1

                              ALIZA LIFSHITZ


                           November 10, 1996

                         Dr. Fitzhugh Mullan,
                             interviewer



Mullan:     Your date of birth?



Lifshitz:    April 1, 1951.



Mullan:     We're sitting in Dr. Lifshitz's dining room, part of the

living room, in Los Angeles, on the evening of the 10th of
November 1996.     She's been good enough to provide me with dinner.
Usually the arrangement is that I would sing for my supper, but,
in fact, you're going to sing for my supper.        [Laughter]
        We're in a very, very comfortable and lovely house, on a
very warm evening, with a Santa Anna wind blowing, and no air-
conditioning, which feels fine to me.      She thinks it's warm.    For
November, it seems fine.      Los Angeles is a home of some years
now, but it wasn't where you started.      So   why don't you tell me
about your background.    You were born, I believe, in Mexico?


Lifshitz:     I was born in Mexico City, and I was raised in Mexico
City.     I went to medical school in Mexico City, and it wasn't
until I finished medical school that I came to the States.
                                                                         2

Mullan:      Why don't you tell me a little bit about your

background.      From what little you've told me, you're of well-
traveled ancestors, and the name "Lifshitz" does not jump off the
page as a typical Mexican name.


Lifshitz:      That is correct. My four grandparents actually were

from Europe.     My father was brought to Mexico by his parents when
he was very young.     He was nine years old, and he grew up in
Mexico.      It was not until he retired that he moved to the States,
when both of his daughters were living here.       My mother was born
in New York, and was taken to Mexico when she was three months
old.   So,    even though my genes are not Hispanic, both of my
parents really grew up in Mexico.


Mullan:      The family came from central Europe, from Russia?



Lifshitz:      From Russia, primarily.



Mullan:      Early in the century?


Lifshitz:      The four grandparents.    On my father's side, it was in
1928, when they were supposed to have arrived in the United

States, but at that time the quota was closed to New York, and
they ended up in Mexico City.        About a year later, the quota was
opened, but it was the time of the Depression. My grandfather
had started a business.     My father and his brother were going to
                                                                        3

school, so it was like, moving to yet another country--they
decided to stay there.
     On my mother's side of the family, they were born in Russia,
but they left--1 don't remember exactly when--to live in England
for a while, and then New York.       And they lived in New York, and
for business reasons, my grandparents, on my mother's side,
decided to go to Mexico.    At the time when my mother was born, my
great-grandparents were still living in New York, so she was born
in New York, even though my grandparents were already living in
Mexico.
     My parents' education was in Mexico, and even though they
had a European background, they had the identification with the
Hispanic culture as well.


Mullan:     Was there much of a community of--it would be Russian

Jews?     Your parents, grandparents, all were--


Lifshitz:    My grandparents tended to, I think, congregate more

with people from the Russian Jewish community.


Mullan:     And there was one in Mexico City?


Lifshitz:     It wasn't very large.    It wasn't very large, but a lot

of people that had--1 mean, probably, for the same reason, had
been unable to come to the United States, because I don't think

that in Russia they had heard about Mexico at that time.       They

ended up in Mexico, and they kind of helped each other.       The
                                                                          4

people that arrived there when they were elders had difficulty
with the language, and that also made it kind of more comfortable
to be with people that spoke their own language.        I was
surrounded by all kinds of languages when I was growing up,
because it was not only the Russian Jewish community.           I mean,
there were people that had come from Poland, there were people
that had come from Hungary, from all kinds of places, so I would
be exposed to a lot of languages.


Mullan:     Other than English and Spanish, were there any that you

used?     Did you speak either Russian or Yiddish or anything else
at home?


Lifshitz:     Well, at home, we really spoke Spanish.    With my

grandparents, on my mother's side, we spoke English.       My father
used to speak Russian with his mother, but we didn't speak
Russian.     We learned French, and when we went to high school,
because we went to a Jewish high school, we also started learning
Hebrew and Yiddish, which we learned, and we had throughout high
school.     The other language that I chose was French.


Mullan:     Growing up as somebody who did not look or, by last

name, seem Mexican, how well were you accepted?    What is the
Mexican culture like, in terms of its acceptance?       In the United
States, there's been so much mixing and assimilation of other
cultures, including particularly Jewish people from Europe.          In
Mexico, my impression is, that's much rarer.
                                                                    5

Lifshitz: Yes.   In terms of sheer numbers, the Jewish community

was not very large, and even though there were a lot of Europeans
that were not Jews, a lot of Spaniards, a lot of Germans, a lot
of Italians. There's even a German school and a French school.
When your skin was lighter and your last name was not typically
Hispanic, in certain circumstances you were made to feel that you
were not exactly like them and that you didn't belong 100
percent.
     Nevertheless, for example, when I started kindergarten and
grade school, my parents sent me to an American school, because
in this American school, we had kids from all over.   I had
classmates that were Japanese and some of them were American,
some of them were Mexican.   Different backgrounds, with the idea
that what was most important was that we're all the same,
regardless of where we come from, regardless of the language we
speak, regardless of the religion we choose to follow, and that
was the message that I got as number one.
     As we were getting to become teenagers, they wanted us to
learn a little more about part of the cultural background that we
had as a family, and the ancestors, and that's when they decided
to send me to a Jewish school. And, interestingly enough, when
it came time to go to medical school, the National University in
Mexico, the National Autonomous University in Mexico City, was
going through a tough time in that, when they were not on
vacation, they were having a strike.
     So there was a new university, which was a Catholic
university, La Salle University, just starting.   I passed my exam
                                                                      6

to go to the National University, but it was incorporated, this
new university, into the National University, so that we would be
doing the same kind of program, plus other things.     And I went to
a Catholic university, although my diploma is from the National
University because I had to also present their exams and
everything.


Mullan:   Because it was on strike so much, that was the reason?



Lifshitz:   Yeah.   The university is a great place, but the

classes tended to be with very many students.   They were very
large classes, and, as I said, it was a tough time, because they
were having a lot of strikes, and this Catholic university
allowed me to be in a smaller group setting, utilizing all the
facilities that the National University used as well.
     And, by the way, they were also going through a change of
calendar, so I finished high school, which, in Mexico, you go
through high school, six years of high school, and then you go
straight to medical school, and it's a six-year program.    But
because of the change of calendar--they were changing from
starting the year in January to starting in July--there was a
nine-month period, in which I became a bilingual executive
secretary, because my parents wanted me to have a profession, and
they were afraid that if I was going to the medical school, I
would not finish, and then I wouldn't have anything.     It was not
customary, when I went to medical school in Mexico, for women to
go to medical school.
                                                                      7

Mullan:     Let's go back and trace that a little bit.    Where did

the idea of medical school come from?


Lifshitz:     I think it was a combination of things.    My mother

would have loved to have been a physician, and I think that deep
down, I must have either inherited that or somehow felt that.


Mullan:     Did she tell you that, or how was that manifested?



Lifshitz:     No, I learned about that through my grandparents when

I said that I wanted to go to medical school, but at the time
when my mother suggested that she would like to go medical
school, at that time, you know, women did not go to college,
didn't go to university. My grandparents thought that my mother
was going a little crazy, so it wasn't given a consideration.
      My parents were always very much involved with helping other
people, in every way, shape and form.     I think that medicine

allowed that, and I wanted to do something creative, and I
thought that medicine allowed me to help people and allowed me to
develop that creative side of me as well, because I believe that
it is the art of practicing that is based on science.


Mullan:     As a child, or as a high school student, was medicine in

your mind?     When did it firm up that that's what you wanted to

do?
                                                                       8

Lifshitz:     It was in high school.    Since you have to decide the
fifth year--you know, you have junior high, and then you have to
decide by the fifth year, because in the sixth year you have some
electives that are sciences.     I was initially a little bit
undecided between architecture and medicine, because I thought
architecture was very creative. Nevertheless, I wanted to work
with people, and that's when I decided. My parents tried to
persuade me, again, not because they didn't think it was a
wonderful profession, but because they were afraid that I was not
going to finish.


Mullan:     Persuade you against--



Lifshitz:    Against going to medical school.     They thought I would

not finish, and they also thought that, even if I finished, it
would be very difficult to practice and have a normal life--what
they considered a normal life.       They were right.   [Laughter] I
am very happy I did it.


Mullan:     The Catholic university that you went to--in your class,

what percent were women?


Lifshitz: At the National Autonomous University, the percentage

was very, very, very, very low.       I can't tell you exactly the

numbers, but I can tell you that in my group, when I graduated,
in my group there were only three women, even though it was a
small group.
                                                                       9

Mullan:     Three of?


