CARL TONEY


                             Fitzhugh Mullan,
                               interviewer



Mullan:   I'm with Mr. Toney in his office at the University of
N e w England in Biddeford, Maine.    It is a beautiful July morning

on the Maine coast, a twinkling sky.        We're in a Quonset hut

trailer, very comfortably appointed, which is the current home of
the Area Health Education Center Program for the State of Maine.



Mullan:   Carl Toney is the deputy director of that program.

Thank you for having me.


Toney:    It's a pleasure.    Thank you.



Mullan:    I want to start with a bit about you and your

background, your early life, and how you got interested in health
sciences in general.    So why don't we start way back about where

you were born and brought up, and what your early thinking was
about your career.


Toney:    I was born and raised in New York City.      I was raised on

the Upper West Side of Manhattan, about half a mile south of

Columbia Presbyterian Medical, which my father worked at for

twenty-five years as a maintenance supervisor, and my sister

worked there for a while as a licensed practical nurse.
                                                                        2

Mullan:    Where exactly did you live?


Toney:    I lived about a half a mile south of there.   Columbia
Presbyterian is on 168th Street and Broadway in Manhattan, and my

family lived on 157th Street between Broadway and Amsterdam.       So

it was a real part of our community.     I guess that connection

really was the impetus for my ultimate interest in health, that
and the family physician that we had, our local community family
physician, who was someone who, to at least me, epitomized what
medicine and being a physician and community care was all about.
He was a really intriguing individual, whose name was Dr.
Reginald Weir.    I grew up in the fifties and early sixties, and
he made house calls, and he was the kind of physician who
incorporated the family--in particular, my mother was kind of the

head of the health care of the family--into the decision-making.
So   he was an extraordinary model to watch.
       I got into health care originally by doing a job. My mother
arranged for me, through a contact that she had, to get me a job
as an orderly at Columbia Presbyterian, and that was my

introduction to health care formally in 1965.    I graduated from

high school in 1964.


Mullan:   Where did you go to high school?



Toney:    I went to high school in the Bronx at Samuel Gompers High

School.    In those days, if you went to public school in New York,

they had a rule where you could go to any high school in the city
                                                                      3

that you were eligible to gain entrance into.     My father had been
an electronics technician, engineer, and I was following in his
footsteps, and Samuel Gompers was one of two schools that offered
a major in electronics, so I went there.
        So I started at Columbia in 1965 and was there until October

of 1966, when I was drafted into the armed forces, into the U.S.
Army, and continued my health care orientation by becoming a
combat medic, infantry medic, in the Army and served f o r a year
in Kansas, at Fort Riley, Kansas, and then a year in Vietnam.


Mullan:    What was that like?



Toney:     Difficult, to say the least.   I was with a combat unit,

the 9th Infantry Division, and our area of operation was
everything south of Saigon in the Mekong Delta, so we had from

Saigon to the South China Sea, which is the tip of Vietnam.       I
served in support of a combat engineering group, a regular
infantry unit, as well as a mechanized infantry unit.     So I was
in the field for the duration of my time there, with the
exception of about two weeks.    I learned a lot of medicine, as
one can imagine, and really enjoyed being a medic.     I didn't
enjoy the war in terms of being there, but if I had to be there,
at least I felt I was doing something that was life-supporting,
rather than life-taking.
        I came back out of the service, came back from Vietnam in
1968.
                                                                       4

Mullan:    Let me follow that up for a second.     Did you see much

combat?


Toney:    Yes.    As I said, I was in for a year, and I was in the

field for ten months and two weeks out of my year tour, and we
were in an area that saw a lot of action.       I was there during the
Tet Offensive, for example, and we did a lot of support work for
some of the other units in the Mekong Delta and central
highlands.       So it was a fairly busy time to be there and a fairly
busy area to be in.


Mullan:    How did you feel about your training and your

positioning vis-a-vis what you had to cope with clinically?


Toney:    I actually, interestingly enough, thought that my

training was superb.      During the time that I really went in the
service, Vietnam obviously was already under way and had been for

a few years, and medics were being killed at a fairly high rate.
Medics had the third shortest life expectancy in the war, behind
officers and radio operators.


Mullan:   Was it that they were targeted?



Toney:    Yes.    The basic philosophy from the enemy was that you

try to identify the officer and kill him and disrupt the
leadership.      You then try to find the radio operator and kill or
wound him to disrupt communication, and then try to find the
                                                                     5

medic to kill or injure him to disrupt their ability to take care
of the other wounded.    So it got to a point--even at that point,

and we're talking 1966-67--that the need for medics had gotten so
great that they set up satellite training centers for medics
around the country. Most medics prior to that had been trained

at Fort Sam Houston in Texas, but when I went in, I was trained
as a medic at Fort Riley, Kansas, at one of the satellite

settings, and the people who were doing the training were senior
non-commissioned officers who had already served not only in
Korea, but most recently in Vietnam.
     So the training that I had was really focused on the type of
situation that I was going to find myself in, and it was clear

that if you were a medic, you were going to Vietnam.    So I

thought the training was excellent.    Being a front-line

individual, in terms of my role, certainly under combat
conditions, was to stabilize, to the best of my ability, patients
and get them medevaced out to more sophisticated medical care,
and I thought both the equipment and the support that I had to do
that was excellent.     In a combat situation, dealing with those
kinds of circumstances as a medic, you really become the senior
person in that scenario, and so what you say goes in terms of

your decisions.   If you say you need someone medevaced out and

this is what you need, the company commanders, the local
commanders, are bound to honor that to the best of their ability.

So while casualties obviously were high because of the
circumstances, I felt that I was well trained.     I thought we did
                                                                      6

a good job, and I thought those of us that were out in the field
saved a lot of lives that otherwise would have been lost.



Mullan:   How did that role contrast with your noncombatant role

the year you were in Kansas where, I presume, you did more on the

order of sick call and--


Toney:    Right.   In Kansas, once I completed my medic training, I

was assigned to Irwin Army Hospital, which was the base hospital
at Fort Riley, and as a medic there, the role that you had

basically was the same role I had had as an orderly prior to
coming into the service.     So it was a much more defined and much
more limiting role in terms of what you got to do.


Mullan:   And one that you did not, from a clinical perspective

feel the same about?    Which did you like better as a role?



Toney: Well, certainly, while no one wants to go into a combat
situation, you're trained to this level of skill and decision-
making from a very pragmatic and practical perspective, and
you've got those skills and knowledge, and you want to be able to
u s e them.   At that time stateside you could not, and in a combat
situation, obviously, that was everything that was brought to the

forefront for review.     So from a perspective of using my skills

and my knowledge, the combat situation in Vietnam was clearly

preferable to what I had to look forward to stateside.
                                                                       7

Mullan:   So you were fortunate to come out unhurt?



Toney:    Reasonably.    I was wounded once.



Mullan:    Badly?



Toney:    Not too bad.    I received a wound from a rifle grenade,

shrapnel wound in my leg and knee.      So,    some chronic bursitis and

osteoarthritis problems.


Mullan:    Did you go back to the field after that, or did you come

home after that?


Toney:    No.    I was removed from the field for about a week for

treatment and convalescence and then reassigned to the field.



Mullan:    Alas and alack, at the end of a year, you got to come

home?


Toney:    Yes.


Mullan:    What happened at that point?



Toney:    Because it was so close to my discharge date, I was

within ninety days of what would have been my discharge date, I

got an early discharge out of the service, and returned back to
New York as a civilian and took a few months off, but then went
                                                                     8

back to work at Columbia Presbyterian, essentially in my old job,

did that for a while, found it to be somewhat frustrating.



Mullan:   As what?



Toney:    As an orderly, and at that point I was working on a
general medicine service in the hospital.    I left Columbia and
went to New York Hospital for a brief stint at the Payne-Whitney
Psychiatric Clinic, again basically as a psychiatric aide, which
is another name for orderly.   Didn't find that to be particularly

rewarding either, particularly with the level of knowledge and
experience that I brought back from my military experience.     So

in 1968, '69, I left health care altogether.


Mullan:    At that point there were no programs that would allow

you to pyramid your new knowledge into a new career?


Toney:    The only one that was around at that point had started a

few years earlier was the physician's assistant started by Dr.
Eugene Stead, at Duke University, in 1965.


Mullan:    That was in existence, but that was the only one?



