     Some wonderful preceptors and teachers there, but,

in general, there were a lot of people who were focused on

academic careers that were much less clinically oriented than I.
                                                                    18

So I knew by the time the year was over that I really didn't want
to stay there any longer.
        It was also a very uncomfortable year, as it turned out, for

Jane.    We had our first child.   Our daughter Jean is twenty-five

now, was born that November.    Basically, Jane was away from all

of her usual supports and I was at the hospital one night out of

two, so I'd come home for about eight hours exhausted every two

days.    So it was really a difficult year for her.   I was not

happy with the program at the University of Chicago, or it

probably would have been, I suppose, a tense time for us in

deciding what to do next.    I think we, in general, decide things
pretty much together, but as it turned out, I was not happy with
the program, and she really needed to get back, realistically,

closer to her support system in the East.

     About that time, Ken Johnson, who had been a professor of

public health at Cornell, and who'd really been a close mentor

there, had left Cornel1 to become the first chairman of a new
Department of Community Medicine at Dartmouth.    His first job was
to begin a residency that was called the "physician-manager
primary care residency," which was specifically intended to train
primary care physicians for rural careers, recognizing that their

training needed to be clinically broad and that they needed

"managerial skills," that is, community-oriented primary care

skills, epidemiologic skills, skills and knowledge about how

community health systems work and what a physician's role in a
                                                                     19

community health system is all about.     That was clearly a very
revolutionary thought.     This was now 1971 that this program was

to begin.



Mullan:     What was it called?



Kirk:     The physician-manager primary care residency.   I think of

it because it was Dr. Johnson who moved on to the Robert Wood
Johnson Foundation, sort of the Robert Wood Johnson Clinical

Scholars Program, I think, to some extent, at least the content

of some of that was shaped, as a separate fellowship, to take

primary care physicians and give them sort of, not just academic,
but sort of health planning and epidemiologic skills.     You
probably know more about that than I do, I'm sure.

        But the program, at that time, it wasn't that I decided yet

that I really wanted to be in a rural area, I hadn't thought

about it.    Again, I'd never planned things like that.   Dr.
Johnson was somebody I respected greatly.    It was very clear at
that time that I knew I wanted to be a clinician, and, relatively
speaking, a community-based clinician. And I still liked
problem-solving skills and some of the social problem-solving

skills that I had learned to respect.    So this program was very

inviting.
                                                                      20

     We had never, neither my wife nor I had ever had thought
that we would particularly want to live in northern New England.
W e hadn't thought about it one way or another.    But we knew we

wanted to come back in general to the Northeast, and this program

was just perfect, and Dr. Johnson was somebody we had had the

greatest respect for and relationship with in medical school, so

it was a natural thing to come back to.
     Dartmouth, of course, at that time, until very recently,
didn't have a family medicine faculty; in fact, in a very
traditional way, looked down its nose quite firmly at the thought

of family medicine.

     So the program really consisted of combining Medicine and
Pediatrics under Dr. Tom Almy, who'd been a professor of medicine
at Cornel1 and had moved to Dartmouth as the professor of

medicine, and Saul Blatman, who was a professor of maternal and

child health, and   Ken Johnson, who had formulated this program.

It said, "You will get your boards in either medicine or
pediatrics, and spend most of your time in that, but you will
spend another year of doing other clinical stuff.     If you're an
internist, you're going t o do six months of pediatrics and a l o t
of psychiatry and orthopedics."
     It was called a clinical complementary year, and another

year would be spent doing fellowship work during which time

boards in preventive medicine were satisfied.     There was a

question about whether to make it a master's in public health or
                                                                        21

exactly what sort of academic degree could give it.        There were
technical reasons that I never fully understood that made it
easier to make it under     preventive medicine boards rather than

an MPH program for these experiences.

        So I did then two more years of internal medicine residency

at Dartmouth to complete the total of three, and then did a
clinical complementary year, and then did this fellowship year

that gave me boards of preventive medicine.


Mullan:     It was five years total.   Four years at Dartmouth and--



Kirk:     Actually, it was '71 to '74.     I did one more year of

straight medicine at Dartmouth, and then the clinical
complementary year actually had some more medicine in it as well

as six months of pediatrics in it and a couple of months of
psychiatry.     So actually, I spent a total of two full years in

medicine, and a year at this clinical complementary one, and then
the fellowship year.


Mullan:     How did you feel about that?    How was it?



Kirk:     Well, it was an exciting program, because, well, the first

year of it was my regular what might be called my PGY2 year of

internal medicine.     It was obviously in a very different clinical
                                                                    22

setting than at the University of Chicago.     I remember being a

little frustrated at first.   But the environment at Dartmouth,

with much closer attention of private clinicians who knew their
patients and cared about them, was so different from the clinic
atmosphere at the University of Chicago.     In fact, I remember
several, at that time irritating to me, encounters with Dartmouth

attendings who were upset because we, the house staff, had taken

some liberties and made some decisions that would have been not
even looked at twice at the University of Chicago.     I've
subsequently come to understand that and to respect it, but at
that time, as a trainee, I kind of thought, "Wow, they're awfully

tight about things like that."

     But I certainly learned a lot more about the relationship of

clinicians, physicians to patients who they knew and cared about
than I'd ever learned at the University of Chicago, but I'm sure

I learned a lot more about some especially esoteric, but also
just an awful lot of clinical experience at the University of
Chicago that came fast and furiously, and it was all a little
more slower paced than Dartmouth.   But in the setting it provided
probably more learning about how to function as a real physician
for people who expected to have a relationship with their

physician.   So that was a sort of real transition.

     Then the next year after that was this clinical

complementary year, most of which was non-internal medicine
stuff.   I remember I enjoyed pediatrics a great deal.   It was a
                                                                  23

real sense, at that time I was functioning like a pediatric
intern, but they all knew that I was older and kind of knew some

stuff that they didn't know.     So I had a sense of seniority, and
it was fun working with children.     I enjoyed that part of it and
some of the other skills that I otherwise would have known
nothing about.     I knew how to put casts on, working with
orthopedics.     I knew much more GYN than any of my internal

medicine colleagues, much more psychiatry, from spending some
very good time doing things like that.    So the clinical training

was fun for me.     I was certainly happy being broader rather than
inclusive and narrowly focused in a subspecialty of medicine,

which is what all my colleagues were doing.

     So clinically I was excited by it and, clearly, was prepared

in a much more logical way to go out to the world and see what
was going on.     I also spent a month of that year, so it was about
1973, here in New London working in the office that we're sitting

in now with Dr. Ohler, who was a general internist here in New
London, who was a wonderful rolE model, and highly respected by
the folks at Dartmouth, which is why I was farmed out to this
experience for a month.    So I came to know the New London

community and this particular office, and the way one very caring

and charismatic and capable clinician worked with his patients.

I had no intention at that time that this is where I would

subsequently end up, it was j u s t one more experience.
Subsequently, it's come back to haunt me, I guess.
                                                                     24

        And again, Dr. Ohler's very extraordinary capabilities as a
clinician were a very strong further influence on saying that's

probably what I wanted to do.



Mullan:     The preventive medicine elemen, of the program, toward

the preventive medicine boards, what was that and how did that
play itself in the program?



Kirk:     So for the follow-up for our fellowship year, it was a lot

of lecturing focused on me and I think there were two other
individuals in the program at the time.    We had a lot of one-on-
three sort of lecturing in biostatistics and in epidemiology,
after taking some courses in that ourselves in a very special
way, we then by later that year were being small group leaders as
part of the medical students' epidemiology and biostat courses.
So we were forced to really use it ourselves and being seminar

group leaders.     So we had a lot of that information, and we spent

some time in--1 don't remember what it was all called, I remember
the curricular book that had been hurriedly put together for this
pilot program.    And we spent a lot of time in seminars examining
community health systems as they existed then, and as I just

thinking about it now, they've come back to life.