Lifshitz:     I think that there were twenty-eight of us.    Because

we started with fifty, and then when we started clinics in the
third year, there were only twenty-eight left.


Mullan:     So you're talking, something like 10 percent were women.

Was that typical?


Lifshitz:     That was in my class.



Mullan:     Was that typical?



Lifshitz:     No, it was less when you take the National--


Mullan:     Less than 10 percent?



Lifshitz:     Yeah, less than 10 percent.


Mullan:     And now we're talking seventies? When did you graduate?


Lifshitz:     I graduated in '76.


Mullan:     Let's talk a little bit about medical school in Mexico.

What was it like, and when was it that you switched from National
to Catholic?
                                                                      10

Lifshitz:     No, actually, I started in the Catholic.   It was
incorporated into the National Autonomous University.      The way it
happened is that I took the entry exam to both of them, but it
was a new school that was going to be using the exact same
curriculum as the National Autonomous University.      We were going
to actually have the same professors for the clinic rotations,
and the diploma was going to be from the National Autonomous
University, because we were complying with everything, and we
were also going to be taking the written exam which they took, in
addition to an oral examination, for which they invited
professors from the National Autonomous University to quiz us.
It was quite exciting, quite a challenge.
     Among the things that we had that were different from the
National University is that they increased the number of
requirements, and one of the classes, for example, that we had to
take, was medical ethics, which was given by one of the priests,
which was fantastic. As a matter of fact, he asked me if I would
help him with a mass when we graduated.     He knew I was Jewish all
along, and I told him that I would be delighted to do that, but
that I wouldn't know what to do.     And he said that he would tell
me what to do, and I helped him, and it was just wonderful, a
wonderful experience.


Mullan:     That's great.   Medical school, as I understand it, in

Mexico, is somewhat less clinical.      It's five years, six years?



Lifshitz:     It's six years.
                                                                     11

Mullan:   How does it break down?


Lifshitz:    It breaks down, the first two years, you have basic

sciences, and even though you do have some rotations in which you
sometimes visit hospitals, like an introduction, it is not about
doing things the first two years.     It is about watching people
while you're learning your basic sciences.     Once you go through
your basic sciences, the third and the fourth year are your
clinical years, and then you go through your clinical rotations.
     The fifth year is what they call a pre-graduate internship,
meaning that you cannot get your diploma after four years.     You
have to do that year, in which, when I was there, there was no
choice in terms of straight medicine or straight surgical,
because it was pre-graduate. You rotated, and you had peds, and
you had psych, and you had medicine, and you had surgery, and you
had OB/GYN, and that was for a whole year.     For practical
purposes, you functioned like an intern here, but with the
supervision of the postgraduate intern and the residents.
     Then the sixth year is the social service year, and the
social service year, the greatest majority of people go out to
underserved areas, little towns, where there's nobody, really,
and they have to provide health care for those communities during
that year.   They get paid for it, but pay is very minimal, but it
really helps these communities, which otherwise wouldn't have
anyone.
     Then after that, you can get your diploma.    You have to,
obviously, take an examination.     You get your diploma, and then
                                                                      12

you can choose to practice as a GP, or you can choose to get
postgraduate training.


Mullan:     In terms of the first five years, the both basic and

clinical science, you've had an opportunity to work in and around
medical schools in this country.      How did they compare to what
you've seen in medical education here?


Lifshitz:     One of the things that happens when you go to a

medical school in a Third World country is that you do not have
technology as easily available.      So   the clinical aspect, the
history-taking, your skills, in terms of trying to get to the
diagnoses with your questioning and your exam, are by far more
emphasized.     The way you take a history in Mexico is more the
French style, which, even the way in which you write it down--
like here you start with chief complaint, then present illness,
and then past medical history, family history--the order is a
little bit reversed.    You start again with chief complaint and
present illness, but then you   go   on to family history.   It's
different, and it's very descriptive.       I remember that my
histories and physicals used to be so descriptive that someone
told me that they didn't have to see the patient, because I had
described it.    But it was part of the teaching.     The style was
different.    It was very clinically oriented.
     I think that probably in terms of basic sciences, it is more
emphasized in this country, and in terms of technology. When I
was in medical school, of course, we didn't have MRIs, because
                                                                  13

they were not even available in this country at that time, but

the technology that was available was not available for everyone.
You didn't have as many machines, you didn't have even things
like, for example, disposable needles and syringes to draw blood.
     Here, it's always been, you get a new one, you know, a
brand-new one, you open it, that's it.   Over there, we used to
sterilize syringes and sterilize needles, and sometimes the
needles were so worn out that it was hard, and it hurt to try and
stick the person.   Sometimes, depending on where you were
working, you might have a pole to hang your IV, but sometimes you

would use something from the window.   You had to improvise.   You
had to be very creative with what you had and what you could do.
     There were, like everywhere in the world, people who could
get their medications, people who could not get their
medications, people who had the sophistication to understand what
you were doing, and the ones that didn't.    But because it was
much more widespread, the "have-nots," it was not unusual to
spend more time explaining to them, or trying to find a way in
which maybe you can call the intern that is at another clinic to
see if they had some extra bottles of whatever.
     It was, I feel, a little more humane.    I believe that here,
science and technology is fantastic and I think it's extremely
important, but on the other hand, there is a certain coldness and
there is a certain fear because of the way the patient-physician
relationship has been established through the history of lawsuits
and lawyers getting involved.   I do believe in protecting the
                                                                        14

patient, but sometimes, if you go overboard, that can actually I
think, deter from care.


Mullan:     Tell me about your social service year.     Where did you

go for that?


Lifshitz: When I was doing my internship, there was one

physician who had been trained here in the States, in Boston, who
was an internist, and whom I really respected very, very much.
Even though the pre-graduate internship is pretty grueling in
terms of the schedule, I always felt that he was someone that was

up to date, and was always reading the N e w England J o u r n a l of

Medicine, and I always found a way to spend a little time and get

interested in some of the projects that he was interested in.
     So   he was doing some clinical research with psychiatric
patients, and I started doing a little bit of clinical research
with him.    So,   for the social service year, he requested if I
could stay to continue doing that.      I ended up staying at the
hospital and working with him, so that we continued with those
projects.    He was also an endocrinologist, and the studies that
we did had to do primarily with endocrine disorders in
psychiatric patients.     It was a time when, universally, they did
not check patients that were depressed, for example, for thyroid,
for hypothyroidism, so that's one of the projects that we had.
It was fascinating, because I had a chance to experience clinical

research beyond what you're exposed to in medical school.
                                                                   15

Mullan:   What was the prevailing attitude, both among your

classmates and in the medical school setting in general, about
specialism versus being a GP, which I gather was the dichotomy of
choice? Describe for me what the dichotomy, or what the
attitudes and options were in the generalist/specialist
opportunity.


Lifshitz:   When I was going to medical school in Mexico, the

availability of residency positions for specialty training was
not humongous.   It was not by any means as restricted as it is
now, meaning, that at that time, if someone really wanted to get
any kind of specialty, they might have had to maybe wait a year
or so, but they could have gotten it.   Nevertheless, the striving
to become a specialist was not really that great.   Being a GP was
something that a lot of people felt very proud about, and a lot
of people that came to the National Autonomous University and
rotated through the same hospitals that I rotated through
actually ended up going back to the places where they came from,
and a lot of them were not from Mexico City.   They came also from
large cities, but there were not very many good medical schools.
     There was the military school; there was a school in
Monterey, which was very good.   The school in Guadalajara was
really looked down upon.   It was the school where the "gringos"
went, when they could not get into a medical school here.     That,
I understand, has changed, and I think that they have really done
a lot in terms of the quality of that university, but when I was
in Mexico, it's one of those universities where, you know, people
                                                                       16

preferred not to go if they were Mexican.      So   that we had very
many people coming from all over Mexico, ready to go back to
where they came from.


Mullan:     And were they planning to become specialists?



Lifshitz:     Some of them were, but I would say that the vast

majority didn't.       The other issue that I'm sure had something to
do with it, was the fact that a lot of the people that went to
medical school, like a lot of the people that went into other
professions in Mexico, were people that came from poor families,
and actually, even though education was not expensive--and it's
still not expensive, if you compare it to United States
standards--it might be expensive for someone that has just enough
to eat, because everything else is expensive.       But when I went to
medical school, what you had to pay the National University was
the equivalent to about, I think, fifteen dollars a year.        I
mean, you had to buy your books and stuff, but it was really very
inexpensive.     So   a lot of people that did not have a lot of money
were kind of eager to start helping their families or to start a
family themselves.


