Part 3: Family Medicine at Duke - The External Review

August 3, 2016

In response to the ongoing tensions between the Department of Community and Family Medicine and the other clinical departments of the Duke University Medical Center, in 1984 William Anlyan, M.D., then-chancellor of health affairs, hired an external consulting group from Washington, D.C. — Llewin and Associates, Inc. — to do a review of the Department of Community and Family Medicine.

According to a memo in Duke University Medical Center Archives, Anlyan told E. Harvey Estes, Jr., M.D., then-chair of the Department of Community and Family Medicine, that the purpose of the review was to “resolve the persistent and destructive conflicts and misunderstandings between the older clinical departments and this department.”

Kathryn M. Andolsek, M.D., MPH, professor of community and family medicine and assistant dean of premedical education in the Duke University School of Medicine, who was named program director of the Duke-Watts Family Medicine Residency Program in January 1985, remembered Llewin and Associates’ team conducting the review from early December 1984 to February 1985.

“They were joined at the hip with us,” Andolsek recalled. “They followed us around doing everything. They looked at files, they went to see patients, they watched how we taught, they talked to residents, they interviewed faculty. They were … a very present consultative group.”

Andolsek said the family medicine faculty were told this type of review was normal and that periodically every department went through reviews like this.

The final report from Llewin and Associates was made available in March 1985 and outlined the history and struggle between the Department of Community and Family Medicine and the other departments at Duke. The report identified four authors: Lawrence S. Lewin, Ann Zuvekas, LuAnn Heinen and Dale Roenigk.

The report stated that the group was brought in by Anlyan to “help Duke University work its way through an extremely difficult decision about the future of the Department of Community and Family Medicine (DCFM).”

Llewin and Associates interviewed 105 people, including Duke faculty members (both within and outside the Department of Community and Family Medicine), students, residents, community physicians in Durham and Fayetteville, state political figures, community members, national leaders in family medicine, and major actors in other private and public medical centers’ primary care programs.

The report pinpointed the conflicts that had been ongoing for years.

“Much of the friction between DCFM and the rest of the Medical Center stems from a set of values in the department different from those in the rest of the medical center,” the report states. “While both groups strongly believe in ‘excellence,’ their definitions vary enough that real communication is difficult. This is also true of their visions of research, teaching and training, and departmental autonomy.

“The conflict is exacerbated by many of the Medical Center faculty’s refusal to regard DCFM as part of the Duke team. In addition, family medicine is not universally accepted at Duke as a ‘legitimate discipline’ and, by its very nature (holistic, integrative, humanistic, etc.) it challenges deep-rooted traditions in academic medicine and clinical practice.”

The report offered four options for organizing the Department of Community and Family Medicine’s core functions:

Option 1: Continue as is with some improvements in DCFM.
Option 2: Strengthen and upgrade DCFM.
Option 3: Move core functions to the Department of Medicine, creating a strong primary care focus there.
Option 4: Reduce commitment to primary care.

The report ultimately recommended Option 2 “as the strategy most appropriate for Duke at this time.”

Estes' proposal

With a favorable report of his department, Estes drafted a proposal for a unified primary care center for Duke. In a letter to Anlyan dated March 7, 1985, Estes wrote that his proposal “offers a reasonable compromise in the direction of equality between this and other clinical departments.” He wrote, “The objective would be to work together to build a truly outstanding and successful unit, which would move Duke ahead in the primary care area.”

Estes’ proposal outlined plans for a single entity for Duke University Medical Center to provide coordinated, high-quality and reasonably priced primary care to its employees and others in the community. He proposed the primary care center would be staffed by physicians from the departments of community and family medicine, medicine and pediatrics, with scheduled consultative services provided by obstetrics and gynecology and psychiatry. He also proposed an inpatient unit, about 10 beds in size, in Duke South, that could be used by the entire group.

Estes’ proposal would never be realized, though.

According to a report written by Estes on April 29, 1985, Anlyan disagreed with many points of his proposal. The proposal was further discussed at a meeting of the involved department chairs — Estes; Joseph Greenfield, Jr., M.D., then-chair of the Department of Medicine; Samuel L. Katz, M.D., then-chair of the Department of Pediatrics; and Charles B. Hammond, M.D., then-chair of the Department of Obstetrics and Gynecology — and according to Estes, Greenfield had “grave misgivings about an expanded primary care program, feeling that it could divert Duke from its excellence as a referral center, and that it would be a drain on financial resources,” and he expressed an unwillingness to participate in a unified clinic.

In a recent interview, Greenfield did not wish to comment on Estes’ statement.

According to Estes’ report, Katz and Hammond supported the primary care thrust, but had misgivings about sharing beds with family doctors.

Estes’ April 29, 1985, report stated that after the meeting of the four department chairs, there were no more meetings on this topic and there was no more direct contact between Anlyan and Estes for two weeks, but there were meetings among and between other department chairs.

A primary care initiative for Duke’s employees

Around the same time as the review of the Department of Community and Family Medicine, there was a movement in the medical center to create a new primary care initiative specifically for Duke’s employees, a proposal not unlike what Estes had presented in March 1985.

Paul R. Newman, senior vice president of Duke’s physician practice, the Private Diagnostic Clinic (PDC), said that in the early 1980s, most of Duke’s employees were receiving care outside of Duke.

“Most of the health care for our employee group was being done in the community,” Newman said. “It was not being done here at Duke.”

Newman said his first project with the PDC in the early 1980s was to help with the creation of an employee health plan that kept employees at Duke for health care. He said administrators in the medical center pushed for Duke to create this plan because the medical center was so specialty-driven at the time.

