Neil Calman, MD; Urban Warrior; New York, New York

Fitzhugh Mullan, MD Contributing EditorHealth Affairs/Project HopeBethesda, MarylandClinical Professor, Pediatrics and Public HealthGeorge Washington University, Washington, DCStaff Physician, Upper Cardozo Community Health Center, Washington, DC fmullan@projecthope.org

Disclosures

Medscape General Medicine. 2001;3(1) 

Introduction

Neil Calman stands in front of a battered Bronx tenement building, one foot up on its broken first step. There is graffiti on the wall behind him. His hands are in the pockets of his lab coat, and a stethoscope dangles from his neck. This picture, appearing in an article entitled "The Urban Frontier," tells a lot about Calman, his values, his strategies, and his chosen battleground. He calls himself "a flag waving family physician" and "a warrior for urban health." A third-generation New Yorker, he created the Institute for Urban Family Health almost 20 years ago and has run it as a command post for training and placing family physicians and nurse practitioners in community practices all over New York. Clippings from the New York Times, the Daily News, the American Academy of Family Physicians' Reporter, and the Robert Wood Johnson Foundation's Advances attest to the tenacity of his technique and the success of his public education campaign.

"My grandfather is an inspiration to me. He was an oral surgeon, an attorney, and a socialist alderman for the city of New York. He lived by his ideals and got arrested for them a number of times." Politics aside, Calman runs a large and effective enterprise from his office over the Sidney Hillman Health Center, just outside the city's garment district -- "an invisible business," he calls it. Recent years have been challenging, given the changing finances of healthcare. "Managed care is like nuclear energy," he says. "It can be a very constructive force or a very destructive force. It is always a little dangerous."

I run the Institute for Urban Family Health, a 20 million dollar business with more than 300 employees. But I haven't always been so comfortable with institutions. I was thrown out of the University of Chicago as an undergraduate, almost got bounced from medical school, and was suspended for 2 weeks from my residency program. Politics seemed to get me crosswise of administrations wherever I went. In 1983, I solved my rebel problem by building my own organization, which now enables me to practice many of the principles that got me in trouble when I was younger.

Growing up in New York, I couldn't help being exposed to a lot of politics and a fair amount of protest, too. I was born in New York City in 1949, the oldest of 3 and then later of 5 kids -- my parents had 2 more children after I was already in college. When I was about 4 years old, we moved across the George Washington Bridge from Washington Heights to Glen Rock, New Jersey. My father was drafted into the army about a year later, and we lived on a base in Virginia for 2 years before we returned to New Jersey for the rest of my childhood and adolescence.

Medicine runs in my family. My dad, who retired from practice in 1995, is an oral surgeon, as was his father. They both practiced in Washington Heights through the whole transition of that community from a mostly Jewish immigrant community to a mostly minority immigrant community today, and they worked out of the same office all those years. My dad now teaches at New York University Dental School.

My grandfather's plaque still hangs in my office. He was my inspiration and a very big influence in my life, passing on to me a passion for political causes. His name was Maurice Samuel Calman, and he was a socialist alderman in the city of New York as well as a dentist and an attorney. An alderman is equivalent to being a member of New York's City Council today. He also had a degree in agriculture, and he was a 3-letter athlete in college. He had a philosophy about everything and he lived by his ideals. As an alderman, he was arrested a number of times. One of his arrests was for exposing a fake coal crisis. In the winter of 1918, companies were hoarding huge stockpiles of coal in outlying parts of New York City to drive up prices. As a result, people in tenements were going through a brutal winter because they couldn't get coal. He went around and photographed all of these stockpiles and led a huge protest in New York, eventually buying coal himself to distribute to the poor. That's just the kind of guy he was. My grandfather was very Jewish, though his were more cultural than religious values. He knew everybody that was half Jewish, a quarter, or an eighth Jewish -- every entertainer, everybody.

My mother's father was a cantor and a holocaust survivor from Germany.