Mullan:     So they would be ready to go back and not do more

training?



Lifshitz:    Exactly.
                                                                       17

Mullan:       My understanding is, then and now, that the default

specialty is being a GP.       In other words, if you don't do more
training after your social service year, and you go into
practice, you go into practice as a GP.


Lifshitz:       That's correct.



Mullan:     Anyone, essentially, who goes on for further training,

is becoming a specialist.


Lifshitz:      Exactly.



Mullan:       So that the specialist-generalist division is not only

one of clinical proclivities, but it's one of advanced training
and rudimentary training.


Lifshitz:      Exactly.   And I do have to say that people that went

beyond being GPs did look down on people that were "just GPs."


Mullan:     Tell me about that, just to understand the mind-set.

That's what I'm anxious to hear about.


Lifshitz:      When you finish medical school in Mexico, you don't

become a "god," like it used to be in the States, (because it's
no longer that way).      But it used to be that when you went to
medical   ,   school here, it was something very, very, very special.
In Mexico, if you went to university and became a doctor, it was
                                                                    18

great.    If you become an accountant, it was great.   If you became
an architect, it was great. And everyone has a prefix before
their name, so it's not just Dr. So-and-so, it's "icenciado" for
other careers, or "architect," or "accountant   ."
     So   everybody had something that would basically describe
them, and being a physician was not something necessarily above
the others.    Some of the people that elected to stay at the GP
level in some ways felt that, yes, we needed specialists, but the
ones that wanted to go beyond that were in some ways elitist.
They had, I guess, in some ways, an ambivalence about, yes, it
would be nice to learn more, but why do you need to learn more if
you can already take care of people? And we don't need as many
specialists.
     The other thing is that you did not have the pyramid-type
situation in Mexico.   So   if you wanted to become a specialist,
once you started, you knew that you were going to finish.    You

didn't have to compete for that position.    And like here, the
academicians always felt that they were the best, and anybody who
was not in academics was not good enough.    And the people that

were in clinical practice always felt that the ones that were
only in the lab and doing research really didn't know what was
happening in the real world.


Mullan:   What were you thinking about at that time?   How had you

envisioned your career as you left medical school?
                                                                              19

Lifshitz:        I was thinking about specializing, because I felt that
I was not really ready to see patients and to have that
responsibility in my hands--without a little more supervision--
although I did want to see the person as a whole.             So   I knew
that, eventually, I wanted to do primary care.              I like clinical
research.        I like the scientific side of it.     So   it was exciting
for me to combine both.       But I saw myself as someone who would
always see the patient as a whole, so that I would not like to
be, for example, the super-specialist of the right hand.
     In terms of coming to the States, it was not something that
I set off to do when I was going to medical school.             When I was
working with Dr. Manzano, who is the physician that I was
referring to earlier, since he had trained here, he said, "You
know, you should go get your postgraduate training there, because
there are certain opportunities that are available there, that
you wouldn't have here.       And then you can come back, and I'd love
for you to come back and work with me."         So   that was my idea when
I came here.


Mullan:     How did you pick New Orleans?


Lifshitz:     It was very interesting.      I didn't know much about the

matching.    .    .well, I didn't know anything about the matching
program.     I knew I had to take the ECFMG to come here, so I took
it to see what it was all about, and I passed.          So    I thought,

"Okay, you passed, you finished medical school."             This was during
my social service year.       So   I said, ''1 guess I should probably go
                                                                     20

and interview at a couple of places, and then choose which one I
want to go to."   As it turns out, it's not that easy.    This
doctor that I was talking about earlier had trained in Boston at
the Joslin Clinic and also--I've forgotten the name of the other
place, because I went to the Joslin Clinic.    Joslin is affiliated
with--1 don't remember the name of the hospital right now.       . New
England Deaconess.     The New England Deaconess.
     So   I decided, I respected him so much, he had gotten his
training there.   I wrote a letter to the New England Deaconess.
I didn't hear anything from them, so I went ahead and I called
them, and I asked to speak with the head of the education
department, whatever.
     Somehow I got through, and he said, "Well, did you join the
matching program?"
     And I said, "What's the matching program?"
     He explained to me what it was, and he said, "Without the
matching program, we really can't even get you an appointment to
come visit us, because we won't take you."
     I said, "Well, even if I were to join the matching program,

I would like to see what you're all about, to see if I'm
interested in matching with you in the future.      Is there a chance
that I can come visit?"     I guess he realized that I was so
decided, that he gave me an interview.    I went there, I went for
a visit, I liked it.
     But then I learned a little more about other things, and I
hadn't written to any other place.    Actually, several of the
physicians that had trained with Dr. Manzano were living in New
                                                                      21

Orleans at that time, and at Tulane there was an endocrinologist
and a hypertension specialist who were clinical pharmacologists,
and they had an excellent program at Tulane.
     So what    I decided is, "Okay, what I'll do is, I'll go, start
with them, while I learn about the other hospitals, and apply to
the matching program, because I don't want to take just whatever
everybody else doesn't want."        I wanted something good.   It was a
two-year program.     So   I started with them and committed to one
year.
     At the beginning, I was participating as a fellow in the
program, but I wasn't getting paid because the opening was not
funded by the university. After I had been there for four
months, I started getting paid because they thought I was doing a
great job.     The peso had devaluated in Mexico, and, financially,
things got a little tougher, so I started getting paid.         I
decided to stay there for the second year, to complete the
program, because I was enjoying the program and was really happy
with the education I was getting and the opportunity to complete
a fellowship.    And then at that time I learned about the
different residency programs and hospitals, the matching program
and what I had to do to apply.


Mullan:     But that was not formally a residency.



Lifshitz:     It was a fellowship.    It was actually a fellowship at

Tulane and the reason they ended up granting me the fellowship
position was because I had the pre-graduate internship, the
                                                                         22

social service.       I had worked with this doctor that they knew.
So that I had really had two years of clinical training before
starting the fellowship.


Mullan:       But then at the end of that, you decided to go back and

start a whole new medical training?


Lifshitz:       Internal medicine.   I wanted to be an internist.   No

matter what, I wanted to be an internist. As I was getting close
to finishing my internal medicine training, and I actually
requested Stanford as my number one, and Ochsner Medical
Foundation as my number two, because during my training in
clinical pharmacology, I had met a lot of physicians at Charity
Hospital who were from Ochsner, and it had what I thought was a
very good program.      LSU was also there, but I really liked

Ochsner   .
     Stanford didn't even give me an opportunity because I was a
foreign medical graduate, and Ochsner took me right away, because
I had met several of their physicians and there was a
relationship.      It was great training. At that time, clinical
pharmacology was something that was not being done in Mexico, so
I thought, again, I wanted to go back to Mexico, and I like to
start things.      I thought it would be wonderful if I could start a
clinical pharmacology program in Mexico, with the government, at
the C'entro Medico, which was kind of like the main general
government hospital in Mexico City.       Starting a serious clinical

pharmacology program, and then do it all over Mexico.
                                                                    23

       I had spoken with the people at Tulane, and they were really
very eager and interested in helping me, but when I went to speak
with people in Mexico--at that time, I looked very young, I was a
woman, and they listened to me very attentively, and when I
finished, they said, "It sounds very interesting.    Obviously
you're Mexican.    You went to medical school here, so you can come
and practice any time, but the studies that youIve done abroad,
we really cannot recognize."
      So   at that time, my heart was broken, and I decided, "Okay,
what do I want to do?"    Obviously, I always had this special love
for endocrinology, because my mentor had been an endocrinologist.
So   I was accepted at NIH [National Institutes of Health] to do a
fellowship, and it was going to be on the effects of the
neuroendocrine system in psychiatric illnesses, which is
something that I did during my social service time, and it was
quite interesting, and I thought I should pursue it further.
      But what happened at that time--my sister was already living
in San Diego, and I come from a very tight family, and throughout
this whole time, I would speak with my parents once a week, and
they would come visit me, and whenever I had a chance, I would go
visit them.    My father was starting to think about retirement,
and they started saying wouldn't it be nice if the whole family
lived in the same place again.    I told them that, if I found a
good endocrine program in San Diego, I would move there.    I was
lucky to be accepted under Dr. Gordon Gill at U.C.S.D., where I
ended up doing my endocrine fellowship.
                                                                    24

Mullan:     What did your father do?


Lifshitz:     He was an engineer by profession, although he also

finished the Conservatory as a pianist, but that was just a
hobby.


Mullan:     He worked for an engineering firm, or he had his own

firm?