Toney:     No, there were a few other programs around.   In fact,

when I was in Vietnam, my old head nurse from Columbia had

written me and sent me an article that she had found about this
new profession and felt that it would be something I should look
                                                                      9

into, should I decide not to go into medicine.     She had been
urging me to go to medical school.     But I really wasn't ready to
do something like that.    So   I left medicine in 1969 and took a
totally different direction and went into aviation maintenance
for a while and worked at Pan American Airways at Kennedy Airport
as an avionics technician for a few years.



Mullan:    How did you learn the skills?



Toney:     From high school, actually, when I was majoring in

electronics.    Then after I graduated from high school, I went to
night school and got a broadcast engineering license from the
Federal Communications Commission.     So I had this training and
license that had been sitting in my drawer for about five years
that I had never thought I would ever use.



Mullan:    What had your thinking been about further education

either at just a standard collegiate level or in terms of
nursing?


Toney:    I was very ambivalent.   I wanted to do more, but I didn't

know what I wanted to do, and I just didn't want to go back to
school for the sake of going back without some legitimate
direction, clear direction.     So I basically put that whole issue

on hold for a number of years.
                                                                     10

Mullan:    In terms of impediments, as you saw them there, was it

academics? Was it finance? Was it uncertainty? As somebody who
clearly had academic achievement under their belt and
capabilities, clearly had career-type interest, what held you

back?


Toney:    I think it was a combination of all three.   First and

foremost, I think, was a lack of clarity on my own part in terms

of what is it that I wanted to do, which direction did I want to
take, but I was also keenly aware, having come out of a blue-
collar background, and if I went to college for whatever reason,
I was going to be the first in my family to ever go to college,
and it was going to be an issue of my paying my own way or my
parents trying to support the effort in some very meager way, so
there was that pressure on me from myself to not just do this in
a flippant way.   So   if I was going to go, I needed to be clear

about why I was going and then address the other barriers such as

cost.
     The other issue was, to a degree, academics, in that I'd
been an average student in school, did well in some subjects and
not so well in others, and it was very competitive to get into
college at that point.     It was right around the time that open

enrollment was being tried as a model for encouraging people to
go to higher education at a college and university level in New
York, and, in fact, it was open enrollment that, when I
ultimately decided to go, that got me admitted into college.       But
mostly it was my lack of clarity for myself.
                                                                     11

Mullan:    You tried avionics?



Toney: Yes and I loved it, but then got caught in what we now

call downsizing and was part of about four thousand guys laid off
in 1970, in December of '70, and so I went back to Columbia
Presbyterian yet again, partially because I knew I could get a
job, but also because I really missed health care.    Airplanes are
fun, but they're not people.



Mullan:    How about the wages?



Toney:    When I went back to the hospital, I think I was probably

making about $65 a week.    I think that was the most I ever made.


Mullan:    Compared to the avionics?



Toney:    Oh, the avionics, I was making a small fortune.    They

paid very well in terms of union negotiated wages, plus they had
overtime benefits that could make you close to wealthy, in a
relative sense.    So it was a real gap in my income, but it really

put me in a better place in terms of what I wanted t o do.
     So I went back in '70 and ended up initially going back to

the general medical service position but then being asked to take
a position in the cardiac intensive care unit for a new type of
position that they had defined t h a t they were calling a technical
nursing aide, which means I got to do a bit more than the usual
bedside nursing functions. A t that time, Columbia was just
                                                                    12

getting into doing some clinical experimentations with things
like the intra-aortic balloon pump, and I got involved in working

with that, with the cardiac and basic teams and so forth.    So    it
gave me a chance to somewhat go back to a skills level, albeit a
technical one, that was a bit closer to what I had been doing in

the military.
        I did that for about four years, working in the cardiac ICU,

loved it, but began to realize that this was pretty dead end,
l'Irmnot going to do this forever," and that didn't feel very

good.     So I began to rethink my options and look at nursing

school, look at medical school, and it was at that point that I
also remembered about the PA profession.    The PA profession was

actually my third choice after looking at medical school and
after looking at nursing school.    I decided I thought at that

point in time of my life in terms of who I was and what I wanted,
that the PA profession actually held the most promise for me.
        So it was at that point that I applied for entrance to

college and to go to undergraduate school in preparation for
applying to PA school.


Mullan:    Had you known any PAS at that point?



Toney:    No.



Mullan:     Except for your knowledge that the programs existed?



Toney:     Exactly.
                                                                       13

Mullan:     And now were more than the Duke program, a few more?



Toney:    Yes.



Mullan:     We're talking 1 9 7 4 ?



Toney:    '74, '75.     There were a fair number of programs around.

I basically had made the decision based on the recommendation of
my old head nurse, who I trusted explicitly.      She said it was a
good profession.      She thought that it had a real future.   Her
father had been John Loeb, coauthored Cecil and Loeb Textbook of
Medicine.     So she knew Eugene Stead and she knew the people at

Duke, and she said, "You really need to do this, and if you want
to do it, you need to go to Duke."      And so that was where I set
my sights.


Mullan:     But you needed to get some undergraduate work.



Toney:    Right.    Because I had no college, and you needed to come

in basically as a transfer student into the program.      So I
applied for enrollment at City College of New York.      I also ended
up being a biology-psychology double major.       I did two years at

City College, and then applied for entrance to a PA program.
Interestingly enough, I applied to, I think it was ten programs,
and got rejected without even an interview at eight out of the
ten, which was rather devastating.      The only two programs that I
                                                                      14

got an interview for, which were the two programs I got accepted

to, was George Washington University and Duke University.


Mullan:   Pretty substantial programs.



Toney: Yes.



Mullan:   How did you find the City College years?     Was it tough?

Was it good?


Toney:    I loved it.   They were tough, and I don't want that to

sound arrogant.    They were challenging, but I love learning, and
I love education, s o to have the opportunity to sit in a
classroom and learn philosophy and learn economics and learn this
and that was absolutely wonderful to me.    What I found tough

about it was because I was paying my own way, so I was working

full-time and going to school full-time and studying on the
subways in between.     That was the tough part.


Mullan:    So you decided to accept Duke, I presume?



Toney:    Yes.



Mullan:    Other than that, what was it like?



Toney:    Well, both programs are excellent.    When I went to Duke

to interview, they took me on the tour of the campus, and I
                                                                     15

looked at the Duke campus, it was like every university I'd ever
seen in any movie.      It was so beautiful, and you could just feel
the education.      And then meeting the faculty at the PA program
and the medical school faculty that were involved with the
interview process, I was so impressed, and I was so impressed

with the quality of the other applicants that it more than
exceeded my possible expectations, and I felt there was no chance
in the world I'd ever get in there, considering the competition I
was up against.      So it was no contest.   If they were going to
take me, I was definitely going to go.


Mullan:    And they took you?



Toney:    And they took me.



Mullan:   And you went.



Toney:    I went.


Mullan:    What was it like?



Toney:    It was the hardest two years of my life, without a doubt.

I almost didn't make it the first year.      I went in there being
what I thought was very self-confident, to the point of probably

a bit of arrogance in what I could do, and the amount of work and

the quality of--and the level that they expected, demanded, began

quickly to wear away both at my self-confidence and certainly my
                                                                     16

arrogance.     So by the end of the first year--and at that time you
did a nine-month didactic and then a fifteen-month clinical--I
was physically and emotionally exhausted and absolutely drained
of self-confidence to the point that when finals came, I decided
I had made a terrible decision and I could not do this and that I
was going to leave.     Fortunately for me, the faculty, who were
superb at that time, and still are, intervened and did some
wonderful crisis intervention and helped me get through that,
because I was going to leave, and helped me transition

successfully into the second year.
        Once 1 got into the second year, which put you back out on
the clinical clerkships, I basically was back in my element, if
you will, in terms of being with patients and doing the things I
knew I knew how to do, and I really blossomed.     So I went from
almost failing out, flunking out, walking away, if you will, at
the end of the first year to graduating as the outstanding
student in my graduating class in 1979 and being awarded the
Sheeley Award as an outstanding student.    It's somewhere around
here.     In any event, it was very, very difficult, but it was
extraordinarily demanding and I loved it, and when I graduated, I
was absolutely convinced that to be a PA was the greatest thing
to be, and to be a Duke PA was to be the greatest PA of all.