My dad was associated with a small hospital, now torn down, called Jewish Memorial Hospital, in Washington Heights. In my dad's day, there was an oncologist-hematologist there named Harry Wallerstein who ran a small research laboratory with funds donated by the family of a leukemia victim he had cared for. Dr. Wallerstein allowed the children of hospital staff members to work in the lab during the summer. He literally closed the lab for those months to run his student program, and set up a group of experiments that we would study for weeks. I started working at the lab when I was 14, washing beakers and glassware for the first summer and progressing to handling mice the next summer. I learned a bit of biochemistry and became an expert in amino acid metabolism at age 15, because Dr. Wallerstein would insist that we learn the basic science behind the research we were doing. By the time I was 18, my senior year, I was the second-in-command of the lab's student programs. I don't think this program produced any work of major research significance, but it was responsible for many people going into medicine and assuming leadership positions.

In college, I became involved in many political causes, a legacy from my father's father. In fact, when he died during my second year of college, it was a very difficult time for me. My interest in politics led me to the University of Chicago in 1967. An article in Life magazine in 1965 about the students forcing the school to deal with issues in the community really caught my attention. That was my first memory of having any kind of real political thought or interest. We could take courses there in any division of the school and we weren't even allowed to have a major until halfway through our third year. I took literature, poetry, music, and archaeology. It was a great educational environment.

At that time, I became very interested in the social issues being discussed on campus, how the school was responding, and what role the students had. The university was like a white island on the mostly black south side of Chicago. The school wasn't integrated at all into the life of the community, and the community responded. I think a lot of people felt that the school needed a different vision. But teachers who wanted to design more socially responsible courses were being persecuted by the school and denied tenure, as they were in many other universities at the time. Then the Vietnam War brought other protests to the campus.

During my second year, I was involved in a sit-in at the administration building to protest the firing of an outspoken female professor. The school held hearings to determine how to punish us. At my hearing, I basically discussed the need to be true to your values and to act on them. Because I showed up for the hearing and went through the process, which a lot of people refused to do, I ended up only being suspended for the spring and summer quarters. About 30 students who didn't show up at all for their hearings were expelled from school. A number of them joined the Weather Underground. It was a hot time in Chicago.

I spent those 2 quarters living at home. I didn't want to get totally off track, so I went back to the research lab and talked to Harry Wallerstein. After he gave me a lecture about how stupid I'd been, he gave me a job. I went home and designed an experiment based on the research I had done there years before. Since the experiment was related to work the lab was doing and because Wallerstein believed in it, he spent about $10,000 on special equipment and supplies that I needed. I became totally engrossed in this project, putting in 60-70 hours a week at the research lab.

The experiment occupied the period of time that I was suspended from school, and we published 4 papers from it. I believe the papers turned out to be the only reason that I got into medical school. I applied to 16 schools, but my transcript noted my suspension and I only got 2 interviews. In a complete quirk, one of the people who interviewed me had actually read one of the research papers I published, on how cancer cells changed their immunologic identity as they became resistant to chemotherapeutic agents over time, as he was doing research in an area very similar to mine.

So, I think I got into Rutgers Medical School for 3 reasons. First, there were 2 professors at Rutgers who were really furious about the homogeneity of the student body and the fact that the school was systematically eliminating people interested in political issues related to healthcare. The admissions committee allowed them to make recommendations for a few slots, and they chose me. Second, the doctor who interviewed me was interested in my research area. And third, the same interviewer was fascinated by my college course work in archaeology, particularly a class I had taken on the Dead Sea Scrolls. His father was actually on the team that discovered and translated the Dead Sea Scrolls and had written one of the books that I read in the course. We talked about that for half the interview and about my research for the other half. So I was lucky.

I really went to medical school to become a researcher. I believed that people with scientific minds had a responsibility to try to solve the big medical problems that people faced. This thought helped me to connect my sense of social responsibility with the fact that I was spending all my time in a lab.

When I landed in medical school, however, I quickly connected with about half a dozen people who were much more socially and politically aware than I had been. This group of medical students used to meet every week or two to discuss political issues in medicine. As I recall, they were very critical of my research interests because the research isolated me from patient care.