        The first HMO that any of us had ever heard of, called

Matthew Thornton [phonetic-]HMO in Nashua, we visited it, and
                                                                      25

examined what this new breed of cat twenty-five years ago was all
about, and there were efforts made to organize care in the upper
valley of New Hampshire.    I'm blocking on the name.    It isn't

that important, a name of one of the Indian tribes here, and this
coalition was an effort to even organize a regional hospital from
Dartmouth, and to really organize satellite clinics around it and
have an organized rural health system.      Anyway, so we studied a

lot of these kind of things.
     Then we did a lot of exciting community work.      I traveled

with Mike Taylor, who was a junior faculty person in the
department, all over most of Vermont and New Hampshire, coming to
know all the communities first hand.      Our job was to answer

communities' calls for help.     "Our old physician is retiring, we
have nobody left, our hospital's closing.      We can't get more
physicians.   We have no f o c u s of health care."
     We wrote two or three applications for National Health

Service Corps sites.    We formed a couple of community health
clinics.   We had an architect, one man who still architects in
the area, Ted Lewis, who traveled with us all the time, and we
would take old doctors' offices and figure out how to make them
into community health centers.
     We went to Lincoln, New Hampshire, where Sherman Adams, the

man of the Vicuna coat and President Eisenhower's aide, had been

disgraced for taking a Vicuna coat in the fifties.      He had

returned to his home in New Hampshire, in Lincoln, which was an
                                                                     26

old mill town up along the Pemigewasset River, a beautiful part
of the White Mountains.     As the paper mill died, the town was
left completely without anything, including physicians.     We sat
with Sherman and other community organizers and figured out what

they needed to do, and we sort of, with Ted's help, designed a
little health clinic, and, anyway, got National Health Service

Corps people and that site is still going, as is the one in

Londonderry, Vermont.     So we spent a lot of time really grass-
roots organizing with the community.



Mullan:     Was that a good year?



Kirk:     Oh, it was an exciting, absolutely exciting sort of year.

I was actively involved as a participant in it, who was expected
to perform, and so I had a real sense of responsibility that I
was trying to solve problems with a small cadre of people who

were very helpful to me, but also needed my help.


Mullan:    That was before the clinical complementary--



Kirk:     I sort of forget myself the sequence of those three years.



Mullan:    As you crank towards the end of this, you now are

approaching the real world.    What was your thinking?
                                                                    27

Kirk:     Well, it didn't matter what I was thinking, because the

Navy had their hooks into me.     I was a Berry Plan person, one of
those folks whom the Navy promised that if I signed up for the

Navy in medical school I would be guaranteed that I wouldn't be
drafted after my internship, that I'd be allowed to finish my
residency before going into the Navy.    So as I went through my

residency, they actually tried very hard to get me shifted from
the Navy, with responsibility to the National Health Service

Corps.     It was an absolutely natural sort of thing for me now to
build one of these sites that we'd organized.     The Navy said no,
despite Senator Norris Cotton and everybody else in power and
influence in northern New England writing in and saying, "This
man should be a National Health Service Corps assignee."
        The Navy wanted me, and sent me to Iceland for two years,

which turned out, again, an exciting experience for Jane and I.
It was a wonderful opportunity to practice medicine, as would
have been a National Health Service Corps site.    We took care of
about 2,000 Americans, families, all ages.    I was the base
internist and the closest thing to a pediatrician that was there.
So the depth of my skills were needed there and also I was the
base preventive medicine officer, which, with the other skills
that I had learned as part of the clinical complementary years,
it turned out to be a wonderful setting, and plus we got to
                                                                        28

travel more than we ever had before or since.        So it was an

exciting couple of years.



Mullan:        That was two years following the residency.   By this

time you must have been pregnant with ideas about what you were

going to do.


Kirk:     Right.     And certainly at that point when I looked back as

we were coming back to the area, we wanted to come back to
northern New England at that point, and the choice was between
taking an academic position at Dartmouth. Actually, they needed
somebody to direct this residency that I had been the first
member of.        But we looked around hard at two or three very rural

and needy sites in northern New England.



[Begin Tape One, Side 21


Mullan:        This is Dr. Kirk, tape one, side two, continued.



Kirk:     So   we looked at some of these far-flung sites that needed

physicians badly because of the nature of the isolation and the

rusticness.       Jane and I, we had our second child, too, by then.
Ian had been born.       So we had two small children.   As we looked

at these isolated sites that needed physicians, we discovered
                                                                  29

that there were good reasons why they needed physicians and a lot
of other services, and everything from educational opportunities
to other halfway cultural experiences seemed to be lacking.

Neither of us is highly involved in any of the arts or culture as

it might be, but clearly it would compromise a lot of lives to
live in some of these other sites.
        So as much as I was really sort of committed to practicing,

we finally decided to take this full-time academic position as

the director of this residency at Dartmouth.     So we moved back to

Hanover and I spent a year trying to further develop the

curriculum for this position of manager primary care residency.


Mullan:     Who had been the leader or mentor earlier?



Kirk:     Well, Dr. Johnson had been the chairman of the department

and really the mentor, and several junior faculty members like

Mike Taylor and some of these. Arthur Jacobs had been sort of
the people who did most of the teaching.    But Dr. Johnson himself
was closely involved with everything which, again, it couldn't
have been a more wonderful experience in that sense of being
right with a very senior and very capable mentor who was very

much interested in your education.    While I had been away,
basically, nobody else had been in the--the residency had more or

less not recruited.    They began recruiting again with the
                                                                    30

anticipation that I was going to come back.    So I had three

residents starting with the program when I arrived back on the
scene in 1976.
     But by then Dr. Johnson had left, and Mike Zubkov had taken

over the department.    I think Dr. Johnson had become frustrated
by the basic resistance within the Dartmouth-Hitchcock community

to this idea.    Dartmouth was still basically committed to very
traditional modes of education and had never really supported
this program in any major way.   In fact, Dr. Almy was no longer

the chairman of medicine, and Dr. Johnson had moved on, and
clearly the forces of tradition had taken the upper hand again.
     I got back into the middle of that, and was expected to try
to develop a curriculum for these residents who were there, and
it was like pulling teeth to try to just be certain that I could
say to these folks, "You're going to have three months of this,

and six months of this, and you're going to be treated like an
internal medicine resident on the internal medicine services, and
you're going to get a good program.''   All of that was a
challenge.
     There was a challenge secondarily that we were going to be
site-visited by the boards in preventive medicine, and it turned
out, as I learned during the course of that year, that there was

no way that we could really fulfill the requirements in the years

that we had allotted for the boards in both medicine and

preventive medicine in that period of time, and I was given the
                                                                     31

job to make it look like we could, and it was very obvious that
we couldn't.     There was conflict there that I was uncomfortable
with in that regard, and conflict with the clinical folks.        Late

in the year, I was eager to get back into seeing patients, and

the resistance, the opposition to what the Department of
Community Medicine was doing, both clinically with this residency
and the fact that we were out there establishing National Health
Service Corps sites, which some folks saw as direct competition
to the somewhat undefined mission of the Dartmouth-Hitchcock

Medical Center.    Were they're doing primary care?   Were they

doing tertiary care?    What was their role?   But they were not
comfortable that we were going out establishing physician sites
outside, and then some folks inside felt that that was a direct
threat.
     They gave me a hard time.    I was as good a clinician as they

could ever ask for, and I'm totally unapologetic about that.

They made it very difficult for me to see patients within the
Hitchcock system.    When I finally did begin to see patients in
the system, I was seeing folks for general medicine
consultations.    I'd see somebody who would come for his/her
physical exam to the Hitchcock instead of to their family

physician twenty miles away where they lived.    The relationship,

there were few long-acting, long-lasting relationships.    There

was none of the satisfaction that I was looking for in clinical

medicine, so I was unhappy clinically.    I was unhappy with the
                                                                  32

administrative job of trying to get a residency through a system
that didn't want to do it.
     I wrote doing that year a primary care internal

medicine/pediatrics grant that, when site-visited, clearly, the
folks were wise enough to say, "You know, this is good on paper,
but we don't think you can do it, because these other folks don't

want to."   And that was very true.
     So by about six or eight months through that experience, Dr.
Ohler, who I had been with here for a month, happened to call me
up one sort of late winter afternoon and said, "Hey, you know, we

really need somebody here in New London.   I don't suppose you're

interested.I'
     It hadn't occurred to me yet that I was going to leave, but

when he called that day, Jane and I talked about it, and it was
like a light went on, and we came down and looked around, and

looked at houses, and within a couple of weeks announced that we

would move on, which was just a fine, fine decision.   So that was

twenty years ago.   It was clearly the struggles and the
frustrations of administrative and academic medicine, especially
in a system that was not by any means ready for what we were
talking about, and the lack of opportunity to do clinical

medicine in a real one-on-one primary care way within that system

as it existed were just two things that there was no point in

staying.
                                                                        33

Mullan:     So what was his practice like when you came to it?