Mullan:    Tell me a little more about the substance of academic

life and like in general at Duke in those years.    How large a

class?
                                                                     17

Toney:    We had a class of forty, which they took that size up

until very recently.       I think they went to fifty, but for most of
the seventies and eighties, they maintained a class of forty.


Mullan:    Men?   Women?



Toney:    At that time that I was there, it was about 65/35 in

favor of men, with many of us coming out of the military.


Mullan:    What percent might have had military medic background?



Toney:    Probably about 50 percent of the men had either military

background, which included in most cases, though not all cases,
combat experience, and the others tended to be people who had had
significant civilian experience at top levels of being
paramedics, particularly full-time paid paramedics coming out of
big urban cities.    So    people that had seen a lot, done a lot, but
we also had pharmacists, nurses, a real array of individuals.
         The curriculum, both the didactic and clinical curriculum,
was very tied into med school, so the medical school community
teaching faculty, from the attendings down to the house, they had
a lot of input.    The standard that you were held to, both
didactically and particularly clinically, was the same standard
as the Duke Medical School.      So there was no such thing as,

"Well, I don't need to know that," or, ''You don't need to know

that because you're a PA."      The philosophy of the program at
Duke, which is certainly the case in most, if not all, programs,
                                                                       18

is to teach from a very applied practical model.     But within that
framework, the material that they taught and what you were
responsible for, you were held accountable to the same level.          So
congestive heart failure was taught the same way at Duke to the
PA students as it is to medical students and residents.
      When you were on clinical rotations, you were expected to

pull your full weight in terms of functioning as a team member on
your team, whether it was either in-patient or community-based
practice, and whatever your team did and for how long they did it
in terms of the hours and responsibility, you were expected to

do.   So   you were fully integrated in, and there was no
difference.     The PA students at Duke were seen analogous to the

second-year medical students, because at Duke the second-year
medical students did their initial clinical rotations in their
second year, and then they did their advance rotations and
electives in the fourth year.    So you were seen as on par with

second-year medical students.


Mullan:    What was life like in North Carolina?   This is the first

time you had gone South?


Toney:     I'd never been in the south, up until that point, except

for one brief week in South Carolina I'd never been further south
than Philadelphia, because my father came from Philadelphia and

my mother came from New Jersey.    We had a very small family.     I
was petrified about going to the South, for obvious reasons, in
terms of the potential for racial issues, and I ran into that on
                                                                    19

occasion, but, to my surprise, I actually found being in the
South a very positive experience in that, one, people were far
more honest in the South than in the North.    They let you know

where they stood in terms of their feelings and attitudes,
whether they were positive or negative.    You didn't have to
guess.    But I also found that there was a much greater sense of
community, and particularly amongst the black community in the
South, because of the tradition of black community in the South.
So   that even coming as a stranger with no family, no roots, no
connection to Durham, North Carolina, or North Carolina as a
state, I was embraced as a member of the community and got a lot
of informal support, which was very, very helpful.    So I enjoyed

my time there, and only on very rare occasions had anything come
up that spoke to the negative side of the racial situation within
the South.


Mullan:   So what happened next?



Toney:    I graduated in 1979, and then I came to Maine.   I had

applied for and had been accepted into a brand-new residency
program in emergency medicine that was based at the Maine Medical
Center in Portland, Maine, and I was in the charter class for
that residency program.    It was a one-year residency for PAS that
had been started as a model pilot project under the sponsorship

of Robert Woods Johnson Foundation.



Mullan:   How was coming to Maine?
                                                                     20

Toney:    It was extraordinary.    I had never been north of New York

before.   So everything was new, and when I came up here to
interview, there were four of us four of us from Duke that were
invited for interviews, and three of us drove up from Durham,
North Carolina, together.      So I got to camp out in the green

mountains of Vermont, which was something I'd never done before

in terms of camping.   And then when I arrived in Maine, I just
thought it was absolutely beautiful and that the people were

extraordinary, and it was probably the quietest place in America
I'd ever been, and you could walk around and the quiet, the
silence, was deafening.   So   I was really looking forward to it.
     Again, I didn't think I was going to be accepted into the
residency.   It was very, very competitive, and particularly with
four of us applying from Duke, or getting invited from Duke, I
figured my chances were nil, but there were two of us selected
from Duke, and fortunately I was one of the two.     My best friend
from Duke turned out to be the other.
     So we came, and   I went through the residency, which was a
very, very challenging program.     It was an excellent program that

Maine Medic put together, and I did part of my training in
Portland at two of the hospitals there and then rotated around
the state at four other hospitals.     So I got to learn a lot about

the state.   I got to learn a lot of good emergency medicine from
some excellent preceptors, and got a bit of social education,
because there aren't very many blacks in Maine.     During that time

it seemed as if I met and treated most of them, because they
would hear about this black doctor or PA or something that was in
                                                                            21

the emergency room, and people would come to see who I was.             I
would go to an area, as I did in Scowkegan, Maine, where there
hadn't been a black living in that area for over a generation, so
families would come in and particularly bring their kids in so
that they could see and meet a real black person.


Mullan:     Black families?



Toney:    No.     No.   White families.    Because their children had

never seen a black except on TV or playing basketball.          So that
was fairly interesting for a guy from New York to sit there and
explain to people in Scowkegan, Maine, why black people can jump
so high in basketball.       But everyone was very, very accommodating
and very welcoming wherever I went.          So socially it was a

wonderful experience, and educationally it was a superb program.


Mullan:     And from there you didn't stay in Maine, though?



Toney:    I did not stay in Maine.        My plans were to stay in Maine.

In fact, when I came out of the residency, I had been offered a
contract, along with one of the other fellows in the residency,
one of my colleagues, to staff a small ER in Gardner, Maine,
which is just outside of Augusta, just about an hour north of
Portland.       But at that time, my wife, who was a registered nurse
and had been a registered nurse for about twelve years, decided
that she wanted to go back to school and become a PA.
                                                                     22

Mullan:     Let's drop back and pick that up a little bit.   Tell me

about your life outside of medicine.


Toney:     I have been married twice.   I was initially married when

I first came back from Vietnam.      I came back from Vietnam in

August of 1968 and met someone who I eventually married in the
spring of 1969, and we were married for about seven years all
told, and subsequently got divorced, found out that we were
better friends than we were husband and wife, and have remained
very good friends over the years.


Mullan:     Kids?



Toney:     Had one child as a result of the first marriage, who,

unfortunately died shortly after birth from hyomembrane disease.
That was the only child from the marriage.
     Met my current wife in 1971, and we dated for a number of
years and got married in 1978 while I was a second-year student
at Duke.     In fact, we got married in between my internal medicine
and general surgery rotations.


Mullan:    She was a nurse?



Toney:    Yes.   She was a nurse.   She had graduated in 1970 from

Georgetown University, and we've been together ever since.



Mullan:    Got any kids?
                                                                      23

Toney:    No.    Our careers have kind of driven our lives in toto,

and we also figured after spending a fair amount of time together
that we were probably kid enough for both of us.     So we've never

had children.



Mullan:    So as you contemplated what to do next after Maine

Medical Center Emergency Medicine Program, her career dictated
maybe a different direction?



Toney:    Yes.   She was very committed to clinical care and had

done basically everything in clinical nursing that she could do,
and she loved patient care.     She did not want to get into
administration or teaching in nursing, and she also wanted to be
able to do more as a clinician.     So she initially looked at

becoming a nurse practitioner, which was an obvious possibility
for her, and she ultimately decided that while that offered some
opportunities, that based on what she had seen watching me go
through both PA school and residency and what I was about to do
in terms of going into practice, that being a PA appealed to her
more in terms of the level of knowledge and the level of
responsibility.     So she decided she wanted to go to PA school.
     So she dragged me, kicking and screaming, out of Maine, not

because I didn't support her decision, but because I didn't want
to leave Maine.     She ultimately decided to go to Duke as well,
and we went back to North Carolina.     She was admitted into the

program, and I was invited to join the faculty within the
Department of Community and Family Medicine at the medical
                                                                    24

school.    So I taught in the PA program, and I also was part of
the attending staff within the department that had clinical
responsibilities at the Duke Family Medicine Center for some
patients, and as part of those faculty responsibilities, I
precepted second-year medical students and occasionally first-
year family practice residents.     So I was on the faculty at Duke

within the department for four years.


Mullan:   How was that, precepting particularly medical students

and residents? Were there stresses or strains there or not?