At the time, my politics weren't well connected to my medicine, but that changed as clinical practice allowed me to integrate these 2 parts of my life. A pediatric faculty member who ran a free community clinic brought medical students to the clinic in the evenings to learn how to take blood pressures and gain real clinical experience. I went there with the other people in the discussion group and liked it tremendously. The first time, however, I was incredibly frustrated because I spent a whole night being totally unable to take a blood pressure. At the end of the night, one of my colleagues figured out that I was listening with the wrong side of my stethoscope bell.

During my first year of medical school, after I had worked in this neighborhood clinic for a while, I started to get interested in what healthcare was really about and joined a study group on healthcare issues. I did the readings and showed up at meetings, but I wasn't a leader. It was all I could do to hang on to the academics of medical school during my first 2 years because I was never particularly good at memorization. I always looked for logical associations between things, so memorizing the names of bones and veins and nerves was torture for me.

While I loved the clinical experience, I was bored in Piscataway, New Jersey, after the excitement of Chicago. At that time, Rutgers was just beginning to establish itself as a 4-year school, so most of my class was encouraged to look for another place to finish our program. Leo Hennikoff, a pediatric cardiologist who was then a recruiter for Rush Medical College in Chicago and is now Rush's president and chief executive, came to Rutgers to interview students. I'll never forget his interview. He took 2 or 3 clinical problems that were clearly beyond what a second-year medical student should know and led me to reason them through for a couple of hours to see how I would approach them. He went through the problems in an incredibly logical way that totally clicked into the way my mind works. I was enamored by that way of thinking and decided I wanted to go to that school. And Rush turned out to be exactly like that. It was a phenomenal 2-year clinical experience unlike anything I've experienced since, with brilliant, thoughtful educators and clinicians.

Even so, I almost got thrown out of Rush, too; it is one of my claims to fame. My roommate and I joined a group called Concerned Medical Students at Rush, which started in 1972, a year before we came. The group members were more widely read than I was in political issues related to medicine, but I was very much in tune with them philosophically. In 1973, I became involved in opposing a plan put forth by the president of the hospital, James Campbell, to divide up the city of Chicago into healthcare districts. My recollection is that the plan showed great disfavor to poor inner-city communities by sending anyone who couldn't afford to pay to Cook County Hospital rather than to Rush. It was great for Rush, but not, many people thought, for Chicago.

This was a major turning point for me at Rush. I was on my OB-GYN rotation and worked on 2 floors, 1 largely for paying, insured patients and another for the poor from the community. They were staffed differently and had different nursing models. One doctor was doing experiments on black women having caesarian sections without obtaining their consent. After anesthetizing a woman, the staff would start taking blood samples before the baby was delivered, which increased the risk that the baby would be delivered sedated as well. I became concerned because we had been taught to deliver a baby as quickly as possible, so I asked the chairman of OB what was going on. In talking with one of the patients, I also discovered that nobody had gotten her consent or advised her that she would be participating in these experiments.

The OB department refused to do anything about it. Another student and I copied a whole bunch of medical records of women involved in this study to show that there were no consent forms and that the delivery times after induction of anesthesia were between 8 and 12 minutes when they should have been 2 or 3 minutes. When we took this information to the OB director and he refused to change the procedures, we took the story to the newspapers. This was probably not the smartest thing for a third-year medical student to do. A black newspaper in Chicago picked up the story and put it on the front page. The other Chicago newspapers then ran articles about Rush University's illegal experiments on black women.

Since the hospital had been caught in the wrong, they were not in a position to dismiss me, but I was in deep trouble for quite a while. Eventually, they set up their first human experimentation committee at the school in response to this issue and asked us to be on the committee. But inside the school, it was clear we had crossed the line. The only thing that saved us was that we had documented every meeting we had with the hospital staff prior to going to the papers. Despite all this controversy, academically I did very well in my third year. Sometime around the end of my third year, when I had to start thinking about residencies, I found out about family practice. Rush didn't open this door to me, however, as there wasn't a single family physician at Rush at the time.

