Interview with Barbara Starfield March 11, 1998 School of Hygiene and Public Health The Johns Hopkins University Baltimore, Maryland Conducted by Edward Berkowitz Berkowitz: I see you're from Brooklyn originally. In what neighborhood did you grow up? Starfield: I went to Midwood High School and grew up in central Brooklyn. Berkowitz: Your dad was a professional? Starfield: Both parents were high school teachers in the New York Public Schools. Berkowitz: When you grew up were you a member of HIP (Health Insurance Plan)? Starfield: Yes, we were in HIP. Berkowitz: You went to Swarthmore. Did you know you wanted to be a doctor when you went to Swarthmore? Starfield: No, I did not. My father was a scientist and I guess there was always the expectation of doing something in science. It was not until April ofmy senior year in college (1954) that I decided to go to medical school. In fact, I never applied to medical school. On Easter vacation I asked for appointments with the dean at the two medical schools that were nearest my home. The dean at SONY-Downstate offered me a teaching assistantship in anatomy and an opportunity to learn anatomy with a cad~ver that summer. I became a medical student at the same time. Berkowitz: There were no issues of gender? Were there other women in the class? Starfield: Yes. Berkowitz: And of these women, did they all go into pediatrics or psychiatry? Starfield: Oh, no. They went to all different fields. 1 Berkowitz: You went into pediatrics. What was the reason? Just intrinsic interest? Starfield: Yes. I just liked kids. Berkowitz: Did you think you'd be an academic doctor? Starfield: I guess I never thought about it. I can't say that I went into it thinking I'd be an academic. Berkowitz: You must have done pretty well to get a Hopkins internship. Were you ranked very highly in your class? Starfield: A complicating factor was that my husband and I had to match together, both in the same class, both going into pediatrics. So it had to be a service that was big enough to accommodate two in the same family. There was one facility we applied to in New York, because I said I wanted to stay in New York, but it only took two interns! Berkowitz: You came here to Hopkins and you stayed? Starfield: Forever! Berkowitz: You did your internship and your residency and at some time you decided you'd get an J\1PH on top of that. How did that come about? Starfield: After I finished my residency, my professor of pediatrics, Robert Cooke, who was also the head of pediatrics, suggested that it would be a good thing for me. It was in his heart to be thinking about what was going on in the world. It was Bob who got me into health services research. Some time half-way through my J\1PH program he actually called me out of class and said he had a great project for me. Would I come back to the department of pediatrics when I finished my J\1PH and do this project? So I came back to the department of pediatrics to run a clinic and to conduct research. 2 The project examined the contributions that a public health nurse could make working through a busy pediatric clinic. We chose bed-wetting children ( enuretic children), to study the impact of nursing. I became an expert on the subject: the "bed wetting doctor." At the end, as we were beginning to wind down this project, the federal government was passing social legislation as part of the War on Poverty. One aspect of this legislation was the Children and Youth Program. As part of that program, I planned a clinic to develop comprehensive services for children living in a defined geographic area, which happened to be East Baltimore. Berkowitz: In terms of your career, did you have an academic rank when you were working on this project? Starfield: Yes. I was an instructor. It's curious because when Bob invited me to come back to the department of pediatrics, he said, "You have three children now and you probably don't want to work full-time." That wasn't my true preference, but I didn't argue with him. As a result I worked half-time or, better put, I got paid half-time for one year. I worked full-time; never again did I agree to work half-time. Berkowitz: And the "instructor" might have been an issue. Other people they might have made an assistant professor? Starfield: That's right. I just think it was the times. Berkowitz: Was your husband also at Hopkins? Starfield: Yes. He was doing a post-doc at that time. Berkowitz: When you were developing the new clinic did you write up your experience? Starfield: Actually, I don't think I ever wrote anything about that project. My particular role in 3 developing that clinic was to develop a community arm whereby we would hire people from the community. I had the l\1PH and, even in the previous project, I was getting very involved in the community, working with public health nurses and community groups. But the funding for that program began to disappear after two or three years-- it started getting cut back drastically. When we planned this clinic, we got people from the community together to say what things they thought were high priority health problems in the population. We got answers we never would have conjured up sitting by ourselves. For example, they cited hearing and vision problems while we probably would have come up with some medical problem. Berkowitz: Were these white ethnics? Black? Starfield: They were all black. The community around Hopkins was all black. Berkowitz: When you were working on this project, did you also see patients at Johns Hopkins? Starfield: I guess most of the time that I saw patients I acted as a consult to the physicians who were working with them in the clinic. Berkowitz: When did you move your primary affiliation from the Department of Pediatrics to the School of Hygiene? Starfield: In about 