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1985-11-11 Interview with Michael T. Romano, November 11, 1985 1985OH239 UKMC 13 01:10:09 UKMC001 University of Kentucky Medical Center Oral History Project Louie B. Nunn Center for Oral History, University of Kentucky Libraries Romano, Michael T. (Michael Thomas), 1924- -- Interviews University of Kentucky. Medical Center -- History Medicine--Study and teaching Hospitals -- Economic aspects -- United States Hospitals -- Employees -- Salaries, etc. Physicians -- Salaries, etc. Academic medical centers Health care issues, costs, and access Health care reform Michael T. Romano; interviewee Richard C. Smoot; interviewer 1985OH239_UKMC13_Romano 1:|11(2)|19(13)|34(1)|43(10)|54(2)|72(10)|85(2)|97(11)|113(6)|131(8)|144(10)|166(4)|181(3)|191(8)|210(6)|227(6)|244(7)|265(2)|277(1)|291(9)|320(2)|335(14)|346(7)|366(1)|376(11)|394(10)|409(1)|424(1)|431(6)|450(2)|468(5)|485(10)|499(3)|510(9)|521(7)|533(13)|548(4)|575(1)|604(9)|619(8)|640(7)|659(4)|676(5)|693(5)|707(9)|721(1)|731(6)|742(6)|752(2)|762(4)|773(10)|786(2)|795(8)|804(12)|816(10)|831(9)|841(10)|855(11)|863(1)|878(5)|891(1)|907(2)|917(3)|930(13)|941(1)|954(5)|967(10)|983(3)|996(7)|1007(6) audiotrans UKMCoh interview SMOOT: Dr. Romano, to begin this morning--last time we were talking, uh, we left off with the philosophy of the Medical Center--the original philosophy of the founders of this institution. Could you tell me a little bit about the philosophy? ROMANO: There was a very definite uh, philosophy. It was articulated well by Dr. Willard and uh, there was every intention to really create a Medical Center that was going in a slightly different direction and I think to understand this direction as it was defined in 1961, one has to understand the status quo of, let's say, academic health centers and uh, I would have to say that by 1961, uh, medical centers were characterized by what I might call entrepreneurship. What you had was colleges, a hospital, uh, that seemed to be related in one cohesive unit--one entity--but the reality is that if you look closely it was a lot of little kingdoms and fiefdoms, each with very well circumscribed boundaries relating to each other and relating to each other on terms that were set by individuals and whereas it seemed as though there was a central administration and there was a central theme to the mission and all of that, still you had all of these strong people heading up little units, doing their thing and safeguarding their interests and safeguarding their future, et cetera. Now, unfortunately that sounds a little critical and I--I'm not comfortable with the way that--that statement came off, but one has to be realistic about people being people being people, and when there is an opportunity for someone to gain security and to look after number one, most of the times you can count upon people taking advantage of that opportunity. Let's put it that way. Okay? SMOOT: Yes. ROMANO: So let me get specific. The surgery department was interested in the surgery department and the future of that surgery department. They uh, had responsibilities in the teaching program. They had responsibilities for patient care in the hospital, but unfortunately it seemed as though they were--their main thrust was to generate funds and they would generate these funds in several ways--first of all, of course, by the actual patient care that they rendered, secondly, by bringing in research grants, thirdly, by being involved on a national scale in presenting courses, papers, being involved in all kinds of organizations--professional organi-organizations, etcetera. As a result of all of this, the main function of the academic health center was somewhat obscured because teaching suffered. You know, meanwhile back at the ranch (Smoot laughs) there were a number of students. You had this responsibility to these students who came there to--to be instructed by you, to uh, uh, to drink of the fountain. Okay? Partake--and where were you? You were on some airplane flying away, going somewhere or you were too involved with patient care. So the perspective was a little, um, skewed in favor of, um--skewed against the--the academic activities and Dr. Willard recognized this and Dr. Willard tried to do something which was unheard of in those days. He came on with a system whereby you got one salary. You received a salary from the Medical Center. You negotiated for that salary. You came with an understanding that that was your salary and then anything else that you generated in the way of funds was put into the main Medical Center fund. In other words, you weren't a private entrepreneur. You worked for the company and whatever you did--whether you went out and gave a paper, whether you were a consultant, uh, patient care fees, uh, research fees from grants--all went into a fund and the Medical Center then depended on that income as part of your activity and you were paid a certain amount and that was it. Now, that whole concept was intended to safeguard the primary mission, which was teaching. Now, you've got to give Dr. Willard a lot of credit for trying this. I don't know if anybody else brought up this point. SMOOT: No. ROMANO: You've interviewed a lot of the folks that were here from day one and perhaps none of them brought it up. SMOOT: I don't--I don't recall. ROMANO: I bring it up because I personally was affected by this immediately. I came on in July of 