I got my first direct experience in family practice through an advertisement in the back of the New England Journal of Medicine, placed by the United Farm Workers (UFW) Health Clinics. A family doctor there, who'd been working in Delano, California, for years without a break, was interested in finding another doctor to come do a locum tenens. I called to find out more and he said, "Well, you have to go and meet with Caesar Chavez (from the UFW), and be indoctrinated into the union first. Then you can work in the center. Even though you are only a medical student, I have no help out here and we'd love to have you."

After getting permission from the dean, I took 2 months off, got in my car, and drove to California. It was spring of 1974. I went first to a place called La Paz, headquarters for the UFW union, and got my indoctrination. Then I went out to Delano and lived in the emergency room of the UFW clinic there, sleeping on an emergency room cot for 2 months.

That, I think, was the single most important experience of my medical career because I learned how poorly the healthcare system met the needs of this community. We were taking care of people who had no health insurance and no access to the general healthcare system. They went to the health clinic and got whatever was available or they got nothing. If they were brought by ambulance to Bakersfield hospital, 35 miles away, they could be seen as an emergency patient, but they were unlikely to be admitted. If there were questions about their immigration status, forget it. Everybody knew that going to the public hospital in Bakersfield was a direct route to possible deportation.

I took with me several lessons from that place. First, I developed the belief that people in medicine could do much more than just what is done in subspecialty areas. The medical world has this view that I think we've all become victim to over time, that you can't do anything unless you're a specialist. But the doctor and I did everything. We did our own lab work and x-rays. He had a large number of books that we used to treat conditions usually covered by specialists. We also did complex suturing on some brutal farm wounds, as well as setting fractures and casting. We delivered probably 20 babies during the time I was there.

The doctor had a whole group of liberal-minded, caring specialists who made themselves available, free of charge, by telephone. So we did a lot of telephone consultations with people all over the state and, in some cases, outside the state, who were sympathetic to the farm workers' cause.

The second lesson I learned, which I recorded in my journal at that time, was that you can't separate the way people feel about their work and their family from their healthcare. The clinic was right there in the community where the people lived. The people who ran the clinic were enormously political. The clinic closed for half a day every week while we all went out marching through some town or grape fields. Only 1 of the nurses would stay to staff the emergency room. I've got pictures of myself carrying UFW flags and banners from the clinic through nearby farm towns, where people would cheer the clinic staff on. It was very clear that the healthcare we were rendering existed within this political context.

I headed back to Chicago for my final year knowing that I wanted to be a family doctor. On my way back east, I visited some family practice residencies in Sacramento and San Francisco. Then I visited Montefiore Hospital in New York City and found a couple of faculty people who were really tuned into the same connection I felt between politics and primary care. In the end, I ended up entering Montefiore's third class of Family Practice residents.

It was at Montefiore that I discovered I had a knack for administration. I was 1 of 3 chief residents and I loved setting agendas for meetings, taking minutes, and writing policies and procedures. A pediatrician there, Jo Ivey Boufford, became my model for administrative leadership. As director of the social medicine program, Jo ran a staff of very radical and independent physicians, all of whom were moving in lots of different directions at the same time. Somehow she maintained a high degree of flexibility with an established set of values and limits that gave the program its special richness. I frequently refer back to her model of retaining control while allowing for distributive decision making.

But I also remained active in politics, and I got thrown out of the residency program for about 2 weeks during my first year, in July 1976. The hospital workers' union 1199 went out on strike and a group of residents and faculty people within the residency program in social medicine organized to support them. The 1199 strike was a bitter, 10-day strike; one of the longest struggles that 1199 had. Those of us who didn't have to go into the hospital went out on the picket line and refused to go to our elective rotations. This was my first experience with a labor movement struggle, and my grandfather's support of the labor movement was heavy on my mind. (My father reminds me that when my grandfather died, the gravediggers union was on strike. Acting against the teachings of the Jewish religion, our family decided to put Grandpa Maurice's body in storage rather than hire scab gravediggers to bury him!) So I didn't cross the 1199 picket line then and have not done so since. The hospital president and some of the faculty members said, "If you don't show up, you're out." That event dominated my life for about a year afterward because we were all fired. Then the National Labor Relations Board came in, supported the faculty people that were fired, and forced the hospital to reinstate us. Thirty or 40 other residents held a sympathy strike in the hospital to support our being rehired. We even received back pay and a public acknowledgement from the hospital that it had been wrong. It turned out that there were laws protecting people who supported others on strike, which the hospital had conveniently ignored.

