1 JOHN YINDRA July 10, 1996 Dr. Fitzhugh Mullan, interviewer Yindra: My name is John Yindra. Mullan: This is the 10th of July, 1996, and we're in Leeds, . Maine. Are we indeed in Leeds, as opposed to North Leeds? Yindra: Yes, we're in Leeds. Mullan: We're in Leeds Center. It's a sunny afternoon, and we're in Dr. Yindra's office in the Daniel Franklin David Russell Medical Center. Tell me a little bit about the center, and who Daniel Franklin David Russell was. Yindra: I think he practiced medicine for seventy years. We have his medical degree from Bowdoin Medical College out there, and his license, which the last one he got was when he was in his early nineties. Mullan: When was that? Yindra: That was in the seventies, early seventies. I think it was started here in 1975. I think he gave some money and some good offices for the town, who got together and got a little 2 community health center going, through the--I guess it's the 330 funding, through the government. Mullan: It's the Public Health Service 3 3 0 funding. Yindra: Right. Mullan: This would have been in-- Yindra: 1975, I think, was when it started. B i l l Flewelling, who was a nurse practitioner, was the original practitioner here. He worked on his own here with a couple of doctors from Lewiston sort of being his supervisor, and then as it grew, they got some doctors through the Public Health Service. Mullan: The National Health Service Corps? Yindra: Yes. They sort of came and went. Max Barris, who's right across the hall here, in the other office, stayed for three years, and wanted to continue to stay, and that's when they hired me. He was desperate for another person, because it was too hard to work just as one person. Since then, we've added another doctor and another nurse practitioner. Mullan: When was that? 3 Yindra: Max has been here now for over ten years. Mullan: When were you-- Yindra: I came here in 1987, and Tom, the other doctor, came about three years ago. So it's been sort of a gradual progression. Mullan: The practice--is it community-based? Is there a community board? Yindra: Yes, right. Still run the same way, which is sometimes frustrating, sometimes difficult. The town pretty much entrusts us to do things well, and pretty much goes along with suggestions that we make, as long as they're in good faith. Mullan: Tell me about yourself. Where do you hail from? My guess is, it's not Leeds Center. Yindra: No, I grew up in Wilmington, Delaware. Mullan: When were you born? Yindra: 1953. And basically lived there until I went off to college, and I went to college in Newark, Delaware, University of Delaware. Went to medical school at Thomas Jefferson. 4 Mullan: Tell me a little bit about growing up. What did your dad do? Yindra: My dad was an engineer. Mullan: Worked for Dupont? Yindra: No, he didn't work for that plant. He was an aerospace and mechanical engineer, and he built turbines. My brother, sister--and mom was a typical mom. Typical sort of fifties' family. Both my parents came from Eastern European backgrounds. They're both Czech. And all my grandparents, and all my relatives, were Czech, and they all came from rural backgrounds back then. So I guess I'm third generation. My grandparents always had a rural place to go live. One set lived in New York City, but they had a little place in the Catskill Mountains, and then the other had a farm in Connecticut, so I spent a lot of time in rural areas. As I was growing up, well, I said that's where I wanted to live. I didn't want to live in suburban Wilmington, Delaware. I wanted to live in a rural area. Mullan: At the university, did you know that you wanted to go into medicine? When did that come about? Yindra: No, I didn't really know I wanted to go into medicine until the very end. I was sort of thinking about becoming a biological researcher, as in marine studies. Started doing 5 research at the end of my career, and didn't really like it all that much. So I decided that I needed to do something practical. Being a doctor was sort of practical, so that was basically how I made my decision. Mullan: Were there doctors at all, in or around your community that there role models or significant players? Yindra: Yes, I would have to say that there were. I really don't even know his first name, but Dr. Kerrigan [phonetic], who was a general practitioner in Claymont [phonetic], Delaware, which is very much a suburban-urban place. I can still remember when he came to the house when I had measles. He came and made a house call, in this suburban development, gave me a shot of penicillin, told my mom to close the drapes, and that was the end of that. But he was a very interesting man. I liked him a lot. In fact, I went to him for my physical before I went to medical school. I thought that would be kind of cool. I hadn't seen him for a long time, so I had my mom make an appointment f o r me to go see him, f o r my medical school physical exam. I can still remember the advice he gave me. He said, "Don't be a doctor, be a broker." [Laughter] Mullan: Really? Yindra: Yes. 6 Mullan: In earnest? Yindra: Yes, I think he was getting a little bitter at the end because of malpractice. He had gotten a couple of bad malpractice--he did deliveries a long time ago, and I think he got stung by one that may have been a problem way back then. But I think that, by and large, he obviously really loved what he did. I mean, he did it very aggressively, I guess is a way to look at it. He was very dedicated to his work. Mullan: So out of college you went to medical school, or you took time o f f ? Yindra: I came from modest means, so I had to sort of get all my ducks in a row, and not waste too much time, and not [unclear] about getting ready for college. I married my high school sweetheart in college. I'm a pretty straight and narrow guy. [Laughter] Mullan: So was Thomas Jefferson where you wanted to go, or that's where you ended up? Yindra: Well, you know, it was interesting. I was really a pretty good student, and I applied to four medical schools, and Jefferson was really like my bailout, because they had a program where they took students from Delaware. Don't tell them that I said that it was my bailout. I applied to Yale and Penn and 7 Duke. Got interviews at every place. Didn't get into any of them. I can tell you my story with Yale. I really wanted to go there, because it was close to my grandmother's house. We were going to live with her. I had two interviews. I had an interview with the dean of a school--1 can't remember his name at the time--and with a radiologist. The dean thing went just like you would expect it to. And then I went into the radiologist's office, and he had stuff all over his room. As I was sitting there waiting, I looked up on the wall, and there was a Texas Longhorn scroll, class of '65 or something. At the time, Texas always had really good football teams, and I played football. So when he came in, we started talking about that, and that's practically all we talked about the whole time. We really hit it off. And, at the end of it, he said, "John, if I have anything to say about it, you're going to get in. You're the first