Toney:    There were really very little, at least from my

perspective, and I believe that was the case because of the Duke
PA program and PAS at Duke on staff were so well ingrained, both

historically and in terms of the actual operation, that the
medical students and the residents saw it was a natural
relationship.   The Duke PA program had emphasized to all of its
students that when you go on rotations that, as a PA student, you
bring certain things to that process, and that one of the ways
you get ahead is by bartering, if you will, what you bring with
what other learners bring, and they really encouraged us to
collaborate and partner with the medical students and
occasionally even with the interns in terms of the kinds of

skills and knowledge that we had.    What we generally brought to
it was either a lot of technical skill and/or a lot of practical

experience.   What the medical students and house staff had,
obviously, were a lot of in-depth theoretical knowledge. And so,
                                                                      25

you know, "1'11 teach you how to start an IV if you'll help me
understand acid-base balance a bit better."        So that really
everybody kind of grew up that way at Duke, so that when you
achieved the level of faculty status, the medical students
understood who you were and what you were, and the residents,
many of them having come up through the Duke system, also
understood that.      So   it was fairly well received, and it then
became an issue of your own individual competency as a clinician
and as a teacher.


Mullan:    So you were four years there in these multiple

capacities?


Toney:    Yes.



Mullan:    A teacher, a preceptor.     Any research?



Toney:    No.    At the time, our chairman, Dr. Harvey Estes, who was

a wonderful, wonderful man and has remained one of my mentors
over the years, really saw--1 mean, not that he devalued
research, but he saw education and service, particularly in the
area of primary care and family medicine, as where he wanted to
drive that department.       So he felt that he had enough other

people doing various kinds of research, including some of the
senior faculty, for example, within the PA program, but he wanted
those of us who were junior faculty members to teach and spread
the mission, if you will, of primary care and also to establish,
                                                                     26

 to the best of our collective abilities, the Duke presence as a
deliverer of primary care services.     Historically, Duke, as you
well know, has been seen, and is still seen, as a major tertiary
research center.     Dr. Estes wanted to enhance the presence of
Duke as a primary care center.



Mullan:    That was the thrust?



Toney:    Right.   That kind of thinking, particularly in that kind

of institution, was very cutting edge, and, in retrospect, way
ahead of its time, in terms of talking about the early eighties
and having someone in that context and environment saying, "We
need to really move forward the institution of primary care."


Mullan:    What was your own thinking on primary care?   Was the

term, at this point, early eighties, being used, and what was

your sense of the distinction between primary care or whatever
you called it, and specialty care, particularly since PAS
statistically have become more specialized over the years?    What
was going on then?


Toney:    Well, from a philosophical and certainly in terms of our

training as PAS, the programs were modeled around generalist
primary care so that right from the inception of coming into the
program, that was seen as an institutional and professional goal,
and that held true despite the fact that, as you correctly said,

more and more PAS, particularly through the seventies and
                                                                  27

eighties, ended up being recruited into specialty settings, but
the educational programs maintained their philosophy and
commitment to primary care.    So   I would say, as a PA, even
trained at an institution such as Duke, that I or any typical PA
was far more aware of and sensitive to primary care and the
issues than a typical medical student or resident, who were being

put through a system at Duke that was almost exclusively
specialty-oriented.
     What happened when people got out of school, and many of

them had a legitimate interest in a variety of specialty areas,
but often what happened was because of where the job market was,
that even those who wanted to go into primary care couldn't find
it where they wanted it or couldn't find it at a salary level
that allowed them to go into practice and pay off their
educational indebtedness and so forth.


Mullan:    It was the market that tended to pull PAS--



Toney:    Yes.   The market was a significant influence, and we did

a lot of counseling for graduates going outl and time and time
again we would hear people sayl "I really want to go into primary
care," or, "I really would like to go to a rural area, b u t either
I can't find the job or I've got a l l this debt and they're paying
this amount over here in this surgery practice, or this
cardiology practice is willing to pay me this and I've got a
family to support," because, as you know, many of the PAS
                                                                  28

represent adult learners who came with adult responsibilities,
including family responsibilities.


Mullan:   At the risk of jumping of ahead in our story, if you

look in the early to mid-nineties at the environment surrounding
the PA profession and academic PA programs, had that changed from
what you experienced at Duke and what existed in the early
eighties?


Toney:    Not really.   I mean, the philosophy of the programs, the

vast majority of programs that have come on line in the past two
decades has maintained its commitment to primary care.    What has
changed and then changed back again is over the years some of the
programs under operation began to, out of necessity, dilute to a
bit the actual clinical experience so that students ended up
taking more specialty rotations than primary care-oriented
rotations because of, again, looking ahead at the marketplace and
also looking at what was available, because there was a real
limiting factor on the number of primary care, particularly
community-based primary care, preceptorships and rotation
opportunities available for a program, and most programs have
very limited resources in terms of how far afield they can send
their students for their training. What has happened with the

nineties and the reemergence or, in some cases, the emergence of
primary care as a policy/service/delivery/educational/focal point
is that the PA programs are now able to refocus their resources
and their energy and be able to sell primary care to their
                                                                   29

students and be able to negotiate more clinical training
opportunities. But throughout the twenty or thirty years that
we're talking about here, with the exception of programs that
were established as specialty programs such as Surgeon's
Assistant Program at the University of Alabama, the vast majority
of PA programs saw themselves and attempted to the best of their
ability to train their students as generalists, with the hopes
that the majority of those students would go into one of the
primary care disciplines with a focus of primary care.


Mullan:     Would it be fair to say that changes in the market with

more primary care opportunity brought the focus back a little
more to generalism than it had been through the mid- and late
eighties?


Toney:    Yes, focus back to the programs and, more importantly,

has made the concept once again attractive to the students.


Mullan:     Why don't we turn the tape over.


[Begin Tape 1, Side 21


Mullan:     This is Carl Toney, side two of tape one.

     You continued on South in 1984, I believe?



Toney:    Yes, and it was in following my wife's career.   She

graduated from Duke in 1982, and after graduating, she was trying
                                                                      30

 to decide for herself what type of practice she wanted to go
 into.    Initially she had thought about going into surgery, but
decided that she didn't want to do that and instead wanted to go
 into obstetrics and gynecology.     So in 1983, she moved to Atlanta

to accept a position at Grady Hospital, which is the single
public hospital in Atlanta.     Atlanta at that time had forty-six
hospitals; forty-five were private.     Grady Hospital was the only
true public hospital.    So   she accepted a position there as the
first PA in their OB/GYN emergency room at Grady Hospital.
     I stayed on at Duke for another year to finish out my
teaching contract and then moved to Atlanta to join my wife.     At
that time I was invited to join the faculty at Emory University
within the Department of Community and Family Medicine there. My

responsibilities there were 100 percent with the PA program,
primarily working on two federal grant projects that they had
gotten funded for.    One was the development of a preventive

medicine curricula and text, and the other was a minority

recruitment initiative that they were trying.     Both projects were
being tried at the PA program with the hopes that if successful,
they could then be possibly incorporated into the medical school.
     So I came on board at Emory in March of 1984 and stayed
until the projects were completed, until the end of June 1986. I
also did some teaching within the program and some other
administrative responsibilities as well.



Mullan:   Why pilot a medical. student curriculum with PAS?
                                                                    31

Toney:    Well, it's kind of like the old commercial, "Let Mikey

try it.   Mikey will try anything."   PA programs historically and
out of necessity have often been willing to try new approaches to
education, mostly because they were always facing the battle of
limited resources, limited time, and therefore being driven to
find a better way to enhance the educational process.     I think
the medical school saw it as something that was of value to them
because they recognized that the PA program overall educational
process was analogous enough to the medical school experience
that if a particular portion of the curriculum could be
successfully developed for this group of learners that were
ultimately going to become clinicians and providers, then with
possibly some minor changes it might also prove to be of value to
the medical school at large.   That's been very common around the
country at various places.
     We worked on the preventive medicine piece and developed a
text, a programmed text, that I thought was very good, that, as
far as I know, was incorporated into the PA program curriculum,
and I'm not sure whether it was ever incorporated at least in the
form that we developed within the medical school curriculum,
because we completed the project and I moved on, and I'm not sure
whether the medical school ever took it on, but I would say that
what we developed people were very pleased with at both the PA

program level, the federal level, and those people at the medical

school who had been involved were pleased.
                                                                    32

Mullan:    Let me ask a question I should have asked earlier about

financing PA training.   How did you pay for your two years at

Duke and, as you have looked at over the years at Duke, Emory,
and elsewhere, how much is individual funding? What other
sources is money coming from?