Montefiore Hospital attracted a special cohort of independent and socially committed people and gave them opportunities to pursue some of their interests. So when they finished their 3 years of residency, instead of a traditional system where one comes out like processed cheese, some people actually had an opportunity to put their ideas into practice.

When I graduated from the residency, I knew I wanted a combined administrative and clinical job, so I worked with New York Medical College for two and half years running the Center for Comprehensive Health Practice, on the border of Yorkville and East Harlem. It was interesting -- we had people who were poor and uninsured and people who had million-dollar-plus incomes, all coming to the same place for care. Administratively, though, it was a disaster. Each of the providers saw 6 or 7 patients a day and spent about an hour with each of them. The head of the place was a behavioral scientist who believed that the more time you spent with people, the better they would get. The medical school was supporting the center, so finances were not a major issue. After a few months, the medical director left, and I replaced him. Just 3 months out of residency, and I was the medical director! I used what I had learned about teams at the Social Medicine Residency Program and I ran back to speak to Jo Boufford every couple of months. During that time, I was the only family physician to get admitting privileges at Metropolitan Hospital.

Because I was the only family doctor in the whole center, I was feeling a little isolated from what family medicine was about. I heard that they needed preceptors for a new family practice residency program affiliated with New York Medical College at Kingston Hospital, 100 miles up the Hudson River from New York City. So every Friday for 2 years, I drove 2 hours up to Kingston. The most important part of that activity for me was working closely with the head of the Mid-Hudson Consortium for the Development of Family Practice, Dr. David Mesches. He was a very entrepreneurial family doctor who had merged his private practice with those of a few other family docs and set up a family practice network, a department, and a residency program in the mid-Hudson area. He was bringing medical students up from New York Medical College to do rotations there. I was totally enthralled by the idea that he had set up a separate corporation and, in doing so, had gone from being an employee of a hospital to having an independent consortium of family practice people. He even went back and negotiated relationships with the hospitals as an independent entity. Hospitals were dying to attach themselves to him, even though the hospitals themselves would never want to do anything in family practice. I thought, "Wow, this is perfect for New York City."

In 1981, I left the Center for Comprehensive Health Practice and became the founding medical director of Soundview Health Center in the southeast Bronx, a federally funded community health center in a Spanish and black community. The director, Pedro Espada, was a social worker in that community and later became a state senator in New York. He was a brilliant guy, also very entrepreneurial, who had a vision of what services he wanted to provide for the community.

It was my first foray into acting like a CEO. I managed the medical and administrative systems, put together the finance department, wrote computer programs for billing and other things, set up the clinical models, and created the charting systems. When I came, I was the only family physician. I felt we had a good model -- a family doctor at the helm with the broadest vision, supported by people in different primary care specialties. Over time, though, we concentrated on bringing in more family practitioners. There weren't many places in New York at the time where family docs could get full admitting privileges, including privileges to do OB. By the time I left, there were 8 family physicians and 2 family nurse practitioners.

We developed a relationship with Bronx Lebanon Hospital Center, which wanted to develop stronger connections with community-based healthcare centers in order to increase loyalty, admissions, and specialty referrals. In my role as the medical director of Soundview, I went up to Bronx Lebanon and started a Department of Family Practice.