Lifshitz:     No, he started working for someone, and when he was in

his mid-twenties, he started his own business, while he was still
helping his dad in his clothing business. My grandfather was
also an engineer, by profession, in Russia, but he could not work
as an engineer in Mexico.     He had started something to do with
shirts.
     So my father was helping him.     He was teaching.   He was
finishing the Conservatory. And then he decided that he wanted
to start his own company.     It was not a large company, but it was
his company. When I said that I wanted to go to medical school,
my father was dying for me to go to engineering school and work
with him.     I only have one older sister, and she was totally
artistically oriented, nothing scientific, or anything like that.
My father knew that I could become an engineer because I was the
one who always helped him around the house.    But I could not
picture myself as an engineer.


Mullan:     So you hooked up with them in San Diego?
Lifshitz:     Exactly.


Mullan:     And did a year of endocrine there?



Lifshitz:     Exactly.   At UCSD.   And then basically, as things

happened, I met someone, I got married, and moved to Los Angeles.
And by that time, I had already decided that I was going to stay
in the U.S., in the sense that I felt that there was a huge need
in the Hispanic community because the availability of Spanish-
speaking, culturally sensitive physicians was really limited for
the number of people that were living here.       I've always liked to
get involved with the community.       It was either the American
Diabetes Association or it was the AIDS Commission.


Mullan:     Before we go on and talk about what you did, now that

you're grown up and going into practice, the years between ' 7 6
and '80, when you were in training, and essentially still had a
twin identity, or a dual identity--Mexican and American--what was
your feeling about the reception that you got in this country,
both in terms of exams, in terms of institutions, and in terms of
fellow physicians, and the medical structure? Were you well-
accepted, were you not well-accepted? What was it like to be an
international grad, arriving in the system?



Lifshitz:    It's kind of a dichotomy, but I must say that I've

always been an optimist and I've always looked at the good side.
For example, not getting an interview at Stanford because I was
                                                                  26

an international medical graduate was a big disappointment for
me, because I felt that I should be valued as an individual.
Other than that, I felt that I had been well accepted.
     There are always people who are not very accepting of people
that are not identical to them, just like in Mexico, a different
skin color, or an accent, or Hispanic, or Jewish.   There are
always some of those people.   But I would say that, overall, the
reception was good, and I think that at that time, a lot of the
people that I interacted with had had very good experiences with
international medical graduates.
     New Orleans was not a place where you have tons of
international medical graduates, but you had several
international medical graduates that had done a very good job.
The head of the nephrology department at Ochsner was an
international medical graduate, so that they had had good
experiences, and the competition was not as fierce as it is now,
so that, given those two factors, I think that, overall, the
reception was good.
     There were still some people that felt that somebody that
did not go to medical school here could never be as good, no
matter how much they tried, because those four years were not
like you do it here.   But there were other people who were open-
minded, and actually welcomed the approach of someone that came
from a different place.
     Just to give you an idea, my first grand rounds was on a

case of amoebic amebic abscess, which was like a big deal, and I
was sitting there thinking, "Hmm, this is interesting.    Grand
                                                                      27

rounds here.    And I've seen so many."   Those are some of the
differences.     I had the experience with parasites.   Some of the
things that came to my mind when we were seeing some patients, as
a first differential diagnosis were not necessarily the same as
those that the American-trained physicians always thought about.
And I think that, the longer I stay here, the more I realize.
And now, obviously, Chron's and diseases that I hardly ever saw
in Mexico, come to mind because I've been exposed to them.     But I
think that having had a different background and having had those
experiences enriches everybody.


[Begin Tape 1, Side 21


Mullan:     This is Dr. Lifshitz, side two of tap- one, continued.

     How about the flip side of it? As you moved towards making
a decision to stay in the United States, did you have any second
thoughts about Mexico, either in terms of opportunities that you
might be foregoing there, or obligations that you might have had
there, based on that's where you were educated, and that's where
you started your medical career?


Lifshitz:    I have to say that I always felt very close to Mexico,

and I was very grateful to Mexico, and I felt very Mexican.       When
I came here, I wouldn't have even considered becoming an American
citizen, because my background, my identity, the way I grew up,

my culture, was Mexican, even though if you look at my
                                                                     28

background, it's not 100 percent Hispanic.      Nevertheless, I felt
that loyalty.
     When I went back to Mexico and I wanted to give back, and
they rejected me.     I never felt like I was angry or upset at
Mexico.     I always felt I would sometime be able to help and
communicate with them, but I felt that I had a bigger opportunity
to help people here.
     Had I gone back to Mexico in the situation which was
originally planned, which was, with my mentor--he really wanted
me to go back and work with him, and I respect him immensely, and
he's in private practice--I would have immediately been able to
go back to work with a group of physicians which we had put
together and that were, and are, highly respected. He was very
well established.     I would have been able to really go back and
move up, earn a lot of money.      It would have been a && easier, a
    easier.     I kind of felt that there were more things that I
could do here with people that needed me more.      The people that I
would have been seeing in Mexico were people that could see any
doctor they chose.    Here, I could see people that maybe other
physicians wouldn't see.


Mullan:     Tell me about that.   Your career from 1982, '83, why

don't you sort of give me a synopsis of how it's developed, in
terms of your practice settings.



Lifshitz:    Initially, since I got married in Los Angeles and I
wasn't quite sure exactly how I was going to practice, there was
                                                                      29

an opportunity.       It was a time when all the clinics, the
emergency clinics, were kind of appearing everywhere.        The walk-
in clinics, not emergency clinics.


Mullan:     Urgent care?



Lifshitz:     Urgent care, right.   So   I had the opportunity to work

in one, with flexibility in my schedule, and I was moonlighting
at Kaiser, and also at Olive View.       The clinic started doing a
little bit better after a few months and they asked me if I would
be interested in being the medical director.       So   it was a
challenge, and I still hadn't decided exactly what I wanted to
do.    I knew that private practice was not what I really wanted to
do, and being in that setting allowed me to see a cross-section
of people.     I was at that medical clinic for two years.


Mullan:     At this point, you were seeing yourself more as an

internist?


Lifshitz:     Yeah.   Oh, definitely.    I've always seen myself as an

internist.     I mean, yes, I have my background in clinical
pharmacology.      During the time that I was in endocrinology, I did
basic research, but I decided that I needed to be with people,
too.   It's wonderful to come up with all the analysis of
everything that you've gathered, but the actual everyday working
with cells.    .   .contact with people was something I missed
                                                                           30

immensely, so that I knew that I could not be just a basic
scientist.     I needed to be with people.
        During the time that I was in this clinic, it was working
well.     But I was limited in the sense that even though I was the
medical director, everybody who walked in there had to have some
way to pay.     So   there was this part of me that wanted to help
people that couldn't pay, and being in that setting was not a way
in which I could do it.       I mean, I had to be on my own to be able
to do that, or to work in a government setting where basically a
lot underserved people would walk in.
        But it coincided that, about a year and a half after I had
started working in the clinic, someone invited me to go for an
audition for a television program, and I thought it was the
craziest thing.       I was not interested, but my friend, who is a
psychologist, was very interested in going, and asked me to go
with her.    And they selected me to host a thirty-minute program,
in Spanish, where people would call in with their health
questions and I would answer.        I really didn't know what it was
all about.     I thought it was all a j o k e .   This is Hollywood.   I

went to the interview. And I ended up being the host of this
program, which I started doing at lunchtime.          It was on an ethnic
channel, and it was thirty minutes of a call-in, live program.
That was the start of my media career.


Mullan:    What year was this?
                                                                               31

Lifshitz:     This was 1 9 8 6 .    What I became fascinated with was the
fact that people would call with all kinds of questions, and they
would write me letters, and I did not have enough time to answer
the letters on the air, so I ended up on weekends, writing, you
know, answering letters.            I felt so bad for these people.   So I
said, "Okay.      The medical clinic where I'm at right now does not
allow me to do what I want to do in terms of helping people.               If
I end up in a very rigid structure, like a government position, I
won't have the flexibility to do a program like this, so I have
to find some way to combine it."           And that's when I decided,
"Well, I think I'm going to have to start private practice."
     So I started private practice.            I still do not like it.     I
do not like the administrative part.            I do not know about
billing.     It's terrible but as long as I have enough to cover my
expenses and, hopefully, bring some money home, I'm happy.               I'm
never going to be rich.            But I have the ability, which has been
decreasing because of the changes in health care, to see someone
who might not be seen somewhere else, or to see their
grandmother.


Mullan:     So what is practice like?        We'll come back and talk

about your show-biz career, but how has the practice developed?
Are you on your own?