A number of Duke employees, however, were already seen at Department of Community and Family Medicine clinics — at the Duke-Watts Family Medicine Center and at the Pickens Family Practice in the Marshall I. Pickens Building on Erwin Road. Estes said in a recent interview that many of Duke’s non-medical faculty found it convenient to see a doctor at the Duke-Watts clinic.

“They could park at the front door, walk in … and see their doctor and get out,” Estes said. “So it became a fairly popular program with Duke faculty.”

The Pickens Family Practice served students and employees of Duke University in addition to private patients. Pickens housed the department’s student health, employee occupational health and occupational medicine programs.

Newman insisted the primary care initiative for Duke’s employees had nothing to do with the struggle between the Department of Community and Family Medicine and the medical center, though.

“It was more of the desire to … get into the managed care movement, and it was really for the employee group, to service the employee group,” Newman said in a recent interview.

According to Estes, Greenfield, James B. Duke Professor of Medicine, had been opposed to a unified primary care initiative when Estes proposed it. However, Greenfield began an internal medicine clinical service in his department around this time, creating a primary care employee clinic in Duke South.

Greenfield, who now works half-time at the Duke VA Medical Center reading electrocardiograms, said in a recent interview that his primary care service was not in any kind of competition with the primary care services delivered by the Department of Community and Family Medicine and that the creation of it was not related to the struggle between the Department of Community and Family Medicine and the medical center.

“I don’t look at us as having any kind of confrontation or anything like that,” Greenfield said. “We [Department of Medicine] just picked up primary care.”

Planning for Option Three

Duke University Medical Center and hospital leaders outlined the details of an “Option for Primary Care” in a series of memos throughout the last week of March 1985, just weeks after the final report of the Department of Community and Family Medicine by Llewin and Associates, Inc. The “option” is an assumed reference to the Llewin report’s option No. 3 on how to proceed: “Move core functions to the Department of Medicine, creating a strong primary care focus there.”

A two-phase plan, which expanded outpatient services to Duke employees and their dependents, was outlined by Duncan Yaggy, Ph.D., then-chief planning officer of Duke University Hospital.

“Beginning July 1, medicine, pediatrics, and ob-gyn will undertake a collaborative effort to expand the availability of outpatient services to Duke employees and their dependents,” Yaggy wrote. He wrote that the plan had been discussed at length, and that the proposal was written at Anlyan’s request. The plan was similar to Estes’ proposal to Anlyan for a unified primary care initiative, but left out community and family medicine and psychiatry.

Yaggy wrote that Phase II of the plan, which would be initiated a year later, was less clear “largely because of our uncertainty about the continuing role of community and family medicine.”

In a recent interview, Yaggy said that when he wrote this memo, he was trying to get Duke to focus on the needs of Duke’s employees and their families.

“Substantial numbers of Duke employees, then and now, were eligible for Medicaid,” Yaggy said. “They were in the same box as every other Medicaid patient, so what I was trying to do was construct an environment where at least we can take care of our own.”

On March 29, 1985, Robert G. Winfree, who was then the associate vice chancellor for health affairs, wrote to Anlyan, outlining details on how to proceed with phasing out the Division of Family Medicine and distribute community and family medicine’s other divisions and programs to other areas of the medical center, or get rid of them altogether. The memo also stated that the department would revert back to its previous form as the Department of Community Health Sciences.

However, Winfree noted many potential problems with this option: Estes could resign his post as chair and there could be potential negative reactions from the public and physicians.

“We’ll probably have some irate family medicine supporters on our hands locally, but the number is small. Jim Mau [executive director of the medical PDC] thinks that the physician community in Durham will support the action — it puts more patients back into their marketplace. At the same time, Jim raised a concern about the reaction of our primary physician referral network in the state. We would face serious political problems in Raleigh unless we “sell” the concept that we’re reshaping our commitment to primary care, not forsaking it. At the national level we’ll probably catch some heat for a while. When word got out that Llewin was doing the study, his office in Washington was flooded with calls of support. We’d go through this again, especially since we have not accepted Larry’s [Llewin] recommendation to pursue option II.”

The memo further outlined the outcomes for the Department of Community and Family Medicine’s programs:

“Dietary Fitness Center: The big question is whether we keep the program. If not, we still owe $1.5 million on the old YMCA Building. No recommendation at present.
Health Administration: resolved with Donelan/Winfree oversight.
PA Program: Probably go to medicine. Would ask Mike Hamilton to continue to direct both that and Dietary Fitness Center (if DFC were continued).
Student and Employee Health: Could stay within present structure or 1) come under medicine or 2) be administratively reassigned to human resources (for Employee Health) and student affairs (for student health).
Occupational Health: Probably should divest ourselves of this one
Biometry & Information Sciences: These are strong programs. They could be moved to the department of medicine.
Sea Level Hospital: Harvey [Estes] could continue to serve in his present capacity or we could get someone like Galen Wagner to help us out.”

Winfree continued, “A lot hinges on whether Dr. Estes chooses to remain as chairman. If he chooses to continue to operate the department for the balance of his tenure at Duke, it would revert back to the Community Health Sciences model as we gradually phase out the family practice component. This would be a phased divestiture and the most desirable outcome. If he should resign and Dr. Greenfield isn’t willing to take on the other pieces of CFM, then we have an exciting opportunity for creative management.”

Greenfield seemed willing to accept some functions of the Department of Community and Family Medicine, though. On March 25, 1985, he sent a memo to Anlyan describing the primary care clinic the Department of Medicine had already started and stated his willingness to take on student health and employee health.

“I am unclear as to your plans regarding the Department of Community and Family Medicine,” Greenfield wrote in the memo, “but I want to erase any doubt as to whether the Department of Medicine is willing to assume the responsibilities described above.”

In a recent interview, Greenfield said he was willing to accept student and employee health as one of his department’s commitments to the university.