At Soundview, I also wanted to establish a training program for students and residents, to help sustain the long-term interest of the doctors coming into the practice. Inpatient training was going to be at Bronx Lebanon and outpatient training at the Soundview Health Center, which would serve as the family practice center. But the community board and the executive director of Soundview, Pedro Espada, did not agree with our plan to turn the Soundview community health center into a training center. So we found ourselves recruiting residents without a family practice center in which to train them. That was how Bronx Lebanon became the recipient of a completely grant-funded new department and residency program. Fortunately, they were thrilled, and agreed to clear out of an 8000-square-foot ambulatory care center for us. We ran the residency program there for 4 years and then moved it to a beautiful new facility. Over time, almost the entire staff of family doctors from Soundview became the core staff of the new residency-training program at Bronx Lebanon.

But none of us actually worked directly for Bronx Lebanon. About the time we made the transition to Bronx Lebanon, 4 of us decided to found the Institute for Urban Family Health, and basically modeled it after the Mid-Hudson Consortium concept of an independent corporation. We proposed to Bronx Lebanon that we would run the residency program under contract to the hospital. The hospital liked the fact that we proposed to run the program on the previous year's budget for the ambulatory care center. Bronx Lebanon gave us a contract and we received $872,000 in 12 installments. We created the first model for continuity of care between outpatient and inpatient services by hospitalizing and caring for our own patients. Fifteen years ago, these were all new concepts.

The Institute for Urban Family Health represented for me the marriage of a personal issue and a professional philosophy. At that point, I saw 2 choices in my life. One was to continue to be frustrated working for people who didn't move as fast as I did and the other was to start my own company and gain independence. I'm a developer; that's what I love to do. The 4 Institute founders became the board of directors of a nonprofit, tax-exempt institute with a charitable purpose.

My professional philosophy destined the Institute to be a not-for-profit. I describe it as a hybrid between a community health center and a private group practice. It extracts the best of both systems -- we take care of uninsured and underserved people but retain our doctors by giving them a real decision-making role. I was sure that the way community health centers employed physicians in the 1970s and 1980s was wrong; they were treated just like clerks. My vision was to create a professional organization that could build on the entrepreneurial spirit of smart people with initiative to achieve our goal of taking care of people that hadn't gotten care before. We had no qualms about not being a community-based or community-controlled organization. We set our salaries according to what people were making in similar positions in the community.

Two months into the program, we heard that the Sidney Hillman Health Center, located off lower 5th Avenue in Manhattan's Garment District, which served the members of the Amalgamated Clothing and Textile Workers Union, was going bankrupt. This center was supported by a trust fund that was losing a million dollars a year. There was $3.5 million left out of an original $15 million established just 6 years before. It was clear why they were losing all this money -- they had 30 specialty physicians and not 1 primary care doctor. The specialists would come in and refer the union members to their private office for surgeries that were covered by their catastrophic coverage. Practically every person that walked in the door ended up in a surgical room or getting an unnecessary procedure. The specialists charged the trust fund $100 an hour to come to the center and do this stuff.

It was the most atrocious healthcare system anybody could imagine. We called in an independent auditor and found that 78% of all of the services done the prior year were medically unnecessary. We proposed that they get rid of the 30 specialists and close their specialty centers -- the same type of proposal we'd given Bronx Lebanon Hospital 6 months before. We offered to make the center financially solvent using just the amount of money lost over the past year and not another nickel.

We met all of our financial projections. I think we lost only $600,000 the first year and then broke even in the second year, 2 months earlier than expected. We closed down 4 of the 6 floors of the building, fired all the specialists, set up a panel of outside specialists we could trust, and brought in 4 family doctors to run the center. We took about 200 patients off weekly allergy shots, some of whom had been getting them for 20 years. We opened up to the community, started working with Medicaid, and developed HMO contracts. The building filled up in 5 years, serving all sectors of the community. Now we have 15 different programs run out of the building: for HIV patients, the homeless, and many other patients.

When we opened, the union had more than 15,000 members and 100 shops, and now I think there are only 2 shops left. The union has shrunk to almost nothing because most clothing is imported now. We still care for the remaining union members, as well as the retirees and people laid off from the union. But we guaranteed the union that, after the first year, they'd never have to touch the trust fund again, and they never did. We told them that no matter what the volume of services, we would never charge them more than the amount of interest on the trust fund. Since interest rates were high then, we received $300,000 or more a year from the trust fund interest. By the time interest rates fell and only $100,000 dollars was coming in from the trust fund, the union membership had dropped too.