down- to-earth person I've met and talked to in a long time." So I felt pretty good about that. I thought, "Wow, I'm going to get into Yale. This is going to be good." I had lunch, and I went and talked to some students, and they asked me how the conversation went with the dean. They said, "Well, did you tell him what you wanted to be?" I said, "Well, yeah. I said I wanted to be a family doctor. I' And they all sort of looked around like this, and said, "Well, that was the wrong this to say." [Laughter] And as it turned out, it probably was the wrong thing to say. 8 Mullan: You were somewhat clear about that at the time? Yindra: I was definitely sure that's what I was going to be. I had read an article about family docs in Newsweek or some place, and it just really appealed to me. I almost got seduced away into OB/GYN. Mullan: Which year was it you were applying? Which year did you graduate? Yindra: I graduated in '79. Mullan: So, about '75. Yindra: Right. Mullan: It was still the Dark Ages for-- Yindra: Oh, yeah, for family practice. Yeah, it was. It was still. But Jefferson, I thought, and still--1 think today, even still, all the things I read about, the articles published, they were very supportive of family practice. Not everyone in the community was, but there was a core group of people who didn't try to dissuade you. Paul Bruckner [phonetic], f o r instance, he's the dean of the school, or he is at this point. So I thought it was a very good experience. I was able to spend most of my clinical years at the Wilmington Medical Center, which is 9 where I did my residency, eventually. So I spent most of my clinical time away from the Ivory Tower, and I think that was very good, too. Mullan: Was your clarity about wanting to do family medicine linked to your rural interests that you had in mind? Yindra: Yes. I knew there was a need for it. I figured I could pretty much live wherever I wanted to go, so it sort of fit together. Mullan: And the Jefferson experience, overall, it was clinical years you were in Wilmington? The first two years, you were in Philadelphia pretty much, I would gather. Yindra: Right. The first two years, I was in Philadelphia. It was good; I enjoyed it. I look back at it with fond memories. I don't look at it as drudgery. Mullan: And they weren't trying to dissuade you from your goal? Yindra: Oh, yes, every now and then, you know, you'd run into somebody who'd say something like, "You're too smart to be a family physician," or that kind of thing. I had one pediatrician who I really liked, who was at the Wilmington Medical Center, and tried hard as he could to get me to be a pediatrician. But he didn't bad-mouth family practice. He just said, "Well, you know, 10 it's much more interesting.'' But I think he was trying to get me to do his residency at the same time. Mullan: Tell me a little bit about the Medical Center. Yindra: It's called the Medical Center of Delaware now. It's changed somewhat. In fact, there's a picture of the whole deal, behind you, right there. An amalgamation of several hospitals that then came to be the Christian Medical Center, long after I was gone. But there were three hospitals--like a lying-in hospital, a sort of general surgical hospital, and then a general med-surg hospital. When I was there, they didn't do bypass surgery. It was still kind of a small place. Wilmington went through tremendous transition in the seventies or eighties. I knew all the doctors at the hospital. And then I went back there to work for a while, and didn't know half of them, in just the space of a year or two. It just exploded, as far as population and doctors, and that kind of thing. Mullan: Who was [unclear]? Yindra: Actually, I had a friend who was a curator in the Delaware Art Museum, and she did this Wilmington retrospective, and she had all these pictures and things, and she gave me this one. That's the front of the hospital. You can't see it here, but there are little trees there. These are the trees there. I 11 don't know, I never saw them. But I just thought it was kind of an interesting pose. Mullan: So they had a family medicine residency? Yindra: Yes. Mullan: And you took it? Yindra: Yes. Mullan: And what was it like? Yindra: In retrospect, now that I've worked in residency programs and been a family practitioner, it was still sort of in an elementary stage. It was more of a hospital-based kind of residency. There still wasn't great emphasis on office-based practice. We spent an awful lot of time in the hospital, on medical services, pediatrics. So I got an excellent sort of broad-ranged hospital experience, but I learned most of skills seeing patients as an outpatient--or, you know, just the nuts and bolts of seeing patients as an outpatient, only. You know, the walk-in emergency centers and things like that. And then practical--after you got out of residency, and really did it. I really learned a l o t in the first couple of years, about how it's done. 12 Mullan: Was there any kind of connection to a placement presumption? That is, were they training people for Wilmington, or for Delaware, or they were just training people with no expectation of where you might end up? Yindra: Yes. I don't think they were really thinking that way then. It's like, you know, you train everybody, and wherever they decide to go, they'll be well-trained to go there. There didn't seem to be this idea that you really had to have a specific training for a specific place. I still kind of think that when residents come and talk to me. We get a lot of students through here, because we sort of become a magnet for them, and we do the AMSA-HPDP program here every year. A lot of times the students will ask me about that, with residency. Mullan: That's AMSA. HPDP is Health Promotion Disease Promotion. Yindra: Right. There are differences. I mean, if you're going to practice in Alaska, it's a big difference from practicing here in Maine, but they're still rural. And you're going to have to learn a lot of different skills if you're going to go to Alaska than you'd have to have here in Maine. So you learn those when you get there. Mullan: What did you have in mind doing, and what did you do, when you finished residency? 