We're talking now '77, '78.



Kirk:     Right.   [Tape recorder turned off]



Kirk:     I can certainly summarize the early practice.   They wanted

somebody with a very general set of skills, which is what I

possessed at that time after the residency, and after the Navy
years.      There wasn't a pediatrician here.   There was one family
physician and a number of general internists.



Mullan:    Here being New London, New Hampshire.



Kirk:     Here in New London, serving this community. Anyway, so I

did a lot of pediatrics.     I put casts on simple non-displaced

fractures.     I never was interested in doing OB and was not

trained to do so, and there wasn't any need for that.     Gradually
over the course of the years, as the community has gotten a
pediatrician and as my own practice and that of the community has
aged, my practice has become a largely geriatric practice.       It's
been closed to new patients for the last probably eight years.

So the practice has indeed aged with me.



Mullan:    Has that been purposeful?   Why?
                                                                     34

Kirk:     Oh, just too busy.   Just too busy and I tend to spend too

much time with people, probably, and at least for the style of
practice that I do, I can't keep up with what we're doing now.
We always reckoned that by closing the practice and as people

literally died off, as they certainly do in an older practice
like this, we have a barn full of old charts to attest to a lot

of old friends that have passed on.        Yet as the other people get
older, their needs get more intense, so the intensity of the need
hasn't seemed to diminish, even though we haven't taken new
patients in all this time.      So anyway, I'm not sure whether to

follow that tale further or not.



Mullan:     Dr. Ohler remained in practice with you for some period?



Kirk:     Right.   And none of us in terms of the organization of the

practice here in New London, or the practices as you've seen
here, there's a medical office building immediately adjacent to
the small hospital.     All the practitioners were always solo
independent practitioners, and I came as a solo independent
practitioner, being more or less promised by Dr. Ohler and
                                       5


several others that I could probably make $35,000 without too

much--they j u s t felt that would be easy, and that's about what I

guess I was making then at Dartmouth, and I wasn't really looking

for--that seemed like a great deal after residency and the Navy.
                                                                        35

They sort of vaguely guaranteed it in kind of a way, you can't

not make $35,000, so come on, implying that if somehow I didn't,

that they would make it up, but there was never any need for that

anyway, because, indeed, they knew well that there was a need for

somebody working very hard.    And it has continued that each of us

here has remained as independent practitioners, each of us taking

care of our own business, but working together in the office
building and having a very wonderful collegial relationship with
each other for the sake of coverage and care of patients.     I
mean, what was back then about four general internists and one

family physician is now six general internists and a couple of

family physicians and a pediatrician, and still all of them in
the same building adjacent to the hospital, with a lot of input.
Dartmouth is thirty-five miles away, and Concord is thirty-five

miles away.     So we have adequate support from subspecialists who
come here and help us when we have problems.     But a very tight

collegial practitioner community, not individual physicians
scattered around town fighting with each other, but very, very
closely working together, and not getting on one another's hide
because of business relationships that often, I think, destroy
groups.   So I don't care if somebody else wants to make more

money than I.    That's their business.   If they want to make less,

and they don't want to work as much, that's their business.       But
when it's their turn to be on call, what I care about is that

they're good, responsible clinicians who will do a good job of
                                                                        35

They sort of vaguely guaranteed it in kind of a way, you can't
not make $35,000, so come on, implying that if somehow I didn't,

that they would make it up, but there was never any need for that

anyway, because, indeed, they knew well that there was a need for
somebody working very hard.     And it has continued that each of us
here has remained as independent practitioners, each of us taking

care of our own business, but working together in the office
building and having a very wonderful collegial relationship with

each other for the sake of coverage and care of patients.     I
mean, what was back then about four general internists and one
family physician is now six general internists and a couple of

family physicians and a pediatrician, and still all of them in

the same building adjacent to the hospital, with a lot of input.

Dartmouth is thirty-five miles away, and Concord is thirty-five
miles away.     So we have adequate support from subspecialists who
come here and help us when we have problems.     But a very tight
collegial practitioner community, not individual physicians
scattered around town fighting with each other, but very, very
closely working together, and not getting on one another's hide
because of business relationships that often, I think, destroy
groups.   So   I don't care if somebody else wants to make more

money than I.    That's their business.   If they want to make less,
and they don't want to work as much, that's their business.       But

when it's their turn to be on call, what I care about is that

they're good, responsible clinicians who will do a good job of
                                                                      36

caring for my patients when I can't.      That kind of relationship
has always been true here.


Mullan:     Has the growth of physicians paralleled the growth in

the population, or has the physician availability and intensivity

greater now than it was twenty years ago?



Kirk:     I think it's more the latter.   Certainly, the communities

here have grown some, but not hugely.      I probably can't describe

enough about the demographics in specific terms to address it in
a more concrete way.     The growth in physicians has been modest.

The community, certainly, has grown modestly, and the community
is New London, and some however you want to throw a circle around

it to include seven or eight or ten rural communities that are

much smaller.
        So exactly how one defines the catchment of the community is

kind of hard to do.    And there's a big seasonal flux with a lot
of people here in the summertime who aren't here the rest of the           '



time.    But I think it's a community that has a large retirement,
an increasingly large retirement population, so older people who
come from urban areas where the expectations of medical care is

that it's pretty intense, that it's time intense, that physicians

spend a lot of time with folks.
                                                                    37

     I have an uncle back in Missouri who's been an osteopathic
GP for many years, now retired, who always talked about, and

quite proudly, how he saw fifty people a day on a bad day, and
more than that on a good day.   I know the nature of the problems

he dealt with were probably different than ours, but I think,

also, there's probably a good deal of difference in what the
expectations of the folks are, and here there's no giving
somebody a pill and saying, "Take three of these a day."    With it

goes an explanation of all the pros and cons, and ifs and maybes,
and "Is this really what you're"--a real negotiated process of
almost every decision that we make.     So we spend a lot of time

with folks who have complicated medical problems.



Mullan:   You entered into practice at a time when the concept of

primary care was, I'll say, first being articulated.    I mean, the
idea had been around forever in a sense, but it was in the early
to mid-seventies when there was a kind of recognition that we
were beginning to drift away.   In fact, we had moved fairly
briskly away from the generalist concept towards one that was
much more governed by specialist and subspecialists.    You entered
into practice under a fairly clear banner of primary care

internal medicine.   Your residency was so dubbed.   You got into
practice as a primary care internist.    How has that evolved?   How
                                                                  38

has that worked in terms of your practice and how you've seen the
landscape around you change, if it has?



Kirk:   It's funny. As much as I was involved, I guess, in

teaching and trying to articulate the concept of primary care
medicine and practice in those years, both as a resident and the
one year directing that residency, I think I probably didn't and

couldn't have articulated those in my own life in terms of what I
was unhappy with.   I'm not sure that I could have said what it
was I was unhappy with in terms of the practice at Dartmouth, but
I had this great sense that what I had experienced as a resident
in a community like this, in a small rural community, clearly
something I've never lived in myself, otherwise, but that what I
had experienced here was suddenly like a light coming on when Dr.
Ohler called and said, "You wouldn't think about coming down
here, would you?"   And suddenly it's like, "Yes.   How come I

didn't think about it before?"   It was a very visceral sort of
immediate feeling, and I think it more or less stayed that way.
It was the opportunity, I guess, to develop very personal
relationships with the people with whom I was working, presumably
coming to know them in various capacities from life in the

community, from church, from school, from neighbors, from all of

those ways, so that you became very much a part of a community,

obviously, and played a particular one-on-one role, as a
                                                                    39

professional personal advisor to people on matters that happen to
relate to their biology and whatever might be referred to as
their health care.     So it was clearly, I think that relationship

with people, that was very warm and satisfying to be in that

relationship, and again, I probably would have never articulated
it as clearly.     It was a very visceral thing that I enjoyed

doing.
        I enjoyed the sense of trust, I guess, that people would
have.    I probably greatly enjoyed, and still do, the sense of
satisfaction that comes from having a problem presented,

grappling with it, resolving it, given uncertainty, and accepting
uncertainty as part of most of what we do.    But probably then
even more importantly, the satisfaction of being able to then sit
with the person and say, "Here's what I think it is, this is why,
these are your choices.    You don't really have to worry about
that thing you're worried about, and this is why you don't have
to worry about that.    It's much simpler than that.   You've got
various choices. Maybe it's enough for you just to know that it
isn't anything serious and you don't have to do anything further,
just knowing that.''   But we could talk about the choices, we
could articulate them, we could negotiate whether it was serious

business around death and dying or whether it was less serious

things about something else.