So, with the Sidney Hillman Center and Bronx Lebanon, the Institute inherited 2 huge projects almost instantly. Then we created a third, a faculty development program. None of our core faculty of community-oriented family doctors had any experience in teaching, so we brought in outside consultants. On the advice of the Health Resources and Services Administration Bureau of Health Professions, the federal agency that provided the funding, we also included spaces for doctors from other family practice residency programs. About 140 people have come through this yearlong training program since it started. We've now started to do advanced faculty development that includes organizational development concepts, budgeting, and some managed care topics, as well as some continuing education for people who've been through the training before. And we have a training program for nurse practitioners, based on a collaborative practice model of how physicians and nurse practitioners should work together -- a model very different from that popular in the 1980s.

About a year after we started these programs, we made a pitch to set up another community-based residency program at Beth Israel Hospital, but the hospital leadership didn't bite. In 1991, when the Medicaid managed care revolution started, we went back to Beth Israel and the next thing we knew, they wanted to be the first family practice residency in Manhattan -- and they were. With the money and resources they were feeding us, we made a swift transformation. By that time, we were administering 2 large hospital contracts, the Hillman center, and our faculty development program. By 1998, we had 30 residents from Bronx Lebanon and 24 from Beth Israel in our programs.

The Institute for Urban Family Health is really a business now. I don't think you can have a $20-million-a-year operation with 300-plus employees and not be a business. The Institute now includes 7 family practice centers and 9 part-time sites that cater solely to the needs of the homeless population. These last are run out of soup kitchens, churches, and shelters. While many homeless people are on Medicaid, and federal reimbursements are available for the rest, they don't have anywhere to go except emergency rooms. We provide them with a care system that doesn't depend just on insurance.

It's important to stay true to your commitment to the people you are out there to care for. We have had a number of opportunities to operate networks and primary care sites that cater totally to a commercially insured population, but we turned them down because they aren't consistent with our mission. As much as I've become entrepreneurial in trying to do new things, my colleagues don't let me stray very far from why they came here. In the end, we don't define our mission around insurance, we define it around people who have difficulty negotiating or gaining access to the current healthcare system in New York City. I think our mission is defined by our being "Ghostbusters" of a sort. If you need primary care and you have a population that's tough to serve, that's the kind of folks that we try to develop healthcare delivery models for.

We have totally integrated delivery systems for the care of HIV, for instance, because there are very few places where you can go for these services in New York that don't have AIDS or HIV written on the door. We have hundreds and hundreds of people with HIV at our sites, but they're sitting with everybody else, being taken care of by the same providers. We have 2 or 3 people who are real AIDS experts who help us provide quality care.

Through our relationship with the Visiting Nurse Service, we deliver primary care to a group of about 40 homebound people who cannot get in and out of where they live, even with assistance. It's a small population, located in both the Bronx and Manhattan, but that's the kind of special work that we do.

We also have a program in the Bronx for people coming out of prison, many of whom have been diagnosed as HIV-positive. They have all kinds of other medical problems, and nobody wants to open their doors to them. So we transfer their medical records over after their release and begin caring for them.

I have been accused of being a flag-waving family physician, which I accept. We have one of the largest primary care organizations in the country that delivers care exclusively on a family-practice model. It is based upon a singular philosophy that if somebody were to wipe out the current healthcare system in the United States and start over from scratch, they would create a front line that looks a lot like family practice and a back line comprised of subspecialists. The role of the primary care internist or pediatrician would not exist.

Nurse practitioners, physician assistants (PAs), and midwives are going to have an enormous new role in a managed care-dominated health system. People are concerned that the physician glut has eliminated the need for these "physician extenders." But in the transition to managed care, I think we will all be depending a lot more on PAs and nurse practitioners, who will focus on doing the preventive and educational interventions that most physicians don't like to do. Nurse practitioners are much better at sitting down with people for 45 minutes and teaching them how to use metered-dose inhalers and nebulizers to treat asthma. Doctors usually just don't do this, although it makes a critical difference in whether or not somebody ends up in an emergency room or in the hospital.