13 Yindra: I tried to go into the National Health Service Corps when I was in medical school, but they didn't want to have anything to do with me for the first two years. It was really a mean two years--'75 and '76, I guess. And then in '77, they called me and said that they'd want me to join. But at that time I saw the light at the end of tunnel. Mullan: This was scholarship application? Yindra: Right. I didn't really feel like I needed to do it, and I had worried about not being able to go where I wanted to go. But I was thinking that I might work for the Public Health Service, anyway, but just be able to pick where I wanted to go. So I decided to forego that. Mullan: How did you finance medical school? Yindra: I worked and I borrowed a little bit of money. I actually had all my debts paid off two years after I was finished with my medical school. I worked as a phlebotomist. I worked in a lab in south Philadelphia, in Methodist Hospital. I don't think they could ever do this now, but back then, they hired me when I was a freshman in medical school. They said, "Well, here's how you run this machine, here's how you run this machine. These are the controls you have to do." And, basically, medical students ran the lab from like five in the evening until six o'clock the next morning. So I did that, and my wife worked. We 14 got along pretty well. I got a little bit of scholarship money from Delaware. Mullan: So you didn't have to take the Corps scholarship? Yindra: No. Mullan: But out the other side, now trained, you were interested in National Health Service Corps placements? Yindra: Right, because I thought it would be kind of nice. It seemed exotic to go out and work on an Indian reservation or in Alaska, or someplace like that. So I actually worked--1 took three months of elective time and spent three months on an Indian reservation when I was a senior in medical school. Mullan: Whereabouts? Yindra: In Fort Washakie. Mullan: Which is? Yindra: Wyoming, western Wyoming. Shoshone. It's sort of between Lander [phonetic] and Jackson Hole. It was a nice place. I had met this guy in my residency, and he was really a good guy, and he wanted me to come work with him and his dad. So I said, "Okay, 1'11 do that." And I like Maine. 15 Mullan: So that was here? Yindra: Yes. Mullan: Tell me a little more about that. How did that come about, and what was it like? Yindra: Well, it was a small town on the coast. Very poor population. Mullan: The town was again? Yindra: Waldoboro. The home of the five-masted schooner. It's where they made the first five-masted schooner. I worked there just f o r one year, and the problem there was that I had all these ideas about how I wanted things to go, and I was trained to give care a certain way. Jack's dad was still working on the premise that you open the doors at eight, close them at twelve noon, and open again at one, and whoever showed up, you saw until there was nobody left in the waiting room. No schedule. Mullan: Jack was a colleague, friend? Yindra: Right. He was a residency friend. He was two years ahead of me, actually. So he was already in practice for two years when I got up there. 16 Mullan: And he was in practice with his dad? Yindra: He was in practice with his dad. Mullan: In Waldoboro? Yindra: Right. And he was struggling to bring it up to date, basically. I got there, and the notes were on little three-by- five cards. It was pretty hard. We were on call every other weekend, every other night, because his dad didn't take call anymore in the hospital. The hospital was thirty miles away, in Rockland. So it was kind of a busy practice. I enjoyed that. It was a great learning experience for me, especially with running a practice, and that kind of thing, learning how not to do it, basically. I learned a lot from his dad, and I still really have a great deal of affection f o r him, and we're good friends. I didn't leave in any animus, but it just didn't work out. Finally, his father retired, after two or three more people came and went. Now Jack has a very good practice. In fact, one of the residents that I trained in the residency is going to work with him, so I thought that was pretty cool. Mullan: So it was only a year that you were there? Yindra: Only a year. Mullan: What happened next? 17 Yindra: I went back to Wilmington, because even though I didn't have any debts, that year I made less than I made in my residency program, which was a little strange. I was very idealistic, and I realized that I wanted to have a house and send my kids to college. I had to buy insurance. I had never bought insurance for myself until that year, because it was the first time I'd had a child. So all these things that we had to start thinking about came about. So one of my residency mentors heard through the grapevine that I wanted to come back, and so she told one of their local docs who knew me, who was in the process of starting an HMO with Blue Cross and Blue Shield. He called me up, and said, "I'd like you to come to work with me, if you want to come back to Delaware." So I thought that was a pretty good thing to do, for a while, anyway. I knew that I'd been hearing about these things, these HMOs. Mullan: What year was this now? Yindra: This would have been 1982, ' 8 3 . '83, that I finally went back to Delaware. I stayed there for four years, working in this HMO, eventually became associate medical director, and went from no patients to 30,000 patients. So it was quite an experience. Mullan: Is it in Wilmington? 18 Yindra: Yes, in Wilmington. I just read in the paper somewhere, where Blue Cross and Blue Shield of Delaware had been bought up long ago by New Jersey Blue Cross and Blue Shield, and now is part of the big conglomerate of Illinois, has become this big mega-company. So I'm kind of glad I got out of that, but it was very interesting. Mullan: Were you working principally clinically, or were you involved in medical management? Yindra: For the first two years, I was principally clinical, and in the second two years, I was doing both. I was half and half, pretty much. Mullan: How was each? Was the clinical practice different than you'd envisioned in a non-managed setting? Yindra: Yes, it was fun. All the people I met, I liked, and the interactions were great. But I did feel bored, because I wasn't taking care of--1 mean, I wasn't doing any geri-care, I wasn't doing any Medicaid, I wasn't doing any Medicare, I wasn't seeing very many older people. And so it was a very sterile practice. You know, just people who worked, and their kids. I knew that I wouldn't want to do that forever. 19 Mullan: Did you hear the common rap against managed care practice, the constraints that one has, in terms of referrals, and in terms of the hospitalization, tests? Yindra: Not really. At that point, I don't know whether it changed, but at that point they were trying to prove themselves, so they were very lenient, and subsequently, never seemed like they were doing very well. But, I don't know. I think that I had a good enough training that I could always pretty much defend what I wanted to do. I didn't think that there were that many onerous constraints. I eventually left. The thing that made me change my mind the most, and to leave, involved patient care, but it was a very unusual situation. What ended up happening was, that was back when AIDS was still just starting to be known, and I took care of like, I don't know, five or six patients who had AIDS. During that time was when it really became--and I can remember taking care of these people, and not knowing what the heck was going on, and then realizing, "Oh, they have this new virus called HIV," and then being able to diagnose it with a blood test, and then, in retrospect, saying, "Oh, well that's what you've had all along. I took care of a kid who was eighteen. His diagnosis was a gastro-[unclear]. We hadn't seen that before, let alone in an eighteen-year-old, and he had HIV. I took care of him for like two years, and then at the end of his care, one of the vice presidents said, "Oh, we found out that