Lifshitz:     I'm on my own.        Yes, I've always sublet space from

someone else, because I have always wanted to have the
flexibility of being able to move to a different place if a
                                                                      32

situation changes.    At the beginning, I was moonlighting because
I wasn't getting enough income from my private practice income.
I just had an answering service, and I would make my appointments
myself.     Quite interesting.   I started without any knowledge in
business--1 still don't have knowledge in business--and it was a
mom-and-pop operation.     I mean, when I look back, it's amazing
that I survived, but that's a very long story.


Mullan:     What have you got now?



Lifshitz:    Right now, I have two people working for me.    I'm

still subleasing space.    The place where I'm at right now, there
are four other physicians and myself, and each one is in solo
practice.     I'm the only one that speaks Spanish, in terms of the
physicians in the group, but the two people that work for me are
bilingual.
     About 50 percent of my practice is Hispanic; 50 percent of
my practice is Anglo.    Because of the AIDS epidemic in L o s
Angeles and the fact that, at the very beginning, a lot of
physicians did not want to see AIDS patients, and especially if
they were Spanish-speaking, they were more limited in terms of
the physicians that might be able to help them.     I started going

out to the community to talk about HIV and AIDS, and I started
getting a lot of referrals for HIV.     Many were Medi-Cals, didn't
have any other kind of coverage.
    My practice is very eclectic.      I get the lady that lives in

Beverly Hills & her housekeeper.       I get a prostitute, an IV
                                                                       33

drug user, an alcoholic, and I get a lawyer.        They all sit in the
waiting room.     Every time that I've moved--because I've had three
offices since I started, meaning that I've sublet from three
different people, and all of them have been wonderful.        The main
reason for moving from one to the other has been financial, in
terms of how much I've had to pay for the place, or the help that
I would get--the support that I would get.     But they've all known
that my practice is very eclectic, and that they could have
anvthinq happen in the waiting room.     Like one guy that came in
drunk, and we had a little scene, and we had to call the police.
But, you know, it happens.


Mullan:     More women than men, or mixed?



Lifshitz:     I would say about 60 percent women; 40 percent men.      I

have a lot of teenagers also, which I love.        I love teenagers.
Because I've been in private practice since '86--in practice
since '84, if you consider the clinic being practice, and the
moonlighting--1 do have patients that I've been following for a
long time, and I'm starting to get to know their families.
That's the kind of medicine that I like, and that's in some ways
what is very distressing to me about managed care.


Mullan:     What is that doing to your practice?



Lifshitz:     First of all, it is limiting the number of patients

that I can see for free, because I still have to pay rent, and I
                                                                       34

still have to pay my staff.     I don't just work because I like it.
I do need to make a living.     So   it's limiting that, and I don't
like it.


Mullan:     Describe to me how it limits that.



Lifshitz:     It used to be that anybody who was Medi-Cal, that

called my office, would get an appointment without any problem.
Anyone that was seeing me and I was taking care of them for free-
-if they had a relative or whatever, a friend, that was sick--
they knew they could call and I would see them.      Now I have to
limit that, because the reimbursement rate for Medi-Cal is so
little, sometimes it's ridiculous.


Mullan:     So is it Medi-Cal in particular that's pinched you?



Lifshitz:    No.   It is managed care in the sense that the idea of

managed care is that you have to have a certain volume of
patients to be able to get a certain income a month.      I cannot
see a patient in 8 to 10 minutes.      I am not a "volume" doctor.
To practice good quality medicine, you need to spend time to talk
with your patients, to examine them.      I have never had a problem
in terms of having patients, but if your HMO practice grows to
the point where you have a lot of people, that can be a lot of
money, but I do not believe in treating patients differently,
whether they're HMO, whether they're cash, whether they can't

pay, or whether they have indemnity insurance.      Even a patient
                                                                     35

that comes to my office is treated exactly the same.     Where I
have to look at the difference is:      do I have to send them to
this certain lab because they're HMO?     Do I have to get an
authorization, or can I get him medicine samples for this?      This
is very time-consuming and the paperwork and bureaucracy is
frustrating.


Mullan:     If I understand, you've signed up with a number of HMOs,

so youlre a provider.


Lifshitz:     There is only one organization, which is a Physician

Hospital Organization, which has several contracts with HMOs,
through which I am working within the HMO system. It is Cedars-
Sinai Health Associates.


Mullan:     But the reimbursement that you get for those patients is

more modest than in the old days when you could charge indemnity
insurance, so that gives you less margin to play with in terms of
treating poor patients?


Lifshitz:    No, it goes beyond that.   It's not only the money you

get.   It's the paperwork and the bureaucracy that you have to go
through.


Mullan:     But how does that curtail your treating?
                                                                    36

Lifshitz:     Because I'm spending longer hours, and the longer

hours are not being reflected in necessarily better quality of
care or more patients.     Most of the time it's paperwork, and it's
not only the HMOs, it is also the other insurance companies, in
which you have to fight--you know, write letters to get paid for
certain things.     So in that sense, the changes in health care

have done that.     When you get less reimbursement per patient, you
do have to limit the number of people that you can see for free.


Mullan:     In terms of HIV-positive folks, how have you felt about

treating them?     You've mentioned it's been an important thing to
you.   How many do you have?   How do you stay abreast of the
confusing domain of HIV therapies?


Lifshitz:     Well, I would say that right now, probably about a

fourth of my practice--it used to be a little bit more.


Mullan:     So that really makes you an HIV practitioner, for all

intents and purposes, right? Because that's far higher than the
ambient population.


Lifshitz:    Exactly.



Mullan:     So people are seeking you out because they know that

you're competent and available and interested in HIV?
                                                                         37

Lifshitz:     And interested, exactly.      And if you think about it,
when it comes to HIV, obviously, being an internist, I do not see
myself as a know-it-all.        So   I try to go to meetings, read
journals, ask questions of people that I trust, learn from the
cases that I have.        But if I have someone that has an
opportunistic infection that requires hospitalization, for
example, I will ask an infectious disease specialist to see my
patient as well.     So    I'm not really an infectious disease
specialist. Of course, there are certain things that become
pretty standard that you follow.
     I do believe that HIV eventually is going to become like
diabetes or hypertension, where the primary care doctor can take
care of most of the problems, and it's just when you have
something special that you need to get a specialist.
Emotionally, it's very draining, because you get a lot of young
people who die, and that is very draining.


Mullan:     Are you seeing more intravenous drug use related to HIV

disease, or gay-related disease?


Lifshitz:     The greatest majority in L o s Angeles is through man-

to-man.     But in the Hispanic community, you also have a lot of
heterosexual.    More than coming from IV drug use, it comes from
extramarital, or previous encounters, man-to-man, but then,
because of the cultural differences, it is not well-accepted.
Homosexuality is not well accepted among Hispanics, or sometimes

they believe that they have to fulfill their role by getting
                                                                          38

married and having children, and then they really have to go
outside of that environment to fulfill their other needs, and
that's the way in which it gets passed on.


Mullan:     Are most of your HIV patients male, or mixed?



Lifshitz:     The greatest majority are male, because it's still

predominantly male in Los Angeles, but I have several women.          I
would say that about 6 0 percent of them are Anglo, and about 40
percent of them are Hispanic.      You tend to see more new cases in
Hispanics in Los Angeles, as opposed to Anglos, because Anglos
have, in some ways, heard the message and are protecting
themselves a little better.      This is reflected in the statistics
where it's plateaued.     Although with the younger population, I'm
not sure, with the teenagers.


Mullan:     Where do you see your pract,cre   headed? Are you going to

be able to maintain a solo practice, or are you going to get
bought up or consumed in somebody's integrated system?


Lifshitz:     I'm not ready to work for an HMO.      I'm not ready,
again, because I do treasure the flexibility that I have--not
only in terms of the patients that I can see, the time that I can
spend with them, but also in terms of the other interests that I
have, so that I do not see myself right now working for an HMO.
     I do not believe that the future of practice, the way I like
to practice will be feasible for me.          I believe that there will
                                                                      39

always be solo practitioners that will do very well, this is
universal.    Other countries, where they have socialized medicine
and other systems, there have always been physicians that have
been in private practice and have done very well.       I don't
believe that my future as a solo practitioner, doing all the
things that I like to do, is necessarily feasible.      Group
practice is something that is appealing to me.    I'm also a little
tired of covering, being on call every day, weekends, so it would
be something nice.    But I would love to be in a group practice
with people that have the same philosophy and the same ethics
that I do.    That is, I am not against making money.    Obviously,
we all like money, and I like to live comfortably.      But I want
the group that I join to feel the way I feel, that the patient
comes first, no matter what--a payer or the non-payer.      The
patient comes first, and you have to work within the constraints
of the system.    I mean, it's just like if an HMO patient does not
have coverage for removal of a little skin tag, I'm not going to
fight for that.    That's cosmetic, that's not going to harm the
patient.    But if the patient has something medical, which might
be expensive, but that he really needs, to receive adequate
treatment, I'll fight for it.