Toney:    Well, I paid for my education through student loans that

I negotiated through Duke University, from national loans and

other funds and Duke-oriented funds.    I also had some support
through the Veterans Administration in terms of their educational
benefits for veterans.   And then the rest I tried as best I could
to pay out of pocket, but I came out of school with about ten
years' worth of debt.    It wasn't a lot of debt relative to what
we're talking about now, but it was still significant for me.
And I think that that's true of most students. Most students
come with a combination of a bit of personal resources, never a
whole lot, because they, again, as I said earlier, tend to have
family responsibilities. But they come with a bit of personal
resources and then finance their education through either
institutional loans or governmental or private loans.
     One of the things that has been increasingly more helpful,
which was either not available when I was a student or certainly
we were not aware of when I was a student, was the support from
sources such as the National Health Services Corps.     So we see

now a lot more students using that either through the scholarship
program at the front end or through the federal loan repayment

programs or federal/state partnership repayment programs in terms
                                                                     33

of paying off indebtedness, which really makes a significant

difference, both in terms of people who can attend school and
what kinds of decisions they make in terms of where they want to
practice afterwards.     If they know that they don't have that
indebtedness on their back, then they have the opportunity to
follow what may be their first choice.


Mullan:    What is the tuition nowadays at PA schools?



Toney:    I believe at Duke it's probably around $35,000 a year.



Mullan:    So it's like medical school?



Toney:    Yes.   It closed the gap, unfortunately.   But there's a

real spread in terms of some schools are still twelve, fifteen
hundred or two thousand dollars a year, particularly at the
public schools.    If you look at Medical College of Georgia, for
example, which is publicly supported, their tuition is a half of
or possibly even a third of what it costs to go to Emory.     So

where the difference really comes is whether it's a public
institution versus private.


Mullan:   While we're on the subject of finance, the federal

government has had a program to support PA schools almost from
the beginning.    What sort of role has that played in the growth
of the profession?
                                                                     34

Toney:   Without that support, there would not be a PA profession.

It's as simple as that.   I mean, the early programs such as Duke
and a few others got some additional funding from private
foundations such as Kellogg and Robert Woods Johnson and Josiah

Macy [phonetic] and some of the others, but the real truth is
that they face having to convince their own parent institutions
that this was a viable investment, and dollars are always scarce.
So had the federal government not stepped in, particularly at the

level it did in 1971 through the [Richard M.] Nixon
Administration with a comprehensive health education bill that
covered PAS and established family practice and nursing and so
forth, I don't think that either the educational component or the
profession as a whole would be where it is today, because
virtually every program, including the first programs such as
Duke, were dependent at some point on those federal funds to
either establish and/or maintain the programs.
     Some programs such as Duke were fortunate that they quickly
developed a significant amount of in-house institutional funding
so that they could begin to come off of federal support, but
other programs, because of a lack of local resources, have had to
maintain a close association with the federal government.     So I

think that's been critical.
     The other piece that people tend to forget about that that I
also think is as critical, outside of just the support, has been

the direction and guidance around how the professions should
evolve or what kinds of things should be looked at as priorities.
Often the Bureau of Health Professions has, through its own
                                                                   35

initiatives, established priorities that they would like to see
the educational programs address, whether it be HIV/AIDS, whether
it be prevention, whether it be geriatrics, as part of the
process of receiving federal support, and I think that that has
been very good for programs because often it raised issues for
programs that programs otherwise would not have raised for
themselves as issues that they wanted to incorporate, including
allowing those programs to turn to their parent institutions, who
may have had little or no interest in these areas, and say, "We
need to do this because it's part of our grant requirements."     I
think that that has helped in introducing issues and addressing
how to educationally address those issues at one level and for
one group of learners, but again through cross-pollinization,
institutionally and individually, then it helps get spread to
other learners.    So I think that that has been a part of the

relationship between the federal government and the educational
programs that I think people don't really appreciate to the level
that they should.


Mullan:    You mentioned HIV and underserved.



Toney:    HIV, underserved areas, prevention, geriatrics.   PA

programs were involved in trying to develop a geriatric

curriculum at that level way ahead of where most medical schools
were, as far as I'm aware of, in terms of legitimately trying to

incorporate that into the initial undergraduate medical training

experience.
                                                                     36

Mullan:    But with apologies for weaving in and out of your story

and the policy issues, you've done a couple years now at Emory, a
year and a half.    What happens next?


Toney:    I finished up the projects at Emory, and so I was there

for two years, and I decided that I'd had enough of academia.        I
had been in academia now for six and a half years, and I had
enjoyed it, but I thought it was time to move on to other things
So   I went back into full-time clinical practice in Atlanta with
an internist, a general internist, and we were doing a
combination of general internal medicine, occupational health,
and geriatrics.


Mullan:    How was that?



Toney:    Overwhelming.    We had a very, very large practice, and

the physician I was in practice with had partners that they
shared call with, but for all intents and purposes, he was really
operating as a solo practitioner.     We had three offices that we
had to cover.   We had, at our height or our depth, depending on
how one looks at it, in terms of our geriatric responsibilities,
we had a geriatric patient census of five hundred patients that
was spread out in five nursing homes across the breadth of
Atlanta, and plus we had patients in the hospital that he
admitted through his general practice.     So it was challenging and

exhausting.
                                                                      37

Mullan:    How did you pick him, and how'd he pick you?



Toney:    I was looking for something in primary care and community

based and, obviously, in Atlanta.    I had heard through some
colleagues of mine--well, he was practicing at Piedmont Hospital,
which is one of the community hospitals in Atlanta, but it's also
affiliated with Emory as a teaching site for Emory folks, and I'd
heard through some of my colleagues that he was looking.      He had
been well established.    He was an older physician when I met him.
He had just turned sixty, had been practicing in Atlanta for some
thirty years, and the connection that we ultimately had that led
to my joining his practice--because we were very different.      He
was white; I'm black.    He was from the South; I was from the
North.    He's a capitalist and a conservative; I'm a socialist
bordering on being a Marxist.    But the two points that we
intersected was that he had done some of his training at Columbia
in New York.   Most importantly, as it turned out, we both had
trained under Dr. Stead at Duke.    Dr. Wiggins had gone through
medical school at Emory, but had done part of his internship and
residency at Duke and had trained under Dr. Stead.   And that, I
think, is what convinced him.    I can remember at the interview,
he said that since we both had survived training under Dr. Stead,
that said a lot about both of us, and if I was willing to put up
with his capitalist conservative ways, he would try to put up

with my radical socialist agenda.


Mullan:   And how did it work?
                                                                            38

Toney:     For four years, it worked pretty well.        It worked pretty

well.     I ultimately left after four years, partially because I

just thought that the practice was growing and had grown to a
point where morally we were out of control.          We couldn't control
the responsibilities we had taken on.         I was very concerned about
that.     But at the same time, I was also personally moving in a
different direction in that while I love and do love patient care
and loved all my patients, I was becoming increasingly frustrated
at seemingly being unable to effect any legitimate change in
terms of the system and how things were being done in terms of
patient care and patient issues, health care issues one patient
at a time.
        So I began to rethink maybe where I needed to be, and began
to come to the conclusion that I needed to--at least I thought I
needed and wanted to move into an area of health policy and
planning.     So   I think I was kind of coming to a closure all on my
own about my own life's activities at that point in time.


Mullan:     Did you enjoy clinical practice?



Toney:    I enjoyed it a lot in terms of the patient contact.           What

I discovered, after spending all this time in health care, going
all the way back to 1965 to now, 1990, was that what I enjoyed
was the patient contact, that medicine in terms of a biological

science bored me.      I mean, to pick up an issue of the N e w E n g l a n d

Journal, while I recognized it was important and relevant, bored

me.   On the other hand, if I picked up a copy of the American
                                                                           39

J o u r n a l of P u b l i c Health and read it or similar-type journals

that talked about the issues around health care, including
clinical issues but from a very different perspective, that
really intrigued me.     So   I realized after all these years that
maybe it was wasn't medicine that so enthralled me as health
care.


Mullan:     And therefore what did you do?