he wasn't really covered, 20 after all." He was like a dependent child. They went and looked at the rules of the coverage, and said, "So you have to stop taking care of him, because we're not going to cover him anymore. We're going to drop him from the plan." I said, "Well, okay, it's all well and good if he's not covered, but 1'11 take care of him anyway, because I'm not going out to my colleagues and say, 'Look, I'd like you to take over this case that's emotionally draining, very difficult, and you're not going to get paid for it. I'm going to give that to you.'" And they said, "Well, you've got to, because if you keep seeing him, then there'll be a tacit understanding that we'll pay for everything. '' I said, "NO, I'm sorry. You'll just have to fire me, because I won't do that. I'll go see him on my off hours." They wouldn't even let me do that. I'd go see him at home. Basically what we were doing at that time was home care, and he was pretty much being a hospice patient at the time. And they backed down, you know. But I thought about it after a while, and I said, "You know, I don't want to deal with this." I did, at the end, bridle at the idea that people were sort of telling me what I was going to be able to do and who I was going to be able to see. And so when the opportunity to come up here availed itself--1 started looking around at different things, but that finally got me to thinking, ''I want to make a change. " 21 Mullan: How about the management side? That was a clinical issue you were being treated with, or dealt with, as a physician. You did play a role, I think, as you explained, on the management/medical director side. What was that like? Yindra: Most of my job there was trying to keep all the doctors happy. That was my bailiwick--scheduling, dealing with patient problems, like a patient complaint about a doctor, and you have to talk to them about what happened. I found that kind of interesting, just in the sense of learning to deal with colleagues and trying to figure out what it is that makes people upset. So I didn't mind that very much. They'd ask for my input on various policies and things that they would be coming up with. But I guess I was mostly managing the doctors. Mullan: In terms of family medicine as a fit in the urban setting, it's been a latecomer, a late bloomer in many places, and there's been an argument, "Well, it's fine for the countryside, but there's just too much demand f o r , expectation of, and availability of specialty care in the urban setting, so it just won't work." You were functioning in the urban-suburban setting. What observation do you have of that? Yindra: I still think there's a large number of people who really wanted that. We took a l o t of care of a lot of people who were pretty obsessive and compulsive, a lot of engineers at Dupont, and all those people. And so there were issues where 22 they wanted to see all their specialists, but that wasn't a big part of it. There were a lot of people who were just glad to have a doctor. The whole idea of being able to come see you for a five-dollar co-pay, or whatever it was, was liberating for a lot of people. You can say that's good or bad, I guess, because it unlocks a lot of maybe pent-up unnecessary demand. Family practice flourishes in Wilmington. There's a lot of family physicians there. Mullan: And how about within the context of the managed care organization? Were there internists and pediatricians available as well, and how did you slot yourself and your patients? Was it the patient's choice as to who got the family doc and who got an internist or pediatrician? Yindra: Yes, patients decided. Yes, they decided. But from the point of view of management, the family docs, that's who I [unclear]. Mullan: Because of the utility? Yindra: Exactly. It's so much easier to schedule things if you have family docs, because they can do it all, pretty much, whereas the internists and the pediatricians have their areas, and so they have to sort of [unclear]. 23 Mullan: Did this clinical organization use nurse practitioners or PAS? And what sort of fit was that? What was your observation of their practices? Yindra: That was really my first experience with nurse practitioners. I was very favorable. I thought that they all did a good job. I learned how to interact. I didn't feel threatened, because I felt like I really didn't have a big role. It was actually a little more work sometimes, you know, because the nurse practitioners, especially at first, I guess a lot of the nurse practitioners were new grads, so that sort of slanted things in the direction of being a little unsure of themselves. In fact, one of things that I did while I was there, I was on the committee that wrote the regulations for nurse practice in Delaware, because they didn't have a Nurse Practice Act when I first got there. So we were probably one of the first agitators for that in Delaware. That was interesting to go through all that. Mullan: You were lined up on the side of the nurses? Yindra: The Board of Medical Practice they passed a law outlining what nurse practitioners could do, basically. Of course, the law was sort of vague here and there, so then regulations had to be made. I was one of the docs on the panel. I was probably one of the sort of nice guys to the nurses, compared to the other guys. It was an interesting sort of 24 interplay. Plus, I was from the dreaded HMOs. Sometimes it was a pretty tough experience, because it was the first HMO in Wilmington, Delaware, and all the other docs. They have a place there called the Delaware Academy of Medicine. It's this old brick building that was moved from downtown Wilmington, built in the 1700s. When the medical community was smaller, even at that time, they'd have CME there. So they had grand rounds every Tuesday. So I'd go to grand rounds every Tuesday. I sat down next to one rheumatologist, a friend of mine, and he said, "John, you're pretty brave in here. You've got a big target on your back when you walk into a place like this. " [Laughter] Mullan: Did you encounter c tright hostility? Yindra: Sometimes. But they all knew me, at that time, and it was hard for them to get mad at me, you know what I mean? But you'd hear it sometimes. Mullan: You were immunized a bit because you were a home-town boy? Yindra: Yes, that, and also I had my residency there, so most of them knew me. But I had one experience where I took care of a woman who worked f o r Stewart [phonetic] Pharmaceuticals [unclear], and she had been in the office a couple of times with headaches. She'd had them all the time, but it was, she thought, 25 because of the exposure to some of the dust from here and there, because she sort of put those things together. She saw a colleague of mine, and then saw me, and I was impressed by what she was saying, so I got a Cat scan, which was wrong. A week later she had a sub hemorrhage and died. I can remember going into the radiology suite with the neurosurgeon, because I ended up seeing her again in the emergency room when that happened, and took care of her with the neurosurgeon. I walked in as the neurosurgeon and the radiologist were looking at her, and I walked in, and the radiologist is going, "Ah, here's another one of those cases from those stupid docs at the HMO. They can't even pick up a Sub hemorrhage. 