1961. Okay. I had, in June, just received a federal grant to do a study--a two year study--of the use of television in medical and dental education. Part of that grant included a stipend to me. Well, I actually had to take a cut in salary for the first three months to make up for that money that I got from the grant. Now, if I had remained at the University of Pennsylvania I would have realized that honorarium as an additional income. So immediately I was affected by this policy of trying again, to insure that the primary mission was not adulterated and that uh, people would not become uh, a little too enthusiastic about extracurricular and extramural activities. SMOOT: Hmm. ROMANO: Well, I liked this concept because I had already seen at the University of Pennsylvania, that this was not working out well as far as--in the academic program. So I came understanding this--everybody else did--agreeing to it. I received a considerable increase in income over what I was making at Pennsylvania for instance, and I came of my own free will and they were the rules. Well, it didn't take long--it took about two years--for the system to break down. Uh, the first chairman of surgery is responsible for breaking the system down. Now, he came fully aware of the system and quite frankly most of us around here were somewhat disconcerted that a person would come understanding the rules and then come on and start from day one to work against those rules and to try to change them and he did. He succeeded. He succeeded in breaking the system down. SMOOT: Hmm. ROMANO: And we then reverted back to being an ordinary Medical Center. Now, I realize that this was almost an impossible task. It was idealistic, uh, but I--I was disappointed that it only lasted two years. I had hoped that it would have lasted long enough at least so that we could document the results, the impact on the teaching program so we would have something to go by and say, "Look, ideally if we starting a new country in a world somewhere--(laughs)--and a new Medical Center and there wasn't already an existing system, here's the way you ought to do it." You ought to get people--say you want to be an academic physician or--or dentist or whatever--come in, here's what you get as a--okay--and perhaps in a--in a system--in a national system--in an international system--where you had this individual entrepreneurship, maybe it was unrealistic to think that this was going to work out. You see, it created--it created an environment of the haves and the have-nots. Just imagine how much more, uh, successful in generating funds the surgeons were compared to the restorative dentists, the pediatricians, the psychiatrists, even the internists couldn't match what surgery did. So Dr. Willard's concept was that even people who were not involved in generating funds, like community medicine--and that's a whole story and if you haven't interviewed Kurt Deuschle you should interview him. Have you interviewed him yet? SMOOT: Not yet, no. ROMANO: Okay, you--are you going to? SMOOT: I hope to. ROMANO: Okay. Well, specifically probe this particular matter. He really, I think, could give you some insights because you see, he was a physician who was in a department--community medicine--that did not generate funds. They didn't do patient care. They didn't do hands on patient care. So therefore their capacity to generate funds was nothing like even pediatrics let alone surgery and yet Dr. Willard, who was in a sense the founder of this whole community con- uh--medicine concept, okay--recognized that these folks would be at a disadvantage, but felt that in the system that he had defined and had--had put in place here at this Medical Center these people would fare just as well as the surgeons. The concept is idealistic and it's a good one and there were many of us that were very disgruntled that in fact it didn't survive and that Dr. Willard's leadership wasn't sufficient--and I say this with all kindness to a man that I respect greatly--wasn't sufficient-- okay--to deal with the big lions in the surgery department. SMOOT: Hmm. ROMANO: And they're big tigers. SMOOT: (coughs) Apparently, if they subverted the system and--was it just the surgery department? ROMANO: Well, the surgery department, you know, uh, started to pick at something that uh--then everybody else--not everybody, but other income--potentially income ge-generators-- SMOOT: Um-hm. ROMANO: --uh, were very happy to go along. He got, uh, you know, he got uh, colleagues who--who supported his uh--his approach. So uh, I--I'd say in basic philosophy that was--that was one of the uh, main facets- -main dimensions--of a philosophy that in the sense did not work. Now, the other aspect of the philosophy was that this Medical Center had committed themselves--in the basic mission-- to be involved with more than turning out manpower. Until then academic health centers were involved in essentially education and research and only the patient care required to carry on the education and the research. Well, Dr. Willard, with his department of community medicine, had envisioned a Medical Center that would have an impact on how patient care is rendered throughout the state-- SMOOT: Hmm. ROMANO: --by virtue of first of all impacting on the health professionals that were out there, and secondly by going into the underserved areas and creating patient services--patient care, and uh, by first, uh sec---thirdly