     So that role as a counselor and sort of hopefully trusted

professional friend was very clearly what has been satisfying.
                                                                     40

It's sort of an aside, but every now and then, when I think about
whether I really wanted to continue a more full-time academic
career, and I've done a lot of stuff part time, but really, do I
ever have a regret about not having done that, or stayed in it,

or gone back to it, and every time I think about that the answer
is clearly no, because there is an incredible satisfaction just
in that relationship, in that simple problem-solving.     At the end
of the day you can really say, "You know, I saw ten people today,
and in four or five of those cases, they came in worried and they
left feeling better."   Maybe every now and then a couple of times
a week I did something clever. Most of the time it isn't that,
it's just more on a personal level of satisfaction.
     So   I think that's what primary care means to me.   When you
think about the words, yes, you're there.   My phone number has
been listed in a phone book for anybody that wants to call,
although we had a call system.    I guess I sometimes abuse that by
being available, although, frankly, as I've gotten older now, I
mean, it's nicer to use that call system and to know that my
colleague who's on will indeed do a good job, and I don't expect
myself to haul in there myself each time when I'm not on call.
But I'm still incredibly available and accessible.

     I've been very fortunate in that my office staff, o u r

secretary/receptionist, Mrs. Gambino, and our nurse, Mrs. Baffa,

have been with us now f o r ten or twelve years each.   They know

the patients as well as I do, and these are really people who are
                                                                    41

now our friends.   People know that they can access us.      So

accessibility is no problem.    They can call Bonnie; they can call
Kelly; they can walk in the office; they know where we are, and

very few people abuse that.    So we're available; we're
accessible.   The continuity of the experience with people has
been there over a long period of time, and will continue to be.
What we learn about how to care for this individual and other
individuals by following them over time, knowing that you can
take your time and you don't have to solve the problem today, you
can wait and let it play out over more time, all of those
characteristics that we talked about as primary care are there.
     Finally, organizing care for people, or managing care, is
something that we've done without thinking about it.       If a person
trusts you, they rarely go--there are exceptions, clearly--but
they rarely go on to those referral folks without working that
out through you, knowing that we're not going to be an obstacle

to that, that we will facilitate it, we will talk to them about
it, and pick a person who we know who is good, who will
communicate effectively, and take care of them.   And we're pretty
comprehensive.   Especially now as I've progressively limited
myself to adult medicine, there aren't a lot of adult medicine
problems now that I can't deal with myself, but we have easy

access to specialists who can help them when needed.   My

colleagues in the community, surgeons and other folks, are
                                                                    42

readily available to take care of the things that I shouldn't be
involved with.



Mullan:     What do you say to the charge, sometimes stated,

sometimes in the air, that primary care is boring?     Certainly one
of the reasons that was attributed to why medical students, or
young physicians, seem to be abandoning primary care in the '85
to '95 period.     Was this simply misperception? What's going on
here?


Kirk:     What a strange point of view, at least after you're out

here.     I guess I would comment that, clearly, people find

different things exciting.     I think there is clearly nothing
inherently boring about primary care unless what one really wants
to do is play with machines in a high-tech atmosphere, in an
operating room, and worry about heart-lung machines and things

like that.    Certainly, if really high-tech things are what
excites you and human experiences don't, then maybe primary care
would be boring.
        In the first place, the human part of it is the most
exciting part for me, and those challenges, and the excitement of

everything from, again, telling somebody that they're dying and
how to make something good of that, and even be able to have a

laugh at the end of it, or relieving people, anyway, the human
                                                                     43

part of it is clearly there.     But the next thing that medical
students who come and share our experience with us recognize very
quickly is that it is a wild and wooly experience.     Certainly,
from the life-threatening acute myocardia infarction, with all

the riveting disturbances and thrombolitics that we are
intimately involved with in this community, we're not a
backwater.   We're able to do all of that kind of thing very

efficiently here.    So from that at one extreme to complicated
metabolic problems, the spectrum is so broad and so varied, and
because we're not so highly specialized, one frequently finds
oneself struggling with something that's on the margin of your
experience, whether it's an ENT problem or an orthopedic problem
of interest, there's a never-ending challenge in terms of the
actual clinical stuff and such a breadth of experience,
clinically, that it's hard to call it boring unless one really
wants to take each of these things to the technologic end point
and play with machinery.


Mullan:   How about the repetitiousness, the mundanity?    These are

words that are used.


Kirk:   Right.   Right.   There still remains very little that I

would call repetitious.    Goodness gracious.   What could be more

repetitious than being an orthopedic surgeon who's replacing hips
                                                                  44

as their major life work.     Clearly, the spectrum of clinical
activity that we have is much broader and, hence, much less
repetitious.     I sometimes wish I had a recording of myself
instructing people about low back pain or about some approaches
and the dangers, the pros and cons of treating hypertension, and
there are certainly occasional times when you wish you didn't
have to go through that again.    But I guess the individual human
element, and that's the part that ultimately makes every one so
very different, that each and every person is so different.
        The thing that for students to come and learn is that
whatever they've learned in textbooks and generalities have to
brought to bear with this person sitting in front of them right
now, and that makes it a whole new game.    You bring the

information that you have from the book, and you have to know
that.    But then you, more importantly, have to know how to apply
that, and how to negotiate that information with this person in

front of you.    So every case ends up being so very different.
     So I think inherently it's broad because what comes in to us

as first-stop caregivers is very broad, but even if it were more
narrow, the fact that each individual is different, everything is
cast in a different light.    So that certainly doesn't seem to be

a problem for any of us.
                                                                    45

Mullan:   Let me ask another sort of difficult question, and it's

really about the internal medicine part of the primary care
spectrum.     It comes most recently from a provocative chat that I
had yesterday with Beach Conger.    He maintained that his kind of

internal medicine practice, not unlike yours, was a dying
phenomenon.    We were sort of exploring this, and I think he was
kind of playing with the idea in his head, although it related to

stuff that you've thought about.    The thesis goes like this.   You
are going to have, on the one hand, some fairly low-tech primary
care practitioners who emphasize prevention and education and
teaching, of whom the generic nurse practitioner is probably is a

good example, but PAS and the family docs who do that kind of
work well, and perhaps at a lesser cost.    Then you clearly have a
fleet of specialists in internal medicine and elsewhere, I mean
subspecialists, who are ready, willing, and eager to intercept

patients at as early a point as possible in the system.

Appropriately or inappropriately, they're hungry, and cruising,
and cardiologists want to get them, and gastroenterologists wants
to get them.
     The diagnostician, the thoughtful general internist who
lives in between the low-tech, repetitious educator, counselor,

preventionologist, if you will, who does the Pap smears and does

the breast exams, and does the health maintenance kinds of stuff,

and does it quite well, and the high-tech subspecialist waiting
                                                                       46

eagerly, the role for this thoughtful diagnostician who was born
of a day when lab tests and technological interventions were

relatively minor players, and osculation, percussion, and good

diagnostic thinking were critical, that day has, at least in this
formulation, is rapidly leaving us.       Therefore, that middle

ground is going to be squeezed out by the low-tech people on one
side and the high-tech people on the other.


Kirk:     Right.   I know Beach well.   Beach is always provocative.