'I I looked at him, and I said, When was the last time you ever made a clinical diagnosis?" He looked at me, and he goes, "Oh!" and got kind of embarrassed. But, you know, from time to time there was some hostility. Mullan: You had the double whammy of being a family doc, except you said that you were more accepted f o r that. Yindra: For being a family doc? Mullan: Yes. 26 Yindra: Well, yes. There wasn't much outright hostility toward the family physicians. Mullan: Did you hospitalize? Did you have hospital privileges? Yindra: Oh, yes. I did OB for two years down there. And then I gave it up when I started getting more managerial responsibilities and didn't have the time for it. It was a little uncomfortable at times. You'd get OB residents hovering all around you, sort of second-guessing every move that you're doing. Mullan: So how did you find your way back to Maine? That was the next move, I guess? Yindra: Yes. My sister and her husband moved to Monmouth, which is right next door here. He's the superintendent for the Maine Experimental Farm there, Clymore [phonetic] Farm. So when they moved back, my wife and I started talking about maybe moving here, because we'd have family, and we were close to them. Mullan: When you say "here," you mean literally to Leeds? Yindra: Well, to central Maine somewhere. We were going to come back. We liked Maine, both of us did. Our children were getting older. They were still toddlers, but we wanted to raise them in 27 an area like this. It was sort of part of the master plan. The reason we chose here was because of my sister. Mullan: And how did you find out about it? Yindra: I just called up a headhunter. I had actually looked at a job at Dartmouth. They were starting an HMO, and they needed a director for the HMO, so I looked at that. They offered me the job, but that community was very different and expensive. I decided I didn't really want to do that after a lot of soul- searching, so I just called a headhunter up and said, "We'd like to move somewhere near Monmouth, Maine." She said, "Well, how would you like to live about eight miles away? Or practice eight miles away?" I said, "Well, it sounds good. I'll come up and check it out. So much just is really on first impressions. Max is a very good physician, a very good person, and I recognized that immediately, and so that was pretty good. Mullan: They were, at that time, expanding? You started to tell me it started just as a nurse practitioner? Yindra: Right. Well, Max had been here for three years. There was a lot of work, and he just didn't have any time to himself, and so he said, "If I'm going to stay, we have to get another doctor anyway, s o that I can have somebody I can work with." 28 Even now, there's pent-up demand, and there's a lot of work to be done, so it wasn't a bad thing to do. In fact, I think that there was no adverse economic impact to my coming the first year. Mullan: In other words, the practice expanded to absorb your clinical availability? Yindra: Right. Mullan: This was 1987, '88? Yindra: Yes, '87. Mullan: At that time, the practice was self-supporting, or was it still getting federal funds? Yindra: I think at the time, the only federal funds that they were getting were the Medicaid and Medicare wraparound, and funds for the sliding-fee scale. Mullan: Those were through 3 3 0 funds? Yindra: Yes, which didn't amount to a lot of money. Mullan: And has that continued? Is i t s t i l l on 330 funding? 29 Yindra: It's still all we get. Well, I think the Medicare and Medicaid is a very important part of it. Mullan: This is the federally qualified health center funding rate? Yindra: Right. Mullan: Which is a higher rate than you'd get if you weren't? Yindra: Right. But the sliding-fee scale, which is something that we really like having, because it gives people some sense of being able to pay for things, they pay what they can, and then the rest is written off on the sliding-fee scale. The amount of money we get is probably less than 5 percent of our total budget. Mullan: In other words, the 330 grant, the federal subsidy, as it were, is less than 5 percent. Do you know how much that is? Yindra: It's about $80,000. The last time I checked. Mullan: Let's talk for a moment about what it was like moving back to Maine, getting into practice here. Yindra: It wasn't difficult. The practice of medicine, I don't think, varies that much, and we are kind of in a good situation here, because we're not that far from a reasonably good-sized 30 hospital. Central Maine Medical Center is twenty miles from here; eighteen miles from my house. Mullan: That's in Lewiston? Yindra: That's in Lewiston. There's a good medical community there. In Waldoboro, if I admitted someone to the ICU, I might spend a day and a night down at the hospital, taking care of the patient, whereas here, if I have someone with a heart attack, there's a cardiologist that I can ask to see the patient. I still see the patient and do my part, but then I can come back and see patients in my office. So it makes the basic system of dealing with your practice a little bit easier. So in many ways it's different from sort of like a rural outpost kind of practice. It wasn't that much more difficult to do. I enjoyed it more. Mullan: You enjoyed which more? Yindra: This practice here, because I was seeing patients, all kinds of patients, all different types of people. Mullan: What is your practice like? Yindra: I do OB, I take care of kids, I take care of adults. It's your basic family practice. 31 Mullan: Busy? Yindra: I see 4 , 0 0 0 patients a year. So that's as busy as I want it to be. Mullan: How many deliveries? Yindra: Between Tom and I, we do, of our own, about sixty. So we have three or four a month. And that's perfect. And plus, in the last couple of years, we've started cross-covering with the residency program, so our on-call is less. I still go in for patients who want me to come in for them. I mean, if they really would like me to be there, I give them my home number, and if I can come in, I will. It started out, I didn't do OB, because Max didn't do OB, and there was no other way for me to do it without being on call all the time, which I didn't want to do. So I started doing OB again about four years ago, when I was able to arrange for coverage with the residency program. I really like doing OB, s o it was something that I enjoyed being able to do again. In fact, I went to New Mexico, to Gallup for a month, to retread. I spent a month in their OB suite, delivering babies again, because it had been maybe four years since I had delivered. Mullan: They were willing to take you on? 32 Yindra: Yes. I called Dan, and he gave me a guy's number, and he was more than happy to have me come out there. Mullan: Within the practice, what's a remuneration arrangement? Axe you on salary? Yindra: Salary. Mullan: Straight out? No incentives? Yindra: Straight out. No incentives. We l o o k at what our productivity