by, um, developing a system where you had feedback on what was happening around the state. In other words, our outreach program was going to be an essential part of this Medical Center's basic mission. Now, that hadn't been done before. Again, you know, you're circumscribed--you belong to a university, you're health- -an academic health center, you worry about your--uh, turning out uh, your students, you worry about uh, g-g-grants and uh, doing research and you worry about running again, the patient care required to do all of this and also to generate some income which would help the Medical Centers to be uh, uh, financially viable. So I think there are the two things that were the key new dimensions of uh--of this Medical Center. Now, if I say that both of these things failed then I'm implying that the Medical Center has been a failure and that's really not the case because although both of these basic concepts were--first the one about the remuneration uh, that came on early, in about two years and the one later came on maybe ten years later, uh, eliminating community medicine. There's no community medicine department in this College of Medicine now. It's not there. It was dismantled by the last dean and uh, he didn't do it because uh, he didn't care about our mission or he had nefarious, you know, motives. He did it because the time simply could not al---permit spending funds for that kind of activity. SMOOT: Hmm. ROMANO: And also that there was a certain resistance from the health community in Kentucky against the Medical Center having all this outreach out there and try to impact on--on uh, their domain. So that's another factor that uh, had to be considered that as a--working against this basic, uh, concept. SMOOT: Making them look bad? ROMANO: Well, not making them look bad, but in a sense, poking around in a territory that's mine. You know, uh, I'll take care of rendering patient care out in the state, you take care of uh, producing manpower and there's something to be said for that, you know. I like to look at most situations in terms of what I call legitimate vested interests. You've heard the term vested interest, but vested interest has a bad connton--connotation. Vested interest implies, uh, a dishonest motive, a selfish motive, but when you say a legitimate vested interest I think that gives it a different sound, a different uh, uh, connotation and- -and uh, they're often--most situations today in our complex society involve what I like to call legitimate vested interest--I have every right to have this--this objective, to have this interest in something, I have every right to have a vested interest in whatever. SMOOT: Um-hm. ROMANO: It's a legitimate one, but that doesn't mean that it doesn't conflict with your legitimate vested interest and of course, you know, this is the--the--the tug and the pull of--of our society, uh, and in a sense this is what keeps the society viable. I look at it as a plus, in contrast to a stagnant society. I--I've never been to Russia, I've only read, but a society where vested interests are subserted-- subverted, rather--to the state and the state says you will do this and that's it. You know, even in the production of uh, automobiles, you look at some of their auto---you look at their automobiles and look at ours--there's no comparison because competition, again the interplay of legitimate vested interests, is the essence of progress, of vitality and it--in the long run it helps the many. SMOOT: Um-hm. ROMANO: So. I look at it as a plus from any point of view, but there's no question that--that, you know, when you look at a situation that uh, you know, like this situation I'm referring to about uh, uh, the Medical Center trying to become involved in uh, the-the health--uh, health care in the whole state. Uh, this was really uh, contrary to some of the legitimate vested interests in the state. SMOOT: Um-hm. ROMANO: So that's another reason why, of course, in the long run this didn't work out and then in the 1970's because we had a whole reevaluation of the funding of Medical Centers--that whole picture started to change in the middle seventies--um, there was no way to support that kind of a department, so we reverted back to, you know, where--where medical education was in the fifties without these kinds of things. SMOOT: Um-hm. ROMANO: Uh, I believe they were the two main facets of--of the Medical Center philosophy. Oh, I could go on and on in the philosophy and how you treat students. Let me talk a little bit about how you treat students. SMOOT: Please. ROMANO: Uh, one of the things that impressed me when I visited was that uh, there was this huge area on the first floor here all devoted to students. They had a lounge, they had a uh--a uh, concession uh, area for food, uh, you know, with the machines, they had not just lockber- -lockers, each student had a cubicle, with a locker, with a bookshelf, with a desk, with a light, there were acres of these things all over the first floor here and I said, "Wow! This is some place, it really gives the student the status that the student really deserves. It gives them the capacity to study here, to live here, to work here, it's student oriented." A little at a time, all these spaces were cannibalized. As departments grew and they needed space the first thing they looked at was the--the disenfranchise--the students-- and what could they say? Go take some space from a department and see