Never known him not to be.      I think in general that that picture
is certainly a plausible direction.       I guess I think that
particularly, and certainly my own experience right now in one
area, and that is certainly with older folks, I think that it
would be hard to find a better fit for older adults than a

general internist.     Their problems are multiple.   Clearly,
clearly, their care would be compromised if it were cut up into
the pieces that it could easily be cut up into, because they all
have, or so many of them have so many different medical problems,
they clearly need a central clearing ground and somebody who's
looking after the entire spectrum of their needs.
        Indeed, prevention in that population, do you know it's

something that we almost don't even think about.      As a separate

item, it is integral to what we do.      For me, the most important

instrument that I have for prevention in older people is a
                                                                     47

carefully kept flow sheet on the back of my problem list that
allows me to look and see, at a moment's notice, each time they
come in with their chronic problems, to know when I last did
their mammogram, last did the breast exam, or the prostate
screening, whatever you want to do is arguable.     It all ends up
being negotiated with the individual anyway, but it tells me when

I last did it and whether it is probably due or not.    These folks
rarely have a health maintenance visit.     It happens as a part of
their regular care.
     Anyway, I mean, it's arguable with people who are much
younger, who have no medical problems, and who just need an
occasional preventive visit.   It may very well be that people
with a lower end-of-the-spectrum set of skills--1 try not to put
"lower" in the sense of important or unimportant, it's just a
different set of less technologically-oriented skills--may very
well be appropriate.   There may be more time for counseling over
things that I'm maybe not as good at as might be for dietary
counseling and things like that.   In any event, there may be,
certainly, a role for the lower-technology people doing some of
the care and then for the singular problem, the [unclear] to
refer them to the appropriate specialist.
     But certainly, I think as adults age, I think that a general

internist is a good fit f o r older adults who may have multiple

medical problems.   Most of us here have worked side by side with

family physicians over the years in the community, and simply
                                                                    48

consider ourselves to be the same breed of primary care
physicians, which is what we would normally think of ourselves

as, who need the same set of behaviorally oriented skills, of
management skills.   If we are going to deal with older people a

lot, we need more of these internal medicine skills, and if we're
going to deal with young families with children, and obstetrical
needs, and orthopedic needs, that the mix of clinical abilities

that we have should be shifted in another direction.
     Again, I've experienced that shift myself in my own

practice.   I, I think, had the same sensitivities more or less,
and the same need to be basically a primary care family-oriented

physician when I was younger, and was taking care of young
families.   But my clinical skills now need to be focused more on
internal medicine, traditional areas of internal medicine, and

less on orthopedics and pediatrics and things like that.   I'm

starting to feel a little challenged with adolescent medicine
except that my own children's growth and development has kept me
fairly alert of that realm of practice.



Mullan:   I know you've had a particular interest in office-based

research.   That's really an important and different contribution,
different than the vast majority of other people I'm
interviewing.   In any event, tell me a bit about where that came

from, how that's developed, and where that fits in your life.
                                                                     49

Kirk:     It's been an important and fun professional challenge.     I

guess it's the sort of thing that, if nothing else, is a sort of

sidelight hobby, has allowed me, in addition to practicing, to

step outside and do something else that I enjoy and can maybe
attach some importance to.       At worst, it might be revealed as an
effort to sort of maintain some kind of academic respect, having
crossed the line twenty years ago to be a practitioner and most
proud of that, but I'm not quite sure of my own internal psychic

needs all the time, but in any event, it certainly is a sense of
some pride and satisfaction to have been able to carry on this
other area in addition to practicing.


Mullan:     Keeping a little gown with your town.



Kirk:     Right.   Right.   And maybe faintly for a long time some

thought that if I ever wanted to go back, that I'd maintain those
skills.     That isn't an issue anymore.   But in any event, it
really emerged out of the residency in primary care at Dartmouth
that I was in.      It started a little bit while I was a resident in
the fellowship year, but it really started more seriously the
year 1977 when I was the director of that residency.
        One of the things that we were responsible for in the

Department of Community Medicine was that the department had a l s o

started sending medical students out for significant Farts of
                                                                  50

their clinical experiences to community preceptors.   Most of the
towns around--Beach Conger's community in Windsor was one of

them, and New London was one of them, and others, had these

wonderful primary care physicians who were teaching students now.
And we had gotten together as a group with these teachers, who

all felt that they invested in this, that we wanted to be able to
do some research, mostly to prove--it was very direct clinical

research.   It was called, "HOW Are We Doing?"   "Is the quality of
care that we are delivering for hypertension, for otitis media,

for urinary infections, is what we're doing of sufficient quality
that we can hold it out to the students as something that is

worthy of their observation?"
     In fact, at that point, when there were still immense

challenges within the Dartmouth-Hitchcock system to sending
students out from the medical center for any of their experience,

it was important from the community medicine viewpoint to be able
to say, "We can say something about the experience and the
quality of the experience that the students are experiencing."
     So we set out to cross the various practices that were doing

the precepting to be able to measure the quality of care around
certain sentinel diseases or conditions. We realized right away
that we had to develop some instrument of data-gathering that
could be shared by the practices, and we fell upon fairly quickly

the fact that the billing systems in the offices--it was the one

piece of paper that everybody filled out.   It was the bill.   But
                                                                     51

everybody was using an assortment of silly, inefficient, and
inconsistent sort of billing forms, and we realized that if we

could improve everybody's billing system for their sake, while at

the same time designing this billing system to allow data-

gathering on it that would be valuable for research, that we
would have killed two birds with one stone.    It was really the

birth of the Dartmouth Cooperative Information Project and the

excitement that the physicians all had in this was that we helped

them in their practices, while also helping all of us figure out
how we could do some research together.


Mullan:    When was this?



Kirk:     This was 1977, '78. So I was starting that.   There were

three or four of us:    Gene Nelson, of course, who's had a very
eminent career in health services research; and John Wasson; and

myself; and Steve Marian, who's an administrator of Dartmouth now
within the system, sort of were the in-house folks, along with
Dale Gephart and Beach Conger, and a number of folks who were
still in these communities who started that system, and started
doing research, and got funding to establish this data system

that would allow research and teaching and quality-assurance

kinds of activities to occur in these community precepting

practices.
                                                                     52

        It kind of grew from there to doing more larger and larger
research, some of which has become internationally known,

especially the efforts in measuring functional health status.      I
was lucky, because even though when I left Dartmouth in '77 to

come to New London to practice, I knew that I was not going to be
far away, and that I would be able to continue what was at that

time an intensely exciting kind of endeavor with developing the
Dartmouth Co-op Project.



Mullan:     The Dartmouth Co-op has continued since that time?



Kirk:     Yes.



Mullan:     How many physicians or practices involved in it?



Kirk:     It depends on how you count now.   We are, in fact, in the

midst of redefining the purposes of it.      In fact, it's come back
around now to where teaching and providing the focus for dialogue
and communication about teaching medical students and residents
in the community is becoming, once again, the major focus of it.
That was a part of it at the beginning as well as doing simple

research.
        The funding ran out in the early 1980s from the federal

government, rather abruptly at that, leaving us to make some
                                                                   53

choices.   We made a choice that basic research with what we were
going to do.   We weren't going to be focused on quality
assurance, office management, data systems, and teaching issues,

we were going to do primary care, office-based network primary

care research, because we didn't have enough money to do
everything, and that's what we decided with the practices that we

were going to do.
     That's where the project went for a number of years and,

again, developed these charts to measure functional status,

something that all of us, as practitioners, were at the grass
roots of sort of saying, "You know what's really important, more

important than whether this person can run ten mets on the
treadmill, or has an FEVl of X, Y, or 2 , what really matters,

especially with older people, is how well can they function, and
what spheres are important in their function, and how can we

measure it simply."   Yes, there are ten-page surveys that will
tell you about functional status, but we've got to do it quick
and dirty in the office and in some reliable way.
     The efforts to do that, which were both intuitive clinical
ideas that were enriched by the kind of hard research thinking
that people like John Wasson and Gene Nelson could add to it and
validate these instruments as something that really could be used

for research and for clinical practice, was a very exciting
experience for all of us, that along with a number of other very
                                                                  54

well-done research projects that we all had a great deal of pride
in knowing that we were a part of that.
     As the projects got bigger, they got further away from the
grass roots, they no longer involved us directly with the process
as much as they had originally.    That was because funding became

available to do specific things that often made it impossible to
really have us as involved as we used to be.    There was recently
a certain lack of involvement of the practices as much as they

used to be, even though we all stayed in touch and went to annual
meetings and enjoyed one another, but there was a little less
research going on.    John Wasson didn't do it at all.
     Now it's evolved to where the teaching part of it, that we

originally enriched all of us, is bigger again as the Dartmouth
Medical School is much more involved with the teaching in the
community.    So that other part of it, all of us for the last

twenty years have been doing teaching.    Students have come to the
office initially for just simple experiential, feel good, see the
doctor, and kind of try to learn anything you can, but very
undirected.   It's gradually evolved into a much more central and
critical part of the curriculum for Dartmouth Medical students,
starting from year one with much more expected of the community--