is in a prudent sense. We really only are able to look at how many people, how many encounters we do, and we're trying to refine that. I think I'm happiest with the "all for one, and one for all" model, myself. I guess I could live with productivity, because I am pretty productive. I think we all have our own talents that we bring to this place. I just think you could bring in divisiveness if you do t o o much incentive- based stuff. That's my own take on it, but Max does all the medical director stuff, so he works hard on that. Tom and I do OB. I don't want to get paid any more for doing OB, which is a traditional thing. You know, if you do OB, you get paid more. Because I feel like Max works hard doing extra things, too. And Bill, the nurse practitioners, they all work hard, too. So I think it'll probably come to that. Plus, we get opportunities for doing little extra things, because we're so close to Lewiston. I take care of the detox place, the detox 33 floor at the hospital that deals with that, St. Mary's Hospital, and I get paid extra for that. So our base salary here is probably on the low end, in Maine, but it doesn't really matter that much. Mullan: In terms of the staffing that you have now, tell me a bit about that, how you've integrated, how it's grown, and how you've integrated the different levels of practitioners. I was impressed with the nameplates out in front. You've got an interesting and diverse coterie of people. Yindra: We hired another doctor first because of the OB. We wanted to have another doctor in here doing OB, so that when we were each gone, there would be somebody in the office who could see people who came in, and be comfortable with it, because Max wasn't very comfortable. He never did OB after that residency program. Mullan: So there's three full-time doctors? Yindra: So there's three full-time docs. And Bill was here first. Bill is a nurse practitioner. Mullan: He's been here right on through? Yindra: Right on through. And then Max got together the resources and all the stuff he had to do to start a school-based 34 health clinic, and when we got that little grant money, we got it from the state, we hired another nurse practitioner, and we're sort of integrating her into our practice, and hopefully we'll be able to pay for her being there once the grant goes away. Mullan: She spends time at the school? Yindra: Right. Mullan: And some time here at the practice? Yindra: And sometimes here, right. Mullan: And is that all ages, or is that teenage focus? Yindra: It's high school. I guess they do the middle school, too, so it would probably be just teenagers. Mullan: Is that Leeds? Yindra: That's the school for the Leeds area, but it's in Turner. [Begin Tape 1, Side 21 Mullan: This is John Yindra, side two. 35 So the school-based nurse is part-time here, part-time at school. She's a nurse practitioner. Yindra: Yes. Mullan: And then there are others in the practice? Yindra: We have a licensed clinical social worker who works both at the school-based health clinic and here. The other social worker is in private practice, but she comes here one day a week. So we have counseling services through them. There is a substance-abuse counselor who comes to us through a state program, one day every couple of weeks. So we have tried to bring in some counseling services, because those are very important in a practice like this, and that seems to work pretty well. We have medical assistants, we have a bachelor's nurse, Sandy Cobbin [phonetic], who basically is sort of the coordinator role of clinical services kind of things, where she trains the medical assistants, and does the in-services, and she also kind of runs some grants that we have, some educational kind of grants. Mullan: Is she the administrator, or do you have someone else? Yindra: No, we've never had an administrator, which has made for some chaos, especially as we've been growing. We've had an 36 administrator, but it's Bill, and he is clinical most of the time, so he sees a lot of patients and doesn't really have time to administrate very well. And then Max has been the medical director, and that's the same thing: They've found that they're being pulled in two directions, and find it hard to fill both those roles. So I don't know what we're going to do about that, but we're working on it now. Bill's the administrator. He's the one who goes through the budget, makes the budget, interfaces with our--we belong to a network, the Rural Health Centers of Maine, and the administrators at the network basically help us to get the grant, you know, to jump through all the hoops and things that we have to do to get the grant every year. Mullan: This is the 330 grant? Yindra: Right. Bill is pretty much the administrator who does that. Mullan: I'm amazed that you have as large a group. You must have ten or fifteen full-time equivalent people operating here? Is that about the right size? Yindra: I would say s o , yes. Mullan: And with a fairly flexible structure, without a kind of administrative pyramid of sorts. 37 Yindra: Yes. And it amazes me, too. Mullan: How does decision-making take place? Yindra: Basically, most people come for the day-to-day kind of decisions, they go to B i l l . "Can we buy this?" "Can we do that?" And then the rest of it, basically, is made by the rest of us, as sort of, again, traditional medical practice--you know, the partners get together and sit down, and think about problems that might come up, and then try to fix that problem together. Mullan: And is it the medical partners, or everybody? Yindra: Well, originally, when we were small, it was the medical partners, but we're bringing everybody into the process now. Max has started getting people into this idea of continuous quality improvement. We've had some sessions with that. So I think what's going to end up happening is that Max is going to end up biting off a lot more time for his administrative capacities, and Bill, maybe, if we can afford it--you know, make it all work. And they'll end up taking over that role. Mullan: Who decides on salaries? Let's take a really central issue. Yindra: We' do. 38 Mullan: Is it a collective decision? Yindra: Yes. We just get together. Bill tells us what the budget's like. Can we afford that salary raise? And if we can, then we say, "Okay, we're going to get a raise this year." Last year we didn't get a raise, because we got burned by a couple of things, and so there was no raise last year. When I came to work here, I said, "You know, we really ought to have some benefits." We had health insurance and malpractice insurance, and a salary, and that was it. I said, "You know, we're going to retire someday. Well, maybe I won't totally retire, but I would like to have some money put away, because I'm not going to count on Social Security." So we started a 301(K) and a pension plan. We fund our pension plan when we can. That's sort of like the thing that gets hit, which is kind of frustrating for us, and we've been trying to change that. But we basically run like a small business, because we only get so much money coming in, and it's got to be distributed fairly