what happens. Okay? SMOOT: Um-hm. ROMANO: So a little at a time we reverted back to each student having a locker and all of these facilities for students, that in my judgment gave us an edge in our appeal as an institution to young people and how unfortunate that today when we're going to be competing to get students, I can't take a student around and say, "Let me show you what you'll have if you come here. You'll have this cubicle, you'll have this lounge, you'll have all these facilities here for you." That's unfortunate. Now, what is particularly distressing to me personally is that in the middle seventies I was involved in the development of the Health Sciences Learning Center across the street and I was involved with convincing the administration that we should reconstitute some of these student areas and that Health Sciences Learning Center had two main student areas--the sixth level where, if you've been there, it's a study center and students can study in a variety of ways and I was involved with the design of that. They can either sit down alone in a comfortable lounge chair. Have you been up to the sixth floor? SMOOT: No, I haven't had a chance to go up there. ROMANO: Oh, you can--should go up there. SMOOT: I will. ROMANO: It's a unique area. SMOOT: I will. ROMANO: Okay. Everything from my--my sitting down alone with my shoes off in a soft chair to sitting at a table and writing or--from a book to going to a carrel with a video cassette or a slide tape to going into a little room--the periphery of that large area has all these little conference rooms--so that I could study with a group of five, seven, eight, ten colleagues. SMOOT: Hmm. ROMANO: That was all designed, you see, with the student in mind. Now, in addition to that we had a lovely student area on the second floor. It was a multipurpose area. It was a large reception area with a-an area at--at one end that could be closed off with folding doors and it served with all comfortable chairs--I don't know if you've ever been through the second floor of the Health Sciences Learning Center--that- -the-the objective was to re---to--to give again to students things that they had initially and--and were taken away from them. In addition to serving as a student lounge areas and--and just social areas let's call them, that second floor area also was important in--in running major conferences because with the two large conference rooms there--we have two auditoria there. You see, when you have a-a conference, you can use that large multipurpose area for registration, for lunches, for all these kind of things. Well, just imagine how distressed I was when about a month ago--I uh, hadn't been there for awhile--I happened to stop by accident when the elevator--I was going to the third floor and I stopped at the second floor and I look and there are workmen putting partitions in that area. They've cannibalized it. Now, again this is the process we went through in--in the early sixties, you see. So that was a major aspect of our philosophy. It's almost as though there's a certain scheme to things and the scheme to things--the scheme of things involves the haves, the have-nots, the powerful, the little less powerful and the-the helpless. Okay, there's all ranges of power and it just seems that no matter what--and I'm not a cynic, I'm most times an optimist in--in almost everything in life--but you've got to be a realist and you've got to recognize that there're the facts and it seems as though you could take society or any element of society and it's all made out of rubber and you can take a piece of it and you can work hard to reshape it and you make all this effort to reshape a Medical Center with all the basic concepts being different--just as we did in the sixties--and all these people who are interested--I picture them--I have this vision of this big structure and all these people are pushing in a little piece of it so that it looks different. From a distance you look at it and, by golly, it does, it looks different. They've reshaped it and then one person relaxes and it bulges out again a little bit here and another person relaxes out up there and it bulges out a little bit there and then that person gets a little tired and (Smoot laughs)--and for whatever reason--and before you know it everybody kind of gets lax and the whole thing--lulilili-- goes back into its original shape again. SMOOT: Hmm. ROMANO: That seems to me like the way things happen because that's what happened to this Medical Center. You know, there's some of us that came here full of idealism, believing in fact that we were on the verge of a--of a new model of academic edu---uh health science in education. So, now again, I'm not--I don't want to come off being bitter about this thing or being sad or disappointed. I'm merely stating the facts as they are. I believe--and I'm not sure anybody else has said this and I'm going to say itcandidly and straight out--I believe it's remarkable that in a fifty--fiftieth rate state--and in so many things we're a fiftieth rate state--we have about a twenty-fifth rate Medical Center. That's remarkable-- as it is today-we started off being a--a tenth rated. We were in the first ten as far as uh--from all points of view. We've slipped, we've gone to be twenty-five, but look at the other public institutions of this state and compare this academic health center with the other public institutions and I believe