[Begin Tape 2, Side 11



Mullan:   This is Jack Kirk, second tape, side one.   Continue.
                                                                     55

Kirk:     So just that in the evolution of the co-op project it's

coming back now to be the focal point for all of us community
preceptors in the area to be talking more about education, and
still doing research, but wondering how we can shift the research
back to very office-based research, in which the students

themselves can participate and see this experience of how

community-based primary care physicians evaluate themselves.


Mullan:     Give me some examples of other kinds of issues besides

measurement of functional status that have been victories for the
co-op.     Just a sample to put on the record.



Kirk:    We published several papers on chronic fatigue as a

presenting symptom in primary care, and how it presents, and what

the causes of it are.    We early on just discovered new and less

expensive ways to look at urinary infections with office-based
systems that didn't cost as much and accomplished just as much.
We've more recently done studies involving the role of telephone
calls to patients rather than visits as perhaps a more efficient
way of using time.
        I think one of the other real important things that the co-

op project did was a community cancer prevention project which,

instead of focusing on something that is sort of high tech and
arguing about how often mammograms ought to be done in different
                                                                     56

populations, it focused on how one can change office record
systems to do a better job of keeping track of prevention.      So

research staff came to the practices in the study group versus

the control group that didn't get these visits, and sat down with
the physician and their office staff and said, "Okay, what are

your goals and how are we going to achieve them?   Do you need
reminders that you need to do breast exams and mammograms and Pap
smears?   Do you have a flow sheet that allows you to identify who
has and who hasn't had these things done?   Do you want smoking
stickers?   Do you want--" whatever.   They spent some very focused

time and came back on several occasions and really helped offices
overcome that, "Oh, my system just doesn't allow me to do it.        If

I just had some time to really sit and think about this, maybe I
would, but I'll probably never take the time to do that."
     Well, this provided a focus to do those things and, indeed,

it was very clear after this intervention that these practices

did a better job of achieving the goals that they had set for
themselves in terms of how often procedures should be done in
cancer prevention than the control group which didn't have that
same focus on office systems.


Mullan:   You've also been involved with ASPN, the Ambulatory

Sentinel Practice Network.   How does that differ from the co-op

in terms of its focus?   Tell me a little bit about it.
                                                                     57

Kirk:     The Ambulatory Sentinel Practice Network was really

established probably in about, again, in the late 1 9 7 0 s by the
academic family medicine establishment, recognizing that family

medicine to be accepted as an integral part of medical centers

and to be respected as an equal partner with pediatrics and
medicine and surgery as departments within a medical center, that
they needed, obviously, to be doing research, and that the
logical place, the logical laboratory for family medicine
research was the place where family medicine happens, and that is
in community practices, not typically in medical centers, that it

seems so logical and yet have been so studiously ignored, or just
been impossible because of the location of research enterprise
within academic medical centers.
        This was clearly something that family medicine recognized

that it had to do not only for its own good, but for the good of
the patients for whom they were caring.    If they were going to
solve the problems of how to do a better job of providing primary
care in family medicine, they had to study these matters where
the problems were occurring.    So the establishment of networks of

practitioners in "real" world, "real" community sites,
establishing networks of those folks linked to some kind of

academic medicine people who had the skills to organize the

research, or had the skills to do the things that the community

physicians could not do.    That was the focus of it.
                                                                  58

     Clearly, the recognition and the respect that the family
physician, number one, had the laboratory and the relationship

with people, and also the clinical intuition to ask the right
questions, to recognize when the wrong questions were being
asked, or when the right questions were trying to be answered by
the wrong methods.   So recognizing that the family physicians

were a critical part of this endeavor, but also recognizing that
they probably didn't have the time, the resources, or the
research technical skills to carry out research and the ideas
that they knew were important, that combining the academicians
with the family physicians was clearly what the goal was.

     Actually, I was asked to be on the board of ASPN because I

had been the medical director of the co-op project, which was
recognized as one of the earlier and successful enterprises.     So
that ended up with me subsequently a very happy and, again, sort
of challenging life as a practitioner on this board, and I

suppose what was the most fun all along was that most of the
other charter board members were academic family physicians who
were very well known in the field of family medicine and
research, and wonderfully inspiring people.   Gene Farley and
Morris Wood--



Mullan:   Larry Green?
                                                                     59

Kirk:     Larry Green, somebody more my own age, but who was as

charismatic as the folks who were somewhat older than us and more
recently working with Paul Nutting.     I hesitate to start naming

names, because it almost diminishes the role of so many of the

others.



Mullan:     Is ASPN and the co-op different substantially? ASPN is

clearly founded on academic family practice, and the co-op is
founded on the geographical alliance in this part of the world.
So those are different premises.    But the concept of office-
based, primary-care-oriented generation of new knowledge through

application of research methodologies pretty much describes them

both?


Kirk:   Yes, it certainly does.    It certainly does.   There were

real logistic challenges that led to political challenges for
ASPN that the co-op project didn't have.    Tried to figured out
how to gather data from Canada and the United States and
scattered all around.    It's a much more expensive process, and
how to keep that laboratory going, the expense of keeping that
laboratory going, presented real challenges for ASPN all along
the way.    Accordingly, it was a much more difficult sort of

political setting than the co-op ever was, which was nestled in

the Department of Community Medicine, which clearly provided the
                                                                    60

support and the nurturing, and the physicians all around it had a
twenty-year relationship with the department.     It wasn't a matter

of politics, it was just a matter of what could be done.
        Much more complicated to try to do what ASPN has done, which
on the one hand puts it in the position to do much more exciting
things, but a lot harder to do.



Mullan:     Is office-based primary care research a viable and

important part of the future of the primary care movement, in
your judgment?


Kirk:     I think it is so difficult to imagine trying to do good

primary care research consistently outside of as real a world of
family medicine and primary care as one can attain.    Most of the
important questions have a lot to do with relationships with the
interface of people with their community, the interface of a
physician with the person who has the problem.     Those kinds of
things are very difficult to study, I believe, in an artificial
setting.     Physicians in practice are better able to ask the right
questions and to recognize how to answer those questions.    Hence,
I think that community practicing physicians need to be
participants in the process.

        Now, as things happen over the years, and as this

organization of medicine is changed so much, it becomes harder
                                                                   61

and harder to define who is a community practitioner and who
isn't.   Does it mean who's salaried by the medical center and who

isn't?   That's obscure knowledge.   Medical centers and hospitals

buy up practices.   But I guess the idea is practices that are
genuinely in the field of primary care, who are seeing people on
the frontier as they come in, that laboratory needs to be a part

of where the questions are answered.
     This is sort of is a sidelight but always has concerned me,
because we've encountered it several times, especially in the
ASPN experience, much of what the traditional research, clinical

research has done at times, I think, is to really take advantage
of patients.   I think patients coming to clinic settings, where
the relationship with the physician is not a lasting one, where
people are somewhat at, not the whim, but certainly are not in a
full position of control and authority, are often asked to

participate in research and put in a position of not being able

to say no very conveniently. We sometimes find ourselves trying
to answer the same kinds of questions, and doing that same kind
of thing to patients in our practices.