to everybody, so what a r e you going t o do? Mullan: What are the demographics of the area like? Who are you treating? Do you see everybody in the area, and what happened before you were here, and what's happening now? Yindra: Before we were here, people had to go to Lewiston, and there was a doctor in Winthrop, which is the next town that way. 39 Or some people might go to Farmington, too, which is up north up here. Mullan: You had Dr. Russell, but he was in a phase-down, I guess, at age ninety. Yindra: Yes, he was only seeing people who were his own age, I guess, pretty much. So now we don't see everybody. Some people still go to Lewiston. Some people still travel away to see their doctor. But we see the majority of people in the area. We see people in all the towns around. We even have people come here from Lewiston, because we are a little less expensive, we don't deny Medicaid, we don't limit Medicare. So sometimes by default, people have to come out here. We have a pretty good reputation, too, so I think sometimes people come out here because they know they can get seen, and we call back, and the things that people want from their doctor. Mullan: Do you get a disproportionate share of low-income folks because of your sliding-fee scale? Yindra: I think so, I think s o . But our Medicaid--I don't know what the percentage is, but it's not high. It wasn't as high as my Medicaid in Waldoboro. Mullan: That may to relate to how many Medicaid recipients there are in the area? 40 Yindra: Could be, yes. It's a reasonably prosperous area, as Maine goes. Mullan: Farming? Yindra: Farming. There's some paper mills around that people work in, logging, state workers, because Augusta's not that far away. Some people from here will go to work in Augusta. A lot of people in Bath, at Bath Ironworks. They have carpools and things, and they drive down there. So it's not like we're just seeing 50 percent Medicaid patients. Mullan: Do many carry insurance? Yindra: Yes, a lot of people are. There are HMOs in Maine now. Mullan: How do you relate to managed care organizations? Yindra: When I got here, about a year or two after, then Blue Cross started an HMO, and then Health Source came in. I was a little savvy with what was going on, so Max and I sort of inserted ourselves into the process. I'm the medical director for Health Source in the area, and Max is the medical director for Blue Cross and Blue Shields, for Lewiston-Auburn. You know, we went to all the meetings, and they asked us if we wanted to help out. We said we would. And the whole idea being is that if 41 you're part of the process, you're a lot better off, because you can form it. I hope we're pretty s a w y as far as the HMOs goes. Mullan: That means you are a provider? Yindra: Yes, although we've had trouble sort of figuring out how to measure what our reimbursements are and how that relates to what it would be otherwise, and what we can bill for, and what we can't. That's an ongoing struggle, I think, for anybody in an HMO. But I think because we're connected, we can get our answers quicker and figure things out a little faster. Mullan: And you're also not being cornered out of the market by not signing on. Yindra: Yes, but in Maine, all the HMOs so far, since it's so new--1 mean, we're talking about this is just a five-year-old industry in Maine. They haven't tried to limit yet, so we're kind of in on the ground floor. Mullan: The practice you have here is unusual by comparison to either a fully managed organization like you were in Delaware, or a private practice that's owned and identified with the doctor-- Russell, or your friend in Waldoboro. It's a sort of intermediate form that has not tended to flourish well. Having been personally associated with a number of practices, National Health Service Corps-related and others, that have a kind of 42 charismatic start, in terms of people principle, they've often floundered or haven't done well administratively, haven't done well interpersonally, haven't done well economically. This ones seems to have extraordinary staying power and growing power. You have seen other kinds of practice, so you're a pretty good judge of horseflesh, as it were. Why? Yindra: Primarily, we all like each other, and we work well together, so there's no personnel conflicts really that much. So we're all invested in making it work. I really like living here. I like the town where I live. We've become part of it, and I wouldn't want to leave. I know Max, and Bill and Tom has become part of his community. I think that's a big part of it. I think we've been able to keep a competitive salary. I don't know how we do it. And also, with these extra moonlighting things we can do, we can actually be a little bit more than competitive sometimes. So it's like a private practice, because like business partners, we're all working together for the common good of the practice. I think that's why it works. Mullan: Tell me a little bit about the personal side--both your life, your marriage, your kids, and how that's all integrated with the practice and the community. It's the same wife--high school sweetheart? Yindra: Yes. 43 Mullan: Congratulations. Yindra: Twenty-two years, come August. I don't think being a doctor makes your family life an easy thing. My wife is very supportive of me and my work, and so I'm lucky in that regard. And my kids--I'm not really a workaholic. I take my time off, and make sure there's a place for my family, and I think that's helped an awful lot, in comparison to some people I've known, been in their practices. We were fortunate with the community. When we were in Waldoboro, the community wasn't very receptive socially. Some places are harder than others to connect. When we came here, our kids were of the age where they going to school, so we met a lot of other people through them. So both my wife and I made some very lasting friendships, and I think that's important when you come to a rural area, that you connect with the community that way. Otherwise, it's really tough. And my kids love it here. Mullan: How old are they now? Yindra: Fourteen and twelve. Mullan: Boys, girls? Yindra: Two boys. I joke with them. My wife went to Southern California this winter for the first time. She went with a friend, just to sort of get away from Maine in the middle of the 44 winter for a week. And she came back and said, "Oh, it's the greatest place I've ever been." I said, "Well, let's move out there." And the kids sort of looked at me like, "You know that we never want to move from here, ever, ever." I say, "Well, all right, let's go." Mullan: Does your wife work? Yindra: She has on and off, but mostly she's pretty much committed herself to be a mother. She worked in retailing when we were in medical school. She ran different stores. She actually ran the art museum store in Delaware, and really got into that whole thing. I think she'd love to do that, something like that, again. She worked as a registrar for a private school for a while, and does a little of this and that when she wants to get out of the house. Mullan: She's content with that? Yindra: Yes, she's pretty