we're much higher. We're--we're--it's amazing that we can survive and exist because, you know, you--your environment impacts on--on what you are. So uh, I think that Dr. Willard and the people that founded this Medical Center should have a lot of satisfaction in recognizing the fact that maybe all of their hopes and aspirations and expectations did not materialize, but having started at such a high level we still today are better off than if Dr. Willard wasn't a visionary and had just started an ordinary health center. We would be at a level with the other edu---public education facets of this state. SMOOT: Hmm. (coughs) So then, you would see this as a residual effect uh, of the original ideas and philosophies of the-- ROMANO: Oh, I--of course. SMOOT: All right. ROMANO: Of course. Um, I think these people were visionaries. I think things being what they are, they didn't achieve all of their goals, but having aimed high it's the old story--you gotta hit higher than if you had just aimed, you know, anywhere. SMOOT: How's the d---the College of Dentistry fit in, in comparison with the other colleges within the Medical Center? ROMANO: Well, I'm biased. I'm very biased. See, again, in a state whose ed--public education system--at every level--is kind of near the bottom nationally--we started off in the sixties with a Medical Center that was near the top. The first quarter, you know, first 25 percent from almost any assessment we-we ranked--as a Medical Center. Now, the College of Medicine may have ranked fifteen , the College of Dentistry ranked two, three, four, five, you know. It would--depending on which assessment you take as valid we were one of the leading dental schools in the United States in the early sixties when we were first developed. Now, I'm biased enough--and this is really a very biased opinion--to think that today we still have the residual effect of being a little bit better. It isn't--um, I don't have any valid reason for saying that on a national ranking we may rank a little higher than our College of Medicine or Nursing or--uh, I won't say our College of Pharmacy. I would have to acknowledge that the--probably the College of Pharmacy is nationally ranked higher than any of the other colleges in this uh, Medical Center, um, but it's a very biased opinion I have about the College of Dentistry. SMOOT: Hmm. How about with the University of Louisville? ROMANO: Well, again I have to be biased. I have to be biased and yet--you see, there's three things you have to teach students in a--in dental education: knowledge--you have to impart, I like the term impart--knowledge, skills, and attitudes. Now, national board examinations, state board examinations only evaluate knowledge and skill. Attitudes are not evaluated except on a long-term basis. I believe that the basic philosophy of this school--which is still intact after twenty years--uh, teaching students or imparting to students an attitude of professionalism, of being broad in their thinking, of being flexible, of accepting the techniques, for instance, that we teach as a good technique and not the only technique, that there are other techniques, we can't teach you all those techniques. It's the first thing I say to the first year students. So what is our responsibility? Our responsibility is to pick one of the good ones and to teach you a good technique as a beginning, but beyond teaching you a good technique we have to instill in you the judgment that permits you, throughout the rest of your professional life, to look at all the techniques and to discard those that you don't feel are in the best interest of that patient and to change the ones that you already know for a new one only after you use your judgment and I believe when it comes to--to those kinds of things, I think our school is uh--is unparalleled quite frankly. SMOOT: Um-hm. ROMANO: Again, a very biased opinion. SMOOT: Most of the students in the College of Dentistry have been from Kentucky, have they not? ROMANO: Yes, of course. SMOOT: Uh, how have Kentucky students performed in their--in their studies here in the College of Dentistry? After all, uh, it's well known that Kentucky does, uh, not rate well in comparison with other states in public education and so forth. Uh, how have they seemingly been prepared and are they of--adequately prepared for dental education? Are they uh--do they have the background necessary or is there a little bit [microphone interference] more difficulty in comparison with students from other states? ROMANO: Well, this was easy for me to answer, uh, in 1961, when I had just come from the University of Pennsylvania and, you know, the day before I came here I was involved with the teaching program at the University of Pennsylvania and I was prepared to make a comparison. I was competent to make a comparison at that point, but remember that in our first class we chose twenty-five people out of some six hundred applicants. We chose literally the cream of the crop. So therefore, I was very pleased at the quality of student, the way they were able to neg-negotiate the curriculum compared to the University of Pennsylvania, but over the years two things have happened. First of all the number of applicants versus the number of spaces we have has markedly changed. For forty-five places last year, we had something like eighty-some out of state appl---in state applicants. SMOOT: Hmm. ROMANO: Okay? SMOOT: Um-hm. ROMANO: So that's a vast change and secondly, after twenty-five years- -it's twenty-four years now--I don't know whether I'm really capable of remembering--of being able to compare how they fare compared to other states or other students or the University of Pennsylvania. You-- tha---I think it's understandable that that's uh, you know, that's the way it is. Uh, I--I've always been, um, well, I'm not going--I'll use the word empathetic to what young students, uh, have to deal with in a curriculum like ours--a difficult challenge. It--those of us that--that end up being good teachers or that are good teachers, those of us that are good teachers are good teachers in my judgment because we always kind of maintain this empathy, this understanding of what the student is going through. Um, when I was a department chairman and we'd take a new person onto our faculty, this person would say, you know, I--I--aren't you going to teach me how to teach, I've never taught before. Often we'd take somebody out of practice and uh, I would say, well, I--I--I know how you feel, but you have had a great deal of experience in the student-teacher relationship because you've been a student for so many years and if you keep that in mind, if you always keep in mind how you felt as a student, it's going to have to be a help in being a teacher. I do that with--with uh, patient relationship also. I tell young practitioners, as a clinician you have a great deal of experience in the doctor-patient relationship because you were a patient so many times, uh, and I--I think that's the key toward devel---towards maintaining a--a good attitude--an attitude that's--that's productive in teaching--uh, toward your students. So um, I'm very biased for the young people that we have here. Um, one of the reasons that I'm pleased that I'm back in teaching after so many years, uh, being away from it--eighteen years I was away from teaching--is because of um, what being with these young people does to me as a person and uh, (laughs) at my age--in--in my early sixties now--I'm-I'm determined to try to keep a--perhaps a more youthful attitude towards life and towards things in general and uh, I think being here with--with young people is a--is a big help in this--in this uh, respect and uh--I like teaching. I like being involved with young people. I like the importance that I feel, um, in having an impact on their lives, having an opportunity to have an impact. Too many teachers lose sight of that--of the tremendous opportunity that you have and it's a--obviously a big responsibility, but you know, you can teach all the techniques you want and all the knowledge that you want and all the skills that you want--if you don't impart to that student a sense of professionalism then uh, you've lost the opportunity, you've missed it. Uh, one of my favorite little, kind of, uh, approaches that I use with students is uh, you have to resist the temptation to kind of be one of the boys in the neighborhood, in your community, in your practice. When there's something wrong with my health--whether it's a toothache or a toe-ache or a headache or I need a new heart--Uh, I don't want an ordinary person to treat me. If I had the opportunity I'd like to have God taking care of me. That's not possible, so therefore, I have to accept a human and I don't want somebody who looks like my buddy (Smoot laughs) or the guy next door. You've got to create an image of being somebody just a little bit better, just a little bit special and then you're going to instill the confidence that patient needs and that confidence is critical to how that patient care comes out, how--what impact you have on--on--on their health problem. I think it's--it's a logical, straightforward approach to what, you know, to the attitude we're trying to impart to our students here and most of us on the faculty have that kind of an approach. Uh, you know, each of us do it in our own way and that's what's beautiful about it. I may say it in that way, somebody else may say it in another way, somebody else may not say it at all. They have the capacity of being the model and not having to say it. That's the best way to do it. You know, sometimes I say to myself, uh, saying it is being redundant--be it. Well, I try to be it, most of us do, but still I want to make sure, 'cause I've got one pass at them. Four years, then they're out on their own, developing on their own. I tell people when they're about to graduate, the only thing that piece of paper does--it gives you the opp--the opportunity now, the responsibility of furthering your education on your own. You're re-responsible for your development. We were responsible to some degree during your stay here at school. SMOOT: Hmm. Doesn't that necessitate; however, uh, striking a careful balance? Um, a lot of people look at the--people in the medical professions and say, oh, this person has a God complex. Uh, they're- -they see themselves as--as the ancient priest looking down upon the masses and imparting certain bits and pieces of knowledge and healing when--when necessary and uh, p--placing themselves on a pedestal. Uh, you see--and I'm sure-- ROMANO: Of course. SMOOT: --you've heard this uh, many times. Isn't there a balance-- ROMANO: Oh, of course. SMOOT: --that you have to really strike at? ROMANO: Isn't there a balance in everything in life? SMOOT: Sure. ROMANO: I was sitting with my children (Smoot laughs) many years ago and