     For me what has happened is a realization that it is indeed
damned inconvenient to do some research in this real-world
setting of family medicine.   It is very much more difficult to

engage patients in studies sometimes if you do it honestly,

because it says, "Listen, really, I don't know what the best

answer to this question is.   I will not sit here and try to imply
                                                                       63

Kirk:     Certainly, traditionally there has not been.   Like most

states, public health folks do their thing and we do ours.      I

think most of what I've done in preventive medicine is just, I

think, to be a very critical thinker about what is and what isn't
worthwhile doing, and to negotiate things more honestly with

patients in my practice.
        The other thing that I'm intensely aware of and increasingly
so over the years, is that I think there is a very inherent kind
of conflict in the information and in the goals of public health
systems and researchers in many clinical areas and primary care

physicians.    The example is that lowering somebody's cholesterol
from 225 to 200 may have an impact on a population basis that can

be interpreted as important.    We have often used some of those
relative risk kinds of numbers.    "Your risk of a heart attack
will be reduced by 50 percent if you lower your cholesterol by
thirty points.''   When you look at that number in the absolute
terms for this individual patient, most folks, when you try to
present those numbers to them, look at them and say, "Why was I
worried?    Why was I worried about eliminating entirely the ice
cream from my diet? And why was I even thinking about taking
this $100-a-month medication?    You're telling me that my risk of
having a heart attack in the next ten years would fall from 10

percent to 7 percent?    Do you know?    That's not very significant

to me.    Thanks for the information."
                                                                       64

     Those numbers may be meaningful on a population basis, but
not to this individual, and I think we've often found ourselves

in conflicts with published--some of this is with published

research--that tends to, I think, overstate risks to people by
presenting things in a relative risk format.       When you get down
to the individual, most people would interpret that as not so
important.    My job isn't to tell them what I think they should

do, it's to give them the data and let them make a decision.       So

on the one hand we have sort of a conflict with goals in that

sense.     I mean, that's sort of public health.
     The other problem, really, the public health problem that I
really perceive has just been the "we" and "them."      The real

health problem that I certainly perceive is the uninsured, the

people who do not have access to medical care, and how do you as
a team get on the same page and try to help that.
     Frankly, our community here hasn't had a lot of that
problem.    There are none of us in our community here that don't
accept folks without insurance.    We all have our share.
Fortunately, compared to other communities it's a relatively
small percentage of people so that nobody's at a loss for it, and
it's sort of the way we used to think of it as ideally.

Everybody takes care of all comers in this community.      Nobody is

turned away either from the hospital or from our offices.      We all

take what comes.    In that sense, public health doesn't

necessarily have to do much more than that, although we know that
                                                                      65

the obstacle for many people, because they don't have money, is
that they won't try to make access.



Mullan:     AIDS is not an issue in the community?



Kirk:     No.    No, it has not been an issue in this community.    None

of us has really taken care of an AIDS patient other than an

occasional folk in the emergency room in the summertime passing
through.        It is still a small problem in New Hampshire in

general, and certainly smaller than that in this part.


Mullan:    Managed care is a problem.     Managed care is a large

topic.     Let's just get on it in terms of your view of how it's

affected your practice and what implications it has for the

practice of primary care in general.



Kirk:     Yes, I'm profoundly disturbed by managed care.    I think it

is built, for starters, on a basically dishonest principle,
including, I think the worst part of it is, the failure to make
sure that patients understand the fiscal relationship between
their insurance company and their physician.       The insurance
companies have put us immediately in a position not any longer of
advocacy for patients, but in a position of conflict of interest.

The term "gatekeeper" is a term that I can barely let that word
                                                                    66

out of my mouth without anger and frustration.    I am not a
gatekeeper.    I am the caregiver for the patient who sits in front
of me right now.    It is my job to help them solve problems and to

advise them of their options.    I find that job most satisfying,

frankly, when people have a large deductible and are on the line
themselves for the costs up to a point of the decisions.      I don't
think that we as a government or as private insurers should be
trying to insure every last dollar of people's medical care.

They need to be in the loop.    There are too many very arbitrary

costs that, if people are fully insured, they are not involved in
taking responsibility for it.   Physical therapy for your low back
pain at fifty dollars a shot, times five or seven or ten

treatments is a very expensive thing.   I have a big deductible on

my policy.    I wouldn't go get it because it would cost me $500
out of pocket, and I'm not about to do that.   I'll survive

without it.
     I think people need to be involved, and my job is best when
I advise them about the risks and benefits, and within some
reasonable reason of their ability to pay for it, that they're
expected to participate in that.   That would be my solution.
Instead, I'm expected to sit here and be the one that tells Mrs.

Jones that I will not approve her desire to go see an orthopedic

surgeon, even after I thought that I'd adequately advised her

about her need, but she'd like to see an orthopedic surgeon.     The

moment that I, as her primary care physician, sit here and say,
                                                                    67

"NO, I will not allow that, and you will pay for it yourself,"
you can kiss goodbye the relationship of trust and a sense that

I'm her physician.    Again, I think I ought to be neutral cost-

wise in the issue, and she ought to be on the line herself to
decide whether she goes to that orthopedic surgeon.    But I think
they put us in a position where we are the ones that are going to
decide whether they're going to pay for this, or their insurance

company's going to pay for it.
        Furthermore, the patient is not supposed to know the nature
of that fiscal relationship. Well, that's where it all came

from.    It's probably going to change, and they will probably be
required to release more of that information, but I do not think

that that is the foundation for an honest, professional
relationship with a person, and I find it just profoundly
disturbing that we're put in that position.

     I guess the next thing that clearly is happening because of

the utter complexity of managed care, and even in this community
where it's just beginning to touch us, probably 10 percent of
what I do is managed care, but that consists of three or four
different managed care companies, small by other areas'
standards. But for this small, very personal office consisting
of me, one secretary/receptionist, a nurse, and the part-time

assistance of my wife Jane, we are suddenly really strained to
keep up with each of these managed care operations and who their

referral list is, and what is the paperwork that we have to do to
                                                                  68

fill out, and the nature of contracting with each of them is a
terribly obscure kind of thing.   Even an actuary full time would
have difficulty with a small practice with a small population

trying to estimate whether we're going to win--we're not going to
win big on the gamble of how much we get in capitation versus how
much we spend on the care of people, but we are put at risk for

the occasional very sick person that comes into our office to the
point where we're supposed to probably worry about whether we're
going to take on a new patient, never a concern in my life
before.   Never would I even question where this person's payment,

if any, was going to come from.
     I recently took on the care of a young woman who's
quadriplegic from an auto accident, and have to ask whether me
and the very small primary care group that I am considered a part
of is going to be absolutely taken to the cleaners by the

predictable excessive costs of her care over the next few years.
For her insurance company, I'm considered part of this little
ten-person primary care group and, frankly, I can't even speak
f o r myself without speaking for them and whether they're willing

to take on this risk.   I am not in this to be an entrepreneur.      I
want to be a simple, honest, professional making bit-by-bit

wages, and suddenly I'm involved in something that is much bigger

than all of that.
     What it is really doing to our community here is that we

have been forced by this to begin organizing in ways that we
                                                                     69

specifically did not organize in the past because it provided no
advantage to us.     We now are constantly in meetings trying to
figure out how to organize our singular practices together, along

with the hospital, how to form physician-hospital organizations,
how to manage all of this, lawyers and practice managers and all

of these people in suits that were never a part of what we were
doing before, and in that sense are never going to provide better
care for the patients that we're taking care of.     In some grand
sense, it's going to bring down the cost of care, and it's

probably done it already, including straining small rural

hospitals like ours that already take all comers, including

people who don't pay, a large Medicare population on which very
little profit, if any, is ever made, and now managed care
threatens the very existence of an entire rural health system.

Nobody ever figured, nobody ever asked, if it was going to do

that.
        The forces that are changing things are certain beyond the
control of people who are actively thinking about the
organization of medical care for people.    Very clearly the focus
is on reducing costs.    It isn't seen that the reduction in costs
are producing savings that are going to people who don't have
insurance, or who can't currently get care.    It's being taken out
of the system, certainly here, and threatening the existence of a

small, rural hospital.
                                                                     70

Mullan:     Why is the rural system such as it exists and hospital

community such as this at particular risk?