Mullan:    What about your role as a primary care provider, as they

say these days?    Is that changing? Both in terms of how you're
treated or what attitudes your patients have, as well as how you
see yourself, is that changing, or is that unchanged?
                                                                       40

Lifshitz:     I've never seen myself as better or worse than any

other physician just because I've chosen to be a primary care
doctor and not a super-specialist.      I never wanted to be a
neurosurgeon.     I was very happy being an internist.       I feel I've
been an internist all my life, and in terms of the perception of
other people, I know that the super-specialists have always
looked down on us.     Right now, in some ways, there's this
competition--which is very uncomfortable--in which they look at
primary care providers as the gatekeepers.


Mullan:     How does the gatekeeping function, to the extent you're
doing it, impact on you?     Do you find patients are disgruntled,

or other physicians treat you differently, better or worse, worse
or better?


Lifshitz:     Because my practice has never been based on physician

referral, I've always interacted with other physicians as
colleagues.     They've never made a big deal about trying to get me
to send them patients, or vice versa.     So   I have good
relationships--it really hasn't changed.
        In terms of patients, there are a few patients that do not
like the system, who might be unhappy, in spite of the
explanation sometimes about the need to get the authorization for
a referral, when it is indicated, or the fact that I can treat an
otitis externa or an otitis media, and that an ENT referral is
not necessary.     If the person doesn't get well, obviously I refer
them.     But I am qualified to treat many problems that HMO
                                                                      41

patients think require a referral.     I think that if you establish
a good physician-patient relationship, that is not a problem.
The problem is when you don't have the time to do that, or when
you have patients who buy a Volkswagen and want to get Rolls-
Royce treatment.    And then no matter what you do, they won't be
satisfied.     If they were accustomed to seeing a specialist for
anything and they now want their PCP to write them a referral
whenever they call with the flu, they won't be happy with the
response.    Many times I have to spend a long time explaining the
system and what they're covered for, and what the mechanism is.
So   in a lot of ways in HMOs, the perception of the public right
now is that sometimes the primary care provider is the adversary.
And this perception is obviously a barrier in the physician-
patient relationship.


Mullan:     But are you experiencing that resentment from patients?



Lifshitz:     From some patients, sometimes, yes.   Very frequently

you get calls from people who have never met me, that say on the
phone to my assistant, "I'm looking for a new primary care doctor
because the one that I had before was not providing me with the
care that I wanted.     I want to know the referral policy of the
doctor, and if I will be seen the moment I call."
      I've had patients who have wanted to come and visit me to

get to know me before they actually sign up with me--which makes
a lot of sense--but, financially, I can't afford to do it. At
the beginning I said, "You know, it makes a lot of sense."     But
                                                                    42

if you're already limited in terms of the time you have to see
the patients that you are taking care of, you can't just spend
forty minutes with someone who wants to get to know you, and
frequently wants free medical advice in the process--advice for
which you're legally liable.
     So I'm not loving the way the system is going.    I don't

believe that physicians are the enemies.    I do not believe that
primary care providers are the enemies.    And, by the way, I have
a lot of respect for anybody who does mvthing--from cleaning the
street to being President of the United States--but I do believe
that there are certain differences in terms of the ability of
someone to perform certain tasks.   And I do believe that
education and experience allow you a certain ability to treat
certain things better than when you don't have them.
     I'm not in any way implying that anybody that has more
schooling is necessarily better than someone that does not have
schooling.   There are good doctors and bad doctors, just like
there are good accountants and bad accountants, and good lawyers
and bad lawyers.   But I do believe that in the financial race and

the problems with resources, sometimes we are disregarding
certain differences.   I mean, if it were not necessary for
someone to go to medical school to prescribe medications, and
psychologists could prescribe medications by just becoming
therapists, then why do we have psychiatrists?    If optometrists

don't want to go to medical school, for example, but do want to

prescribe, and ophthalmologists only need to go to medical school
to do surgery, then why do we have the system that we have?      And
                                                                    43

why are we switching away from it?    Training and education
matter.
       I don't believe that the switch is because we have found
that we can provide better health care by letting people do
certain things that they didn't do before.    I think that what
we're saying is, "Well, if we just have this much money, then
maybe we won't do a great job, but that's all the money we have."
And then, you dress it up as though, "Oh, it works.    It's just as
good."    I think that there's a little schizophrenia in the
system.


Mullan:     I know you've been active, increasingly, with organized

medicine at the state and national levels, and in Los Angeles,

too.   LACMA Physician is a publication of the Los Angeles County

Medical Association.    "What does the Hispanic patient expect from
her gynecologist?" What was the answer to that?      [Laughter]


Lifshitz:    You know, it was very interesting. When they asked me

if I would write that, I said, "First of all, I'm not a
gynecologist.    Second, I think that Hispanic patients expect what
other patients expect, and that is concern, caring, respect."
And the gist of what they wanted me to write in that article was
the fact that due to some cultural differences, for example, if a
Hispanic patient goes to the doctor and the doctor doesn't touch
them, it's almost like they didn't really go to the doctor.       It's

kind of like part of what's expected. And sometimes, for
example, with an Anglo patient, it could happen that if you
                                                                       44

become too touchy-feely, they might feel that you are going
beyond your limits.


Mullan:     The expected role.



Lifshitz:     Exactly.   And yet these are some of the cultural

differences.     So   I talked a little bit about that--and there are
some differences--because of my upbringing.       Some things that, I
have to say, I did not understand, having grown up in Mexico and
gone to medical school in Mexico.      Until I came to the States, I
did not realize the differences between the way men and women
were treated,     in terms of the opportunities in work settings and
stuff like that.      I didn't believe that there was any kind of
discrimination while I was living in Mexico.


Mullan:     In Mexico?



Lifshitz:     Yeah.   I mean, so what if I was in medical school and

the men wanted coffee.      I served coffee.   Big deal.   You know,
what's the problem?      I never saw it any differently, because
that's the way I grew up.      It wasn't until I came here that I
started realizing that there were some differences.


Mullan:     Because there were differences in Mexico?



Lifshitz:     Exactly.   Meaning Latinos and the role of the Latina.

And the role of a woman.      And the role of a woman physician. And
                                                                        45

then you come here and you start looking at some differences, and
you realize that there are differences that you had never
noticed.    When you are in the middle of the forest, you only see
the trees around you.      And that's one of the beauties of coming
from another health care system, from another country, from
another culture, so that you can see some of these differences.


Mullan:     Perspective.



Lifshitz:    Exactly.   And what happens.   .   .I don't believe that

only Hispanics should treat Hispanics, or only women should treat
women.     That would be very narrow-minded, and I don't in any way
believe that.    But I do believe that we can learn from women how
to treat women.     I can learn from men how to treat men.     I can
learn from Chinese how to treat Chinese patients, and I think
that that's one of the great things about America.


Mullan:     The International Medical Graduate Conference within the

AMA [American Medical Association], the IMG organization, I don't

have the name right.       What is it called?


Lifshitz:    This is interesting.    It used to be FMGs, and just

like with "blacks" and "African-Americans" and "Hispanics" and
"Latinos" which became kind of "politically correct," they
switched it to IMGs, which is international medical graduates.

It's the same thing.
                                                                          46

Mullan:     And what is the IMG section?


Lifshitz:     Well, they're trying to get a section right now.       It

started out as a task force, actually, and we are kind of in the
second wave of a task force that became an advisory committee and
now is a caucus.       They're trying to get a section, and the main
reason why all of this has happened is because, again, with the
financial changes and the competition, the IMGs, which at one
point were needed and appreciated, now are not needed, and a lot
of people believe that it would be great if they could just
disappear.
     When I was invited to be part of the IMG Advisory Committee
to the AMA, in all honesty, at the very beginning I wasn't
thrilled with the idea.       I felt that I was pretty much
mainstream--that I had been able to accomplish a lot of things--
and that I didn't know why it was needed.      Nevertheless, as I
learned the issues, I understand why it's needed right now.


Mullan:     Tell me.