1967 or 1966 Kerr White came to Hopkins, and I somehow linked up with him. We talked for several months, and by February of 1967 I joined him here (across the street from the Johns Hopkins Hospital at the School of Health and Hygiene). Berkowitz: Does that mean that you then gave up your clinical work? Starfield: I continued to do some, but I gave up all primary clinical research. Berkowitz: What was your research focus then in this new role? Starfield: I think that that was just at the time when Kerr and his faculty were becoming involved 4 in the international collaborative on health care utilization. The implicit question behind this effort was, given that you had a condition that should make you seek health services, what were the inciting things that made you do it at a particular time in the different countries? Berkowitz: Did you have the statistical background to be able to do this kind of work? Starfield: I guess I hadn't actually done it before except for my ~H statistics courses, but that first project when I went back to the department of pediatrics involved me in a fair amount of it, so I learned on the job .. Berkowitz: What sorts of expertise were mobilized for the utilization study? Starfield: All kinds. We had truly a collaborative study, because the co-investigators were people from all these countries. . We worked very hard on it. Berkowitz: Did this project lead to lots of publications? Starfield: Yes, although not for me particularly. I was the first author on some of the papers that dealt with the Baltimore data. Berkowitz: Have you always had a main project? Starfield: I'm always doing lots of different things. Berkowitz: I'm interested in this question of how one gets into health services research. When you got into Kerr White's department at Hopkins, were you then ipso facto in health services research? Starfield: Well, remember I'd already done health services research even before I came to this school. Berkowitz: But in terms of your own outlook when you went to professional meetings, was your main professional meeting the American Association of Public Health or was it pediatrics? 5 Starfield: I have always been ~n the field of pediatrics. I think I helped to galvanize the field of pediatric health services research by going to pediatric meetings. Berkowitz: What sorts of agencies were funding your work as you went on? Starfield: The National Center for Health Services Research and Development, now known as the Agency for Health Care Policy and Research, gave me a career development award which was very critical in my thinking. It enabled me to fill in the framework of structure, process, and outcome that Avedis Donabedian had developed. It led to an article that appeared in the New England Journal in 1973 ("Health Services Research: A Working Model"). Berkowitz: When did you get this career development grant? Starfield: Probably it was the late 1960s. I think they only gave them once or maybe twice. It was a five-year grant with very few restrictions. Berkowitz: Have you also played advisory roles for some of the federal agencies concerned with health services research? Starfield: Yes. I was on study sections for the Agency for Health Care Policy and Research and on its Advisory Council. Berkowitz: What's your sense of this agency's mission? Starfield: To put it simply, there wouldn't be health services research if it weren't for that agency. It's parallel to the NIH in the federal bureaucracy. Berkowitz: Could you comment on the differences between the work of the National Institutes of Health and the work of the agencies concerned with health services research?. Starfield: The difference between what the NIH does and what I do is that the NIH is disease- focused whereas true health services research is generic: person or population focused. 6 Berkowitz: The epidemiology of cancer rather than how to handle individual health problems? Starfield: That's right. And what I do concerns the health services system. Berkowitz: Of course, there is a National Institute of Child Health and Human Development. Robert Cooke was actually very instrumental in starting it. Starfield: Right, right, but it's part of the NIH and it's still very oriented toward particular conditions. Berkowitz: For you does being in the field of health services research give you freedom to do more community-based work? Starfield: I would prefer to say population-based. Although I continue to think much like a clinician, I would like to believe that my work is people oriented, not disease oriented, and that makes me different from most other pediatricians and other academic doctors. Berkowitz: I want to ask you about another institution in the field of health research and that is the Institute of Medicine of which you are a member. Where does the IOM fit into the array of organizations concerned with health policy? Starfield: The Institute of Medicine is still an honorific organization and heavily dominated by basic and clinical researchers. Many of their studies are excellent, but a handful ( especially in the area of health services delivery) were not as good as they could have been. This is particularly the case for studies that attempted to deal with concepts such as "access." It is very difficult to do this with a committee structure. Berkowitz: I see. What are you doing now in your own work? Starfield: First of all, primary care continues to be an interest. Berkowitz: I see you published a book on that subject in 1992. 7 Starfield: Yes, and there's one coming out in the fall (of 1998) called Primary Care: Balancing Health Needs, Services and Technology. It synthesizes my research as well as that of others in this country and abroad and introduces the concept of equity in health systems. Berkowitz: Very good. Thank you 8