Kirk:     The hospital, in particular, certainly sees itself at

great risk.     This is a very strong and relatively well-off

community, and a very well-off solid thirty-bed hospital plus

fifty extended-care bed, very capable hospital.     The managed care
corporations that are coming into the area clearly want to make
all of their care, including the hospital care, on a capitated
basis.     The costs, what they are willing to pay the hospital in

the capitation system, to the very astute controller of the
hospital, he just says, "We cannot do this and stay alive.      We

cannot do this and stay alive."
        What he is particularly concerned about is that Medicare
would be capitated.    When that happens--and that's 60 to 70

percent of our business here--it is virtually impossible to

imagine the hospital continuing as a full-service hospital.       And
even now, just everything from--you know, those few areas that
hospitals could make some profit in to offset the losses for
Medicare, lab and x-ray, clearly all of those, any of those areas
where any profit could be made are gone with managed care.      I

don't blame them in that sense, but the change has come without
really asking the question, "What if ten more of these hospitals
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close?     Is that an advantage? Does that do better for people's
medical care?"


Mullan:     What is going to happen?   Where do you see the system

headed, particularly from the primary care perspective?



Kirk:     I think apart from the challenges, for instance, to this

hospital, the other thing that is very clearly happening, I don't
think there's any doubt that myself and the five or six other
fifty to fifty-five-year-old physicians in this community who've
been here for twenty-five years, will be replaced by people who

will be part of probably a hospital-owned-and-operated group
practice.     In fact, that may all be owned and operated by
something that owns and operates this hospital, whether it's the
Dartmouth Hitchcock Medical Center, the Leahy-Hitchcock

Foundation, Health Source, or whoever else, but clearly people of

the future are going to part of a much larger system in which
individual practitioners within the system, will seem to kind of
come and go as kind of hired guns.     Patients clearly buying a
svstem with their insurance dollar, not a physician, that they
have reason to believe that they can work well with, but rather

that they buy into a larger system and become a part of that
system which will have frequently interchangeable parts as if

clinicians could be interchangeable parts.     There will be clearly
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motivation for economic reasons to have as much of the care
provided, as you mentioned before, by folks at a lower end of the
salary level.       Efforts will be made in various ways to do it

cheaper.       Pressure on practices to see people faster, and to see
them at the lowest level of technology.
        This hospital, as it is now happening, is sort of primarily

in charge of recruiting a physician to take over a practice of a

retiring physician here.       That incoming physician has been
notified ahead of time that she will see thirty patients a day.
Well, I guess I reckon when I came to town, I saw as many people
as I could comfortably see, thinking that I was doing a
reasonably good job.       It was not because somebody was telling me
that I had to see them at a certain pace.       It may not have made
economic sense, but it made sense to me and to the patients that
I cared f o r .

        So   I sense the locus of control is clearly not going to be
in the hands of physicians.      Individual physicians in the cottage
industry of it is clearly going to be swept away, because we
cannot as individuals figure out how to contract with managed
care.    They don't want to contract with individual physicians.
They want to send their person to talk with one spokesperson for

as large a group as possible.      So everything is clearly going to

move to that higher end of organizational spectrum, which I don't

personally think provides better care for individuals.

Certainly, the twenty years here in this kind of a setting
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convinces me that the best of all worlds is this for individual
patients, as long as the physicians are responsible professionals

and are not about to take advantage of people for economic gain.



Mullan:     What are you going to do?   What's the future for you as

you see it in twenty years?



Kirk:     Well, the changes are just beginning here.   A very serious
question that has been in my mind on any given day when the

frustrations of dealing with managed care, whether it's in
meetings or an individual patient that I have to work through
paperwork, I swear to myself that I will not work within that

system as it becomes the major part of my practice.       I still

think that that's going to be the case.

        Apart from the philosophic thing, I don't think I'd be
comfortable within a larger system now where the locus of control

and the marching orders come from outside of me.       I personally
think that we've been an extraordinary responsible professional
office, and I think what larger systems do is they may get rid of
the worst, but I think they get rid of the best in terms of
fitting care to individual patients as well as possible.      So I

don't think I'm going to be comfortable working in that system.

    We're doing a lot more teaching with the Dartmouth folks.

The experiences that I've had over the years teaching and helping
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design curriculums, and the primary care research projects have
put me in a position to do a lot more teaching and those kinds of

administrative jobs.      I don't want to leave the community that I

live in.     I guess I would like to see a transition to doing more
of that kind of teaching and curriculum development, and less of
the practice.      I guess it's hard to continue to work sort of
twelve-hour days with a lot of on call, and being available to

people.     It would be nice to have that part of the load shared a

little bit more by somebody else and to really free me up
genuinely to do the teaching and administrative things, rather
than just have that be an add-on, which is what it's been all

these years.


Mullan:     That would be a neat loop back to where you started.



Kirk:     Right.   And that's, I guess, how I'd like to see it.



Mullan:    An   area we've neglected is your family life.   Let's just

drop back quickly and pick up on your marriage, kids, and all
that.


Kirk:     That's thoughtful of you.   As always is the case, I guess,

when one gets wrapped up in professional life, the greatest

potential problem is to take the most important thing in your
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life for granted.     My wife, Jane, who has been very happy as a
mother and rearer of children and keeper of the home, has,

basically, because of her satisfaction doing that, has been very

happy through the years, allowing me to work a lot of hours with
her working as many hours being the primary person in the home
front.     We've had a very happy and satisfying relationship, both

kind of understanding each other in that regard.     It's that kind
of relatively traditional, I guess, relationship that is

difficult now for younger people to perceive.     Her career was
very clearly something that she carried out easily, as well if
not better than I've carried out mine, and that has been, being
the primary one to raise the children and to take care of the

house.     Actually, it's interesting because that's sort of in
transition as our children are more or less grown and gone, and

it's more important for me to be able to find some time now for

us to be able to spend more time together than we have in the

past.
        Our oldest child, our daughter, who was born when I was at
the University of Chicago is twenty-five, and out of college.


Mullan:    What is she doing?



Kirk:     She's married and she actually has been working at the

Health Institute with A 1 Tarlov.   Talk about curious circular
                                                                        76

things.     But she's getting a master's degree in education now,
and wants to teach.        She spent two or three years as an Outward

Bound instructor.     She's a little bit of a thing, about four

foot-eleven, and weighs about ninety pounds, and has carried

canoes in the boundary waters and heavy packs through the Sierra
instructing Outward Bound.       Anyway, she likes teaching and will

be very good at that.       I think that's what she's really embarking
on that now as she just left the Health Institute doing some

research assistant work there with John Ware and functional
health status people, and sometimes encountering the work that
the co-op has done in functional fields.
        Our middle son, Ian, is a snowboarder by inclination and by

part-time trade.     He's twenty-two.    He finished two years at

Colorado College where he went because that was going to be close
to the snow.     He's taken two years off, spending time really

working in the snowboarding field, both as a semi-professional
snowboarder in the winter, and building snowboards for a little
company in the summer.


Mullan:     In Colorado?



Kirk:     Yes, in Colorado. Never Summer Snowboards.     He's made

most of them, and they're good ones.       He's probably going to get

back into school after one more winter of living in Vail and
                                                                       77

riding his board.       He thinks he may even, which is music to our
ears, come back East to finish school.
        Our youngest son, Cameron, has just finished his freshman

year at the University of Wisconsin, and is home for the summer
with us.     Cam's very happy.   I'm not sure what he wants to do.

None of the children have been interested in medicine.      I think
they saw enough of just hard work to not necessarily want to

pursue that.      But they all have ideas about their own careers,

and I guess ultimately if you can feel any sense that they're
happy and worthwhile and capable people, it's a great sense of
satisfaction. Certainly, my wife can take most of the credit for
that and, me, at least, focused on that when I wasn't practicing

medicine.



Mullan:     That's terrific, Jack. Anything else you'd like to add

at all?    We've covered a lot of ground.


Kirk:     Yes.   I think more likely I should probably subtract a

great deal from all of that.      But it's nice of you.


Mullan:    Thank you.



[End of interview]