Toney:    What I did was I went back to school at that point at

Georgia State University and got a bachelor's degree in political
science with a minor in economics.       When I had graduated from
Duke, I had not received my degree from Duke because I had been
sixteen credits short of being degree-eligible.          At the time I
didn't think that was a problem, and I would just stay at Duke
for an extra semester and do advanced basket-weaving.           I needed
some credits that had nothing to do with my professional

training.    But I found to my dismay that the board of trustees of
Duke had many years previous to my arrival passed a rule that
only applied to the PA program, that said that if you did not
receive your degree at the time of graduation, you could not
receive a retroactive degree from Duke in that discipline.            So I

was basically locked out of the process.
     What I then found was that in trying to go to another
institution to get my degree, that I ran into the problem that
other institutions didn't know what to do, literally, with how to
evaluate the academic credit I had earned at Duke within the PA
                                                                       40

program.     They knew what physiology was, and they knew what
anatomy was.       They weren't sure what to do with pulmonary
medicine or general surgery.       So   I would always be told, "Now
you're going to have to start all over again," which was totally

unacceptable.       And it wasn't until I made this decision in
Atlanta that I was going to go back to school and change
directions that I decided, "Well, I'll try one more time," and I
went and spoke with the folks at Georgia State University,
explained my situation, brought copies of my transcripts and let

them look at them.
     Fortunately for me--and it may have just been the person I
talked to that particular day, but they said, "We can work with
you on this," and worked it out so that they could bring me in as
a transfer student and allow me to either continue in my
discipline of biology or change disciplines in terms of getting
my degree.       Since I was interested and knew that I was headed

toward health policy and planning, I elected to get a degree in
political science with a minor in economics.


Mullan:    So you did that while you were in practice?



Toney:    Yes.



Mullan:    And then?



Toney:    I finished up there.    I left Dr. Wiggins' practice in

1991 after I finished school and joined the Georgia Department of
                                                                     41

Human Resources in what was then their Primary Health Care
Section as a health and manpower specialist, and my job there was
to be the state liaison with the Bureau of Primary Health Care in
the National Health Service Corps around those kinds of primary
care state/federal initiatives.     That was my initial introduction
into health policy and planning.


Mullan:    At the federal level?



Toney:    Yes.



Mullan:    That must have been an interesting time.   A lot of
National Service Corps assignees in Georgia?


Toney:    Yes.   It was very active in Georgia in terms of the

National Health Service Corps.     Plus we were fortunate that the
U.S. Public Health Service regional office is based in Atlanta.
So we had a lot of very close and ongoing and intimate

interaction with the regional office staff, which I think really
enhanced my maturity and growth around the issues, because they
were very welcoming and were very good teachers in terms of what
some of the issues were, but it also allowed us to partner in a
way that being located in another state and farther away would

not allow you to do.    So it was very active.
     Georgia's a rural state and has a very large community
health center, migrant health center system, as well as it was
emerging through the rural health clinics.    So there was a lot of
                                                                   42

activity that needed to be done around systems development for
primary health care services, and we were at the forefront.
Shortly after I joined the staff, the issue came up about the
creation, the formal creation, of a state Office of Rural Health
and who would staff that and where would that be located within
state government.    Fortunately, at least from my perspective,
after a lot of negotiation, the governor decided that it belonged
within the Department of Human Resources and that the Primary
Care Section that I was currently in would be evolved into and
become the state Office of Rural Health.    And so it expanded
almost overnight, our role and responsibilities and visibility
and presence, both at a policy and planning level as well as an
operational level.   So   it was a wonderful, wonderful training
ground.
     I was the first clinician that they'd ever had within this
section, which I found intriguing in terms of making decisions

about how you're going to use clinicians.    So it was really good,
and we had those kind of responsibilities, both urban and rural.
At the time that I joined, it was also the time the federal
government downloaded the foreign medical graduate situation with
the J-1 visa waivers, and that became a state function, and that
was immediately turned over by the governor's office to my
office.   So there were a lot of different--



Mullan:   That being that you got the responsibility for

deciding--
                                                                      43

Toney:    For developing the process and working with communities,

those communities that wanted to recruit foreign medical
graduates to come practice through the J-1 visa labor system.


Mullan:     It was a federal waiver, but the state could help?



Toney:    The states decided where and when and basically did all

the work.    All the work up until 1991 had been done at a federal
level between the federal agencies and the local community.       The
federal agencies decided they were being overwhelmed and it made
more sense to move the operational level to the state and leave
their participation as being the final approval mechanism.       So

the state agencies became the real broker.


Mullan:     How did that dynamic work?   Who was pushing and pulling

for foreign graduate placements?


Toney:    The experience that we had in Georgia initially was not a

good one, although I think I need to say that from what I've
heard in talking with f o l k s around the country, that our
experience did not necessarily represent the norm but possibly
more the exception.    By that I mean initially we didn't have a
lot of interest in this program by communities, and we had to go
out and really talk communities into it, and usually they were
very, very desperate communities who either could not recruit
physicians at all or who could recruit them, but could not retain
                                                                    44

them for any reasonable length of time.    So then it became a

question of finding physicians willing to go there.
     There were a lot of physicians who quickly popped up either
directly or through representative intermediaries, usually

attorneys, because this quickly became a real money-making deal
for attorneys, to do these J-1 visas, even though you really
didn't need an attorney to do it.    So I was inundated with phone
calls and faxes and CVs, unsolicited, from people around the
country who were trying to find positions.
     The problem that we had, at least in the first three years,

in the years that I oversaw the program in Georgia, was the way
that the program unfortunately was set up at the federal level,
and that was that the states were to do all the work, get the
match done between the provider and the site.    If the provider
didn't work out and left or didn't uphold the contract in some

way, there were sanctions that could be taken, which included a
quarter-of-a-million-dollar fine, possible jail, possible
deportation.    Well, the first couple of placements that we did,
that's exactly what happened.   The physician got there and
stayed, in two cases, less than sixty days and left.      And then we
appealed to the federal agencies for support, and then in
addressing this, we found very quickly that that support was not
forthcoming.



Mullan:    That is, support in enforcing the sanctions?



Toney:    Enforcing the sanctions.
                                                                      45

Mullan:    What sort of support were you looking for?


Toney:    Well, we were looking for the federal government either

to tell this person to come back or to fine them or to deport
them, and we saw those as being very important, not so much for
that individual, but as a clear lesson to others who may come, to
send the word out that you cannot get away with doing this, at
least in Georgia.
     Where the problem was with the system at that time was the

whole labor process was set up so that in order to be able to
stay in this country long term, you were going to get a waiver in
having to return to your home country and go through two years of
service.   Well, once you agreed to do that, the Department of
Immigration and Naturalization Services gave you your Green Card
immediately. Once you had your Green Card, there was no
compelling reason to stay, and people would leave.      And because
the federal government wouldn't enforce the sanctions, it quickly
became known through the underground network--and believe me,
there is a very, very sophisticated underground network--that you
could do this with relative impunity.
     So we ran into a couple of major problems where communities
who had gotten their hopes really raised around this and rallied
around the individual physician as well as the program were just
devastated.   So in a sense, at least psychologically and
emotionally, the community was worse o f f than they had been.   And

that made those of us at the state level very, very angry.
                                                                    46

Mullan:   As far as you've been able to follow it, either in
Georgia or here in Maine, for that matter, or generally, has the
situation improved any, or is it still a very loose, sloppy
system which a lot of people abuse?


Toney: As far as I know, and certainly my experience up until I

left Georgia, there was no change at the federal level in terms
of their attitude about the program.    What seemed to be the case,

and it was more serendipity and chance than I think anything

anybody was doing, is that as the program evolved and matured,
what appeared to be the case, and certainly outside of Georgia

and from what I hear since I've left, even within Georgia, that
the majority of people that have come through have been honorable

people who have been willing to stay at least for the two years
of their obligation, and some of them have stayed on beyond that.
     Here in Maine, for example, and some other places, they've

had wonderful experiences.     In West Virginia, from what I have
been told from my counterparts there, they had a wonderful
experience.   I think that we just had an unfortunate series, but
it was like the first two or three, maybe even four, placings we
did were just horrible.   The worst-case scenario was the final
case that I dealt with that was a major problem, was receiving a
call in my office in Atlanta from the VA in Denver, who wanted a

recommendation about this physician who was applying for a

position with the Denver VA.    And I said, "Gee.   You know, I
don't know what to tell you.    This individual was up in so-and-
                                                                    47

so, Georgia, doing primary care.    They're not going to even be
available for another two years."
     And the person said, "Gee, I don't understand that.    We're
communicating with this person, but we're communicating with them
at the University of Alabama in Birmingham."
     And once I initiated investigation, what I found out was

that this person that we had approved and to the best of our
knowledge was providing care in this rural community in Georgia
was, in fact, doing an invasive cardiology fellowship at the
University of Alabama in Birmingham, and his sponsoring physician
was covering for him and lying to both us and the federal
government, falsifying reports and so forth.   And so I had to go

up there as an official state agent representing both the state
and federal government and confront this sponsoring physician
who, under interrogation, finally broke down and admitted that
the whole thing had been a fraud.   That was kind of the worst
there.