content with it. She's a singer. She sings with various little groups around town, and in the area, s o that's an outlet for her. Mullan: Is there any "insider/outsider" sentiment, like you, or you all, are not Mainers, Maine-ites, whatever the proper word is? 45 Yindra: Not really, because it's such a cosmopolitan area now. This is central Maine. A lot of people moved here. They come and go. I mean, a lot of people come and go, but it's reasonably cosmopolitan. Mullan: So it's not families who have been here forever, and then the newcomers? Yindra: No. There's some of that in town, every now and then, at a town meeting, you know, but when it comes right down to it, they're glad to have you there. I don't think there's a person in town who isn't glad that we're there. And it's a little different than it was in Waldoboro, because there it was much more, but coastal people in Maine are that way, very closed and to themselves. But, you know, that's just my impressions from living in both places. Mullan: How about confidentiality in a small practice, in a small town like this? Is that difficult? Yindra: Not really. I think most of the times that confidentiality has been an issue, it's been with the people who work here. Not us, so much. I just tell people, they ask me in town, "Oh, how's so and so doing?" And I say, "Well, I can't really tell you too much, but they seem to be doing okay." And people are comfortable with that. And, you know, it may be reassuring to them when I say something like that. But we've 46 never had any big problems with that, because we've sort of hammered that home with people who work here, that they have to be very careful about what they do and what they say. Mullan: A couple of big-picture questions. First, how do you feel about your work? You're twenty years in, or fifteen years in, to your career. You've made a number of decisions, got yourself well established. How do feel about day-to-day, day in and day out? Yindra: Well, you know, it's like anything. Sometimes you can feel like you're the myth of Sisyphus--you know, you've just rolled that rock up the hill one more time. But that's only when you're just at a low point. I love this j o b . I don't think I would ever make a different choice. If my kids wanted to do it, I wouldn't tell them not to. I wouldn't tell them to be a plumber, that's for sure. Of course, I haven't been sued yet. So I'm happy. Mullan: What do see as the future of your career? And then the larger question, of primary care medicine, in general, with your career being an example of it? Yindra: I don't see it changing too much here in my lifetime, I hope. I think that, if anything, maybe it'll become a little bit more prominent, or prestigious. As we l o o k at things, and if managed care is really what's going to be in the future, in the 47 grand scheme of medicine, we may become a little bit more understood, and respected a little more. I think there's plenty of respect, but I mean more as equals with the specialists, rather than one rung down, or whatever. . But as far as my work, I expect to continue to make a pretty good living, and to continue to be able to see patients. I have plenty of work. I don't feel like I'm going to suffer from managed care, if that's what ends up happening. Mullan: In rural areas, do you think it will penetrate in a fashion that's relatively gentle-handed? Yindra: So far, that's what's happened, because there are no big huge companies for the insurers to come and capture. There are some big companies, but not a lot. Mostly it's small businesses, and I think that's a harder market to go after. Mullan: There are those who argue that managed care, at least competitive managed care, can't exist in the countryside. You don't have enough aggregation of people to compete and drive prices down. Yindra: And when I look at the information that I get, like how good of a managed care doc you are, it's kind of hard to do, because don't have that many patients. Their sample size is so small. If the whole practice is only 10 percent managed care, 48 how can I really say how well I'm doing? So I don't know. But I hope things don't change too much. Mullan: Anything else you'd like to add, in terms of observations or reflections about rural medicine, family practice, this practice? Yindra: Well, I don't really have anything else to say, really. I guess in my own long view, I think a lot about Dr. Richard [phonetic], Jack's father. I think to myself, rrIrm not going to work all my life." Or even Dr. Russell. You know, I don't know if I want to work all my life. But at the same time, my father retired and then didn't like it at all, and started doing some consulting, and he's happier than I ever have seen him. He works part-time. He feels fulfilled. People want him. I think to myself, "Well, maybe that's the way to go.'' I really do think that, that I probably will never stop. But I know I won't go at it so hard as I get older. I hope I can do that. I hope that the system will allow that when I get older. I wouldn't want to have to just go work in a nursing home. Max and I spend time trying to expand our horizons. He'll take a month off; I took three months off last year. The center doesn't pay for it. We have to save for it. We do it. And I would like to travel and do some medicine in other countries. Mullan: What did you do with your three months o f f ? 49 Yindra: I went to Alaska. I worked up in Bethel. Mullan: With the IHS? Yindra: Yes. And went fishing. It was a perfect fit. Max goes to Costa Rica. He likes it there. He'd like to go do some medical missionary kind of stuff, the kind of stuff that doesn't help anybody's lives too much, but makes you feel a lot better. [Laughter] Let's you go to a new place. Mullan: You took your family with you when you went to Alaska? Yindra: I didn't, because I only went for a month, and it just didn't work out. I'm glad I didn't, because when I was working, there would be nothing for the boys to do, really. You may have never been to Bethel, but nothing to do there, except for watch television, which I don't let them do anyway. And then fishing and things were all either sporadic kind of--would do it now--and I did take a trip. It was expensive, and I couldn't afford to take them. So I did better on my own. Mullan: Has fishing been an important activity for you? Yindra: Oh, pretty much all my life. In spurts. I can do a lot of it f o r a while and get fanatical about it and then-- Mullan: This is fly fishing, I presume? 50 Yindra: Yes, it's fly fishing. I'm pretty snobby about that. And you know, it's a good place to be for that. Maine isn't the greatest fishing place in the world, but it's pretty good. I've met a lot of nice and interesting people. And my wife has finally decided she's going to try it, so I may get her going on it. Maybe as we retire, we'll be able to do that together. Mullan: Well, good. I think you told a great story of one aspect of rural medicine, and really an extraordinarily successful one. I'm impressed. Yindra: I hope it continues. We're working hard on it. Mullan: Good. Thanks. Yindra: You're welcome. [End of Interview]