Lifshitz:     The reason it's needed is because, just as I said

earlier, in terms of my application to Stanford, it was a
disappointment, but it was not the end of the world.          It's just
that once you are an IMG, it doesn't matter what you do.         You're
always an IMG.     For most people nowadays, being an I M G is like
being a second-class citizen, and the opportunities are not the
same--so much so that there are some insurance companies which
                                                                    47

are advertising, obviously not in writing, because it would be
unconstitutional, that they only have "good" doctors.    That all
of them are trained here.     I do believe the training here is
excellent, but I do not believe that anybody who is not trained
here could not be just as good or even better than a lot of the
people trained here.
     The perception has been, I think, more emphasized as
competition has grown, because there was a kind of an open-door
policy for anybody who wanted to come in.    And financially, in
some areas they needed physicians because it was cheaper than
having even nurses.    They started allowing international medical
graduates who might have not come in under different
circumstances. But, because they did not have enough people to
fill those positions, they let them in.
     So   it's a combination of things.   But what I find very
unfair is that there is a perception that is being perpetuated
without the background.     For example, there was someone at the
California Medical Association who came to present to the board,
who said that the Board of Medical Quality Assurance (which
recently changed its name), which is the organization that
overlooks physicians' work, wanted to request that IMGs get an
extra year of training.   And when she presented that, I said,
"What data are they basing this on?    Is it that you have more
malpractice insurance claims?    Is it that you have more patients
complaining? Are you having more complications from the patients
that are being treated by these physicians?    We are physicians.
                                                                          48

We should have scientific data.         It's not 'I feel this should
be. ' I '
            And she says, "Well, actually, no.   All that data,
malpractice claims are the same for the American-trained and
international-trained physicians.         Patients don't complain more.
No, it's just that "they feel" that with the changes in Medicare
and the changes in the number of residency slots and the
specialty positions and this and that and whatever, that IMGs
should not have the same opportunity."
            Well, I think that we need to separate a few things.   I do
not believe a non-American citizen who wants to come here, either
to go to medical school or to do training, necessarily has to
have the same opportunity as an American citizen, because I do
believe that countries need to protect their citizens first. But
I also believe that if someone has actually fulfilled all the
requirements, has passed all the exams, has proven that they have
complied with all the requirements, have been working here, have
gotten post-graduate training here           have been taking care of
patients here--providing good medical care--and are legally here,
deserve the same protections as American-trained doctors. And,
some day, they should be acknowledged as good physicians--
physicians just as good as any other.        I've been in this country
since '76, so it would be nice, if my performance has been good

performance, or, let's say, not worse than someone who was
trained here, that at some point in time I might be considered as

good as an American graduate.
                                                                       49

     Now, if we're talking about limiting the number of new
international medical graduates that are coming to this country
because of the situation, the ways things are now, residency
position competition, that's a different story.


Mullan:     It isn't clear to me when the hot topics and tough

topics of I M G politics and policy are discussed, that within the
I M G community there is a distinction between protecting the

rights of individuals from abroad who have trained here and are
now part of the system, and future generations who would like to
train here, but aren't yet part of the system.        Is that a
meaningful distinction in those discussions?


Lifshitz:     You can't talk about the I M G community as a community
that has a unified voice.     That is not the case.    You have
different opinions, depending on who you ask.      The advisory
committee felt very strongly that the United States was a country
that was built on immigrants--you know, most people in the United
States are immigrants. Whether they're first-generation, fifth-
generation, or tenth-generation, they're immigrants. Very few
people actually have their roots in the United States. And they
feel that competition should be for the best qualified, and that
competition should be based on merits, not on place of
graduation.    I believe that there is some merit to that.
    A lot of the IMGs are American citizens, born and raised

here, and the government gives grants for American citizens to go

abroad to medical school.     So there's a discrepancy here.      If
                                                                         50

medical schools outside the U.S. are so bad, why does the
government pay Americans to go to them?       NOW, if the training of
international medical graduates is so terrible from the
perspective that some people have, then they should not fear the
competition, because the "best" doctor will prevail anyway.         So

it's a very difficult and very hypocritical situation.


Mullan:     But surely the I M G community, in practice in this

country, looking at the growing numbers of physicians and the
diminishing demands for physicians, must be concerned about the
future.


Lifshitz:     I'll tell you something.    Whether you're an American

graduate or an international medical graduate, you're a physician
first.    I mean, regardless of where you trained.     It doesn't mean
that you're not a physician first.


Mullan:     I'm even talking about just the pure raw economics of

it.   As a physician in practice looking at a large body of
physicians in practice and many more coming along, wherever
you're trained, you must have similar concerns.       If you can cast
your mind on that, the question is how to slow down the
production of physicians.       What does the international medical
graduate practicing physician feel about that?



Lifshitz:    It's very mixed.    A l o t of international medical
graduates would love to see more people from their countries
                                                                         51

train and go back to their countries, because it really helps
other countries.    Some of them would like them to stay here.       I
believe that we need to find a way in which we can find a
balance.    And that is to the benefit of everybody, not only
physicians, but just people living in the United States.       But
when you're talking about a surplus of physicians and you're
opening more osteopathic schools, and you're not limiting the
number of students going into medical school, there's a problem
right there.    It's not only the IMGs.


[Begin Tape 2, Side 13


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


Lifshitz:    I think that we will look at the situation with

physicians and the work force and the economics.   We cannot look
at IMGs as an entity, isolated from the whole picture.   We have
to look at IMGs as part of a puzzle, and if we're going to attack
it, we have to attack the problem from all the different sides,
not isolating it to one group.    It's easier to isolate it to one
group, because you can keep a hell of a lot more people happy.


Mullan:    Not talking about people in practice, but about future

generations, and you have an indigenous production capability,
U.S. medical schools, allopathic and osteopathic, and then you
have large numbers of people coming from abroad, and if you want
to recalibrate and decrease the number of people entering the
                                                                     52

workforce, does it seem, to you, discriminatory or unfair to say
that from a policy point of view, where we should diminish the
input, the throughput, is from the folks coming from abroad,
rather than from U.S. schools? How does that seem to you?


Lifshitz:    Well, I believe that we have two issues.   One of them

is--and I understand, I'm following you very well--and the way
you state your premise, at first glance it would seem as though
it makes a lot of sense.     The problem is that the United States
could still probably train, and I'm not saying train with the
idea of having them stay here, but train a large group of
international medical graduates who could go back to their
countries.


Mullan:     If we were talking about a legitimate exchange program.



Lifshitz:    Exactly.   And that is something--a policy--that could

be implemented.    I know that there are loopholes.   The government
has utilized the loopholes because they've needed the IMGs, like,
for example, in underserved places.    And what they do is that
they offer that, if they go work there, then they can stay.    You
can't say you have to shut this door 100 percent and not allow
people in, when I think also the United States benefits from the
exchange of people coming from abroad.    It's just that you have

to establish a policy through which people who meet the
requirements can come to train, and then go back, and close the

loopholes.
                                                                          53

       And if they don't want international medical graduates
because there's a surplus of physicians, then they should not be
producing as many American graduates while still having American
citizens go abroad.      Thank God we're not in a dictatorial country
where the government speaks, and everything's done.          But there
are ways in which the government can influence things, and
there's no question the market forces are what's going to
determine what will end up happening.       Obviously, if you start
producing so many physicians that they end up in Mexico,
Argentina, Spain, driving cabs, because there's no place for them
to work, more people will elect not to go to medical school.
       On the other hand, we also have to look at the broad
picture, look at what's happening, also, with the population.            We
cannot always project, with statistics, what's going to happen
twenty, thirty, forty, fifty years from now.       The population is
aging.      We're having a more diverse population.      There might be a
need for some things that we are not necessarily projecting right
now.
       So, am I in favor of opening the door to anyone that wants

to come here?     No.   Am   I in favor of continuing the status quo?
No.    Am   I in favor of fair competition? Yes.    Am    I in favor of
looking at the problem the way it Bs, with all its multiple
facets, and attacking not only one, but all of them?         I'm in
favor of that, and I'm also in favor of doing things in an
incremental way, with some pilot studies.
       Again, if we are really scientists, we have to have some
data, not just prejudices or opinions.       Some things we can
                                                                       54

predict, some things we cannot predict, but we have to have the
data that backs it up.    And if you look at some of the data,
excellent data from places that are excellent, they don't all
come up with the same projections.     So    that means that there is a
margin of error, and in some ways, everybody is trying to protect
their turf.


Mullan:     Tell me about the Advisory Committee on IMGs.    You

chaired it for three years?


Lifshitz:     I chaired it--1 think it was two and a half years or

three years.     I don't remember exactly.


Mullan:     How did you become chairperson, and what was it like?

What were the interdynamics, interpolitics, between different
groups?