Managed care, in my mind, is like nuclear energy. It can be a constructive or a destructive force, and it will always remain a little bit dangerous. On the constructive side, it's the first time we've had a financing mechanism that truly supports prevention, that recognizes that keeping people healthy is in an organization's financial interest as well as its philosophical interest. The entire financing system before was designed around illness and sickness to make money. I think that redesigning the system with the opposite incentives has more potential payoffs than problems.

The real danger is that we're designing a system that the American public doesn't yet understand. We're all familiar with being sold something we don't need, and that's how the way the old healthcare system often worked. But the new system is like having prepaid insurance for your car; there's a danger that the garage mechanic will tell you not to worry about the noise your car is making instead of telling you that you need a new fan belt or muffler. There's really no incentive for him to do anything, because the price of the fan belt or muffler comes out of his pocket. Most Americans don't realize that the healthcare "garage" they now go to also has a financial incentive not to provide care. So even though I'm a big supporter, I'm glad the media keeps running stories about managed care abuses. After the transition is complete, we'll have a protective mechanism for the public and a much better financing system. Both managed care companies and family doctors want to keep people healthy, and thus can be said to have similar goals. They want to keep people out of the hospital; limit hospital stays to the shortest time necessary for good health; and use tried and true, less expensive, medications wherever possible instead of new designer drugs. The danger is that the entire country is trying to reduce what it spends on healthcare, and that cannot be done. The population is aging, technology is expanding, and treatments cost more every day. If we try to save money while we convert to managed care, the system will surely collapse.

At the Institute, we're working to improve our medical records systems to keep pace with patient and practice needs for immediate information related to drug recalls and interactions. In the future, we will use the Medicaid managed care company we started to help figure out how all these special-needs populations fit into managed care -- HIV-positive patients, homeless people, and others, who will be the most vulnerable during the transition. I would like us to have a network of sites in each of the boroughs and in the neediest communities.

I would know my life was successful if a large number of people from very poor communities in New York City received care at our centers on a par with or better than that dispensed on Fifth Avenue. If we do this right, at least in certain model places, we're going to end up with a truly first-class system of care, serving the people who need it most. My job continues to be to fight the system, but now on behalf of an organization that is trying to serve those who are truly left by the wayside in our healthcare system. But now I also have to worry about meeting our payroll obligations, raising money for our work, and planning for a future in a healthcare environment being starved for resources.

I have always believed that one's professional life mirrors one's personal life, and my family life has been both a challenge and a blessing. My father provided stability to my family of origin, teaching by example the rewards of hard work and perseverance. He went to work 6 days a week and later recruited my mother to work in his office. My mother was a Holocaust survivor and struggled, as many do, with the memories and terrors she faced as a 9-year-old fleeing the oncoming Nazi army. She survived, but with a legacy of nightmares and memories that would come back to haunt her whenever life's stresses became too great. Perhaps because of her childhood experiences, she developed a knack, early on, for emotional sensitivity and could never pass anyone less fortunate without a helping hand. Our family home frequently had boarders -- orphans from the local institution where she volunteered or children of family friends in need.

My relationship with my wife, Renee, started in the midst of the 1199 strike in 1976. Her parents were also Holocaust survivors and we shared many interests. Though she was nonpolitical, a fact that disturbed some of my more radical friends, she always supported me in my struggles with the system and, I think, was more afraid for me that she let on. We were to face many challenges together -- first infertility, then the adoption of 2 boys and, many years later, divorce. I often wonder if some of the same issues that caused me to challenge authority in my life and work didn't cause me problems as a parent and husband. I recognize that every human trait, like every new drug, has potential ill effects as well as benefits. What keeps me going is a belief that my shortcomings at home and at work are the results of the same traits that have driven me professionally to prove wrong all those who said that the centers we built and the doctors and nurses we trained and the models we created for inner-city health were impossible to do. The remaining challenge is to be able to teach that perspective to my children.

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