Mullan:   Let's move your story forward.   In 1993 you decided to

come back to Maine.


Toney: My plan had always been to come back to Maine, both for

personal and professional reasons, and in 1993 I did a U.S.
Public Health Service Primary Care Policy Fellowship within the

Bureau of Health Professions, and felt that that experience
alone, where it evolved to through my work with t h e state Office
of Rural Health had prepared me to a point where 1 thought it was
                                                                      48

time to move on and it was time to make the move back to Maine if
I could find a way to do that and maintain the kinds of interest
that I had.   My wife was also ready to move back.
     So   I was fortunate enough, at that point, in the fall of
1993, to relocate back to Maine and to be invited to join state

government here with the Bureau of Health as the director of
their HIV/STD Prevention Program for the state.      They were
looking for an individual who had primary care clinical
background who also had public health administrative experience
and who was a mid-level practitioner.    So I thought it was a
perfect job, as far as that's concerned.


Mullan:   Was it good?



Toney:    I really enjoyed it.   I had a fantastic staff.   I had a

staff of about ten people that I inherited, who were absolutely
superb.   The challenges that I found here were two, one that I
knew about and one that I didn't appreciate until I actually came
and interviewed for a position.    The one challenge I knew about
is that the program had been without a full-time director for
about three years, so it was basically just treading water and
not making a whole lot of headway around either HIV or STD
prevention activities here in the state at all.    Maine is a state
that has a unique challenge in that both HIV and the array of

STDs are present here and the numbers are small, even though the

percentages and rate of incidence reflect the national
perspective, but the absolute numbers are small, and so the
                                                                       49

challenge here in Maine was to try to convince communities,
people at risk, and policy-makers that this is an issue that
Maine desperately needed to deal with.      So   the good news was you
didn't have a lot of HIV and STD in Maine.       The bad news was you
didn't have a lot of HIV and STD in Maine.       So the challenge was

to make the case.   So that was one challenge that I knew about

corning into the position.
     The other that I didn't really understand until I
interviewed and ultimately got here was that the model was very
different from Georgia.      The public health system and
infrastructure had been a mess.     Georgia has 159 counties, second
only to Texas in terms of the number of counties, and the public
health infrastructure is decentralized and present in every

county at every level.    So you really had this network that you
could maneuver through.
     Here in Maine, the public health infrastructure is really
the people who sit at the central offices in Augusta.       There is
no infrastructure here at the community or county level.       There
are three counties of health departments in the state, and all
three of those are located in one of the three "urban cities,"
and the interface between public health and the local community
is actually done through a negotiated interface through the
private delivery sector of health care.     So it was a totally

different model than what I was used to and how I had framed, in
anticipation of arriving, what I thought I could, would, and

should do.
                                                                     50

     When I got here I found out, well, tear that up because

there's no infrastructure to do that.     So what that required then
was for me to basically get in my car and spend a lot of time out
on the road, particularly in the area of HIV, meeting with
infected individuals, meeting with AIDS service organizations and
other community groups, meeting with community leaders, meeting
with local physicians and other service delivery folks to, one,
explain the issue and help local communities to kind of figure
out where they're at around the issue and what their needs may
be, and also explain what public health is and what the public

health mission is around this issue.     It's that, "I'm from the
state and I'm here to help you," type thing.
     But it was a wonderful, wonderful experience, and it was an

exciting time to be here, because a lot of things were coming
together from various corners around HIV with new initiatives,
some of them federally sponsored, others locally sponsored.     So
public health had an opportunity to really be a broker and a
presence in pulling private-sector initiatives and federal new
initiatives together and begin to weave together public-private
partnerships.


Mullan:   You described once before how the demography of Maine,

where there are very few blacks. As a state official trying to
work across the state, how were you received?



Toney:    I had a wonderful time f o r two reasons, and I'm laughing
because both of them would seem to be liabilities, but they
                                                                      51

actually proved to be assets.     To the best of my knowledge, at
that time I was the only black in all of state government and had
been only the second black ever in the state government other
than one other elected official state representative.       So even
though I did not inherently have a high-profile position in the
structure of state government, everybody knew who I was.       They
didn't know my name, but if you ever asked where I was, "He's the
black guy."
     "Oh, I know who he is.    Okay."
     So that really helped because people knew who    I was, and
people within state government and outside of state government
were very receptive.   The issue of my being black was not an
issue at all.   What really was an issue for people and what
people struggled with when I met them was how could I have lived
in Maine before and left?     That's the part they didn't
understand, not that I was black.
     The other thing that proved to be a real asset, my
philosophy is I really think you've got to get out.       Whatever the
issues are, you've g o t to go where the issue is located.     You
can't do it long distance.    You can't do it by phone.     I'm an old
throwback.    I mean, I know computers are here and interactive TV
are here, but I still feel like I need to go look you in the eye,
hear what you have to say, see what's really going on.      And so
when I went places, people were shocked, because since there was

no infrastructure, they very rarely saw anybody from state
government, and particularly anybody representing public health.
They knew there's an 800 number you could call up and get
                                                                           52

information about this issue or this problem, but to actually
have somebody come up in the community and say, "I want to sit
down and hear what you have to say about this situation,'' they
were literally amazed.      So my willingness to do that, out of
survival, more than anything else, from my perspective, really
afforded me and, by extension, therefore, the program, which is
really the important thing, a lot of credibility and a lot of
renewed visibility.     And all of a sudden people began to
understand and appreciate, some for the first time, that there
even was such a program in Maine.
       And in Maine, unfortunately, like many states and many
governmental entities, had split the process.         So there was one

part of state government that was doing AIDS and STD prevention
work, and then there was a total separate part of state
government doing Ryan White service delivery work, and there was
absolutely no communication between the two.         And often, people

who had difficulty or problems with the Ryan White side for one
reason or another, assumed, since it was all the same and that
they heard about this other public health HIV o f f i c e , t h e y
assumed that was the people who were giving them problems.            So

you either had to run up against people not knowing who you were
o r misunderstanding who you were.



Mullan:   In 1994, end of the year, you moved back to academia.

Why?
                                                                     53

Toney:   When I took the position at the state with the Bureau of

Health as AIDS director, I came into that with a promise to
myself that I would evaluate the position and how I felt about
what I was doing at the end of a year.    This was an area that I
was very interested in, but my concern going into it was that I
had been so involved for so many years with primary care in a
rather global and expansive way, that this was the first time I

was narrowing down to really kind of a single-focused issue, you
know, just take HIV/STD as a single issue.     My one concern about
taking the position was that it might be too narrowly focused for

me, although I said well, part of the way I'll trying to deal
with that is to kind of wedge open the door and make people
understand, if I can, to the best of my ability, that while this

is a very important issue, it's part of a larger picture of
health care.   And to some degree I think I was successful in
doing that, but to be very truthful, at the end of a year, what I
found was that my fear was realized, that for me, while this was
very, very important, it was still too confining.    And as my year
went on, I found myself constantly kind of looking over the
fence, if you will, to see what was going on in the primary care
community here in Maine and both national.     I just couldn't
settle into what I was doing, and I began to get more and more
distracted by what was going on.
     It was also a time when, obviously, things are going on at
the federal level around health care reform.    Maine was going
through its health care reform initiative.    The school was here.
Let's talk about the P A program.   Muskie Institute was
                                                                     54

coming out with a lot of research and information about health
care policy and primary care.     So there was all these things

right on the other side of the fence. And so I decided that I
didn't know what I was going to do, but that I probably would not
stay long-term with the Bureau of Health.     I felt I'd gotten it

to a greater degree of presence.     I had done what Dr. Estes had

always told me to do, that when you take a new position, the

first thing you do is l o o k around and find who's going to replace
you, who you want to replace you, and get that person geared up.