Lifshitz:    Well, it was a diverse committee because there were

representatives from different groups.        In the international
medical graduate community, there have been groups that have been
more active than others, and that includes the Indian physicians,
and the Pakistani physicians.    Some of them are people whom I
respect immensely and that are fighting for things that they
really believe in.    Some people fight in ways that we like.        Some
people fight i n ways that we don't   like.    Their styles may be

different. And     this is not exclusive to that community.     But
                                                                  55

they have been the most vocal and they have been the most active.


     On the advisory committee, we had representation from them
as well, and they tended to be very vocal.   And they had a lot of
experience from past situations that they had tried to resolve.
For example, there have been cases in which someone has been
denied an interview because they have a foreign, Pakistani or
Indian name.    They were treated as international medical
graduates when, in fact, they were American graduates and
American citizens who just happened to be born from Indian
parents.   You know, examples like that, actually enlightened a
lot of us who had not really heard of those things.   They believe
very strongly in fighting for merit, given somebody's merit,
rather than where they trained. And the committee felt, and the
AMA shared this feeling, that, if   rather than saying, "If you
are an international medical graduate, we will not grant you an
appointment for an interview."   If you   said, "If you are
African-American, or if you are a woman," that would really
create havoc.   So why does it not create havoc because it's this

group? And if you look at it that way, you know, you should be
given the opportunity.
     The way the greatest majority of the people on the committee
felt was that, the moment you are an international medical
graduate, you're already put kind of at the bottom of the list of

applicants.    If someone who is an international medical graduate

competes with these other American graduates, and as it turns
                                                                       56

out, the people that are interviewing feel that this person is
more qualified, that they should allow that person to go forth.
     On the other hand, people who          would basically feel
differently would say, "Well, Americans have invested a lot of
money in the education of this person going through medical
school, and if they've invested that money, then they should be
the ones that can get the residency training, as opposed to
someone that we didn't invest any money in educating."         Or
someone can say, "That's great.       You can have people that don't
cost you, are very qualified, and can perform, which, rather than
trying to shod them away, you should be happy that it didn't cost
the taxpayers the education."     I think that the advisory
committee felt, overall, that that was the case.
     Personally, although I do believe in the premise that
competition should be based on merit, I do believe as well that
we are asking the United States to be what it's always been--and
that is, the country of opportunities--to open the door to anyone
who is qualified, even when other countries do not do the same.
Mexico didn't do the same f o r me.     Yes, I could go back to
practice, but what I have done here would have not been
recognized. Would that have translated in me not being able to
make a living, or do very well?       No.



Mullan:   But what about the brain drain, just to put it in very

simple terms?   Within that group, and I'm asking now not alone
for your opinion, but from the discussions that are abroad and in
the IMG community, it's fine for physicians from all over the
                                                                     57

world to say, "We want an opportunity to make a new start in
America."      But the fact stands that in many cases these are the
most intelligent, best-trained people, the elites, or people who
have benefitted from the educational systems of their countries
to en masse, and when you talk about Indian or Pakistani
physicians, the numbers are very substantial, to up and leave.
And that's not alone the United States, it's England, Canada,
Scandinavian countries.     I know the arguments, that in India the
opportunities, they've got a good education and a rich education
in terms of a lot of people, and the opportunities to have a
sophisticated medical practice and make a good living are
limited.     So I understand that conditions at home may not be what
they would like, but is there no concern that there is an
obligation to the country that sired them, that supported them,
that educated them?


Lifshitz:     I think in terms of the feeling that they would like

to give back to their countries, in one way or another, a very
large percentage of physicians do t h a t .   There are t o n s of
physicians who go back to their countries and provide care at no
cost.     Who send journals and equipment and a lot of things that
they would not be able to get if not for the group of physicians
which is organized and lives here.


Mullan:     Money.
                                                                          58

Lifshitz:    And money.    So   I don't believe that there is a

divorce, necessarily, in terms of helping.       It is a different
kind of help.     Can the United States absorb anybody that wants to
come?     Of course not.   Nor should it have to.      But I have never
heard of international engineering graduates or any other
profession being singled out as, "Well, if you did not go to an
American school, you should not have the same opportunities."
And the reason is that the competition is not ass strong.


Mullan:     In medicine, it is true that, if you don't have American

graduate medical education, you're singled out.          In medicine
we've already, for better or for worse, for state licensure
purposes, established a pretty much uniform requirement of
graduate medical education in this country.       So    I think it's
different than engineering and architecture and others.
Engineers and architects apply through their quotas from whatever
country.    Their licensure, though, is not dependent on training
in the United States, whereas in medicine it & dependent, so
it's a bit different there.


Lifshitz:    Right.   But even if you meet all the requirements--and

obviously you're very knowledgeable about this--but if an
ophthalmologist has been a professor of ophthalmology at a
university for twenty years, has been recognized by his peers in
one state and wants to move to another state, they might not
grant him a license to practice ophthalmology in the other state
because, when he went to medical school, he didn't get the ten
                                                                        59

hours of psychiatry or the ten hours of public health.           That, to
me, is not right.
       We all know that American medical schools are not all the
same.     Some of them are better than others.    And we know that not
every American graduate is a superb physician.        There are good
ones and bad ones, just like in the IMG community.        So,

sometimes, certain requirements are not really set up           in a fair
way.    And I'm not saying that it should be identical, because
there        some differences, but there has to be a time and there
has to be a way in which things are fair.        If I wanted to go
practice somewhere else, I might have problems.


Mullan:     What is your guess about the future of the IMG

migration?


Lifshitz:     I believe very strongly that, because of financial

constraints and the changes with Medicare reimbursement for
residency physicians, and the changes in terms of specialty and
primary care and everything else, that the number of IMGs who
come to this country is going to decrease dramatically.          I think
it's happening already.     I believe that some of the IMGs who come
to this country might end up being exploited, because they're
going to be cheap labor, but are not really going to get a good
quality education.


Mullan:     Different than now?   That doesn't go on now?
                                                                        60

Lifshitz:     I think it's going to get worse.    I believe that a lot

of doctors--in general, with the changes in health care--but in
particular I M G s , are going to be singled out in terms of being
employed by large HMOs and in places where you end up with two or
three large HMOs dominating a market.     A lot of I M G s who have
serviced a community very well are going to end up not being part
o f the system because they might be older and they might not know

the HMO way of practice. And, because OF the xenophobia that we
see wit PROP 187 in California as an example, and other things
happening in the country, the perception that I M G s are second-
class doctors is going to be perpetuated and accentuated.       So

that it's going to be tougher.    There are still going to be some
I M G s who are going to do very well.   But as a group, the battle
is going to be uphill.


Mullan:     Let's go to a cheerier topic to conclude.   How about

yourself? Where do you see your practice going?


Lifshitz:     I know that I love practicing, and if was

independently wealthy, I would not be in private practice.         I

would donate my services.     If I got to the point where I could

actually have enough income from other things related to health
that I love--education, communications--I would love to just
donate my services to underserved populations.      That's what I
would love to do.    Will I be able to do that?    I'm not sure.       If
I'm not able to do that, I see myself probably joining a group.
I hope that I can find a group that believes in what I believe
                                                                        61

in, in terms of patient care, and that allows me the flexibility
to be able to do the other things that I like to do.


Mullan:     Are you going to stay in Los Angeles?


Lifshitz:     I don't have any plans to move anywhere else.   I'm

married, and my husband has a business here, which makes it more
likely that I will stay here.     I'm not saying that if an
opportunity came up that was just fantastic, that I would say,
"NO, I have to stay in Los Angeles."    Do I believe that Los
Angeles is the place where you have the best quality of life?
No.    [Laughter] It's been very good to me, but it's not a very
safe city.     In some ways, it's a bit more materialistic than I
would like it to be, so that I'm not sure.    I'm really open.
       I hope to get a chance to continue to work with underserved
groups.     I believe that, in terms of my role in the Hispanic
community, because of my background it's easier for me to help
that group, but it doesn't mean that that's the group I'm
necessarily interested in exclusively.    Well, I can tell you, it
is not.     I'm interested in everybody, but I believe that I have a
little more knowledge and expertise to help that group, so it
just happens that the opportunities have been there, but we'll
see.
       Even though I gave you a lot of the negative things, I don't
in any way want to imply that I see everything as terrible.         I
think that change is necessary--and I believe that there's still
a lot of work to be done to find what that change really needs to
                                                                       62

be--but that zeroing in on one area alone will not take care of
the problem.        Just like managed care is not the best nor the
worst.    It has some good things, it has some bad things, and
eventually, hopefully, we'll get the best out of it, and will
continue to evolve.


Mullan:     Good.    Well, you've been very generous, and thank you.



Lifshitz:     Thank you.



[End of Interview]