I had identified that person, and I thought actually I had gotten
a lot of energy generated. Maintenance-wise, I felt the person I
had identified would probably do a better job long term than I
would have done anyway.    And so I thought, "This is not a bad
time.     Everybody's excited."   Leave while they're still
applauding.


Mullan:    And you came here?



Toney:    At that time this position open up as well.



Mullan:    What is this position?



Toney:    As the associate director of the AHEC, Area Health

Education Center program.    At the same time they were also
looking for a director of the PA program t h a t they were trying to
start.     So I actually ended up looking at and interviewing for

both positions.     I decided that I wanted to work with AHEC
                                                                       55

because it was more in line with where I was at and what I was
interested in relative to broad-based development around primary
care, and even in this position I could contribute to the
development of the PA program, but I didn't want to go back to
limiting my activities only as related to PA issues.


Mullan:     What do you do for a living now?



Toney: As associate director of the statewide area AHEC program,
and we have one program which is based here at the University of
New England, and we have one community-base AHEC Center which we
relate to through a contractual relationship, and they're located

up in the northern part of the state, in Lubec, and we do a
number of things.    First and foremost, we support, through
logistical health and scheduling, clinical training of health
professional students.    Particularly we do rural training sites
for the medical school here at the university.      We also have a
contract now to develop the clinical rotation sites for the new
PA program.    We work on an as-needed basis with some of the
allied health and other clinical training programs or foreign
nurse practitioner programs in the state.      There are PT programs
and OT programs and other allied health who, on occasion, as
needed, will come to us to ask for assistance.
     Our mission, even though we're based here at the University
of New England, is statewide, so we work with all programs based
at all institutions, regardless of the type of program or the
location.    The other part of our mission or the second third is
                                                                    56

to help in support of sponsoring or coordinating continuing
education for practicing clinicians, particularly those located

in rural or isolated areas, so that they can maintain their
clinical skills and competency, but are often prevented, by the
very nature of their practice, from getting away to large

national conferences.
    And the third thing that we do is involved in kind of

collaborative health planning and health policy work in terms of
trying to do systems development work to develop the primary
care, particularly the primary care, but the overall health care
infrastructure for Maine.      Maine is going through a lot of
changes.    Managed care is just coming into the state.   We have

about a 12 percent penetration at this point, and it's going to
dramatically increase, and it's a real challenge in a state
that's basically a rural state with real isolated small community
pockets.    We work closely with the community health center
organizations.    Rural health clinics are very big here, as well--


[Begin Tape 2 , Side 11



Mullan:    Tape two, side A.



Toney:     So as I was saying, we work on both a policy planning

level, support for continuing education of practitioners and on
support of entry-level health professionals, and we try to
collaborate as well on the regional level.      So, for example,

we're involved in trying to get a new initiative up,
                                                                    57

collaborating with the AHEC here and the University of Maine
Interdisciplinary Training Service and the Harvard Geriatric
Education Center to develop a new education model around clinical
training for geriatrics.    So we take on a variety o f tasks.



Mullan:    Where do you see the system all going?   That's too broad

a question.    Let me focus it.   Particularly somebody who has come
up through the PA ranks, done practice, done academia, done

policy work, really had an extraordinarily broad experience,
where do you see the primary care part of the system going,
particularly from the perspective of a PA?


Toney:    As Uwe Reinhardt said ten years ago, we're headed, at

least for now, in the direction of managed care, and I think
managed care clearly is, and will be, the driving force, at least
for the foreseeable future.    Whether it's the ultimate model or
not remains to be seen.    I think much of primary care will be
delivered out of that model.
     The two exceptions to that that I think we're still not sure
about yet is truly where are the poor, both the urban poor and
the rural poor, going to get their care and whether it's really
going to be through managed care or not, and f o r states such as
Maine and other rural states where the managed care model, at

least the traditional managed care model, seemingly will have

difficulty working because there isn't a critical mass of

patients that can support it, what are we going to do about that?
                                                                     58

     So    I think primary care, one, is going to continue to grow
as a primary policy focus and service delivery focus and
therefore an educational focus for the foreseeable future.    I
think there will continue to be, despite the amount of what's
written and talked about managed care, there will continue to be
four or five different models of care and operation, stretching
from managed care on one end to community health centers and even
the traditional fee-for-service local-doc model on the other end.
I think the necessity of where people are and the kinds of
services they need will ensure that there is a spectrum.
     For PAS, I think on the one hand that it's very promising.
PAS as clinicians who are trained quickly and put out into
practice, who are cost-effective from a training perspective and
cost-effective from an overall employment perspective will
continue to be attractive and be very attractive to managed care
systems.    Where I think we don't know what's going to happen and
it may turn out to be problematic both for PAS as well as the
system at large is what's going to happen as the inflation for
PAS in terms of salaries continues to rise, thus closing the gap

between physicians and PAS, and if you really do have more and
more physicians who are going to become available, then their
market value, on one hand, is going to be driven down, but their
attractiveness to that very same market is going to rise.    So as

an employer, if I were to say, "Gee, I can hire this PA for X
dollars or I can hire this physician f o r X-plus-one-dollar," I

would probably hire the physician.
                                                                      59

        I think those kinds of issues and those potentials for
competition remain to be addressed.      I think there may well be a
problem.     Some discrete areas have already seen this happen, some
of the sub-specialty areas where PAS have become so attractive
that their salaries were raised so dramatically by inflation that
they priced themselves out of the market.      I think that that may
well happen to a degree in primary care.      Personally, as a PA and
someone who's committed to health care, I think it's very
important for both the PA educators and the PA profession,
including the professional associations both at the national and
state level, not to give into the seduction of existing for
existing's sake.     You know, we came into being to meet a need, to
fill a void, and why that void was created varies depending on
who you talk to, but I think it was a legitimate need and a
legitimate void.
        I think we need to be careful that if we're going to exist,
that we also need to continue to have a legitimate role.      If we
don't have a legitimate role or if that role is diminished
because of other changes in the delivery system or the
marketplace, then we need to have the courage to reorient and
retool.     If we don't, and if we decide we're just going to draw a
line in the sand and that's going to be where we fight, then I
think we'll lose.



Mullan:     That was well stated.   You've had really a marvelous

career committed more than I appreciated to the theme of primary

care.     Every time you wandered off, it tended to come back to
                                                                    60

this generalist concept.   As you look back on it now, what
connects you to that concept? What is it about you and what is
it about that approach to people, to health care, to life, that
is important?



Toney:    Well, that's hard to answer.   I think it's a couple of

things.    I think if I had to narrow it down, it's three things.
First, I think it was the philosophy and therefore the training I
had from my parents in terms of, you need to make a contribution
to the world.    No one should just take up space, and if you have
skills and abilities, you need to use them for the betterment of
something and someone other than yourself.
     Second, I really go back to the family physician that we had

growing up who I just saw as an extraordinary individual, and so
whatever I was going to be, a part of him was going to be in me,
to try to be what I saw that he was.
     And lastly I was extraordinarily fortunate to go to Duke for
my formal training as a PA and to be trained by people like Dr.
Estes and Dr. Stead and Dr. Carter and Dr. Michael Hamilton, who
was then program director, all individuals who lived and breathed
and really believed not only in PAS, but believed in primary care
and service and who really drove into you that to be the best was
to be the best at giving, not taking.    That reaffirmed what I
brought to the process.    I've always been proud of being a PA and
being a Duke PA, and I always want to live up to the standards

that they set.
                                                                      61

Mullan:    Great.   We're going to have to end there.   When you're

editing the tape, if you wanted to add in something along the
lines of what we've been chatting about over breakfast, about the
role and functioning of the NP, the PA vis-a-vis the primary care

physician and particularly the different approaches of the
professions to their "independence"--I think it's a more

complicated issue than just independence--but you had some great
thoughts there, and unfortunately time isn't going to let me draw
them out of you, but if you have some thoughts you just want to
add on at this point, the question would be something to the
effect of tell me about your thoughts about the role of the PA
vis-a-vis the ongoing practice of medicine, and how does that
vary from the nurse practitioner's role, and what do you see as
issues f o r nurse practitioners in addition to those for PAS in
the evolution of this?    If you'd take a crack at that on your
own, that would be great.    Thanks for a wonderful interview.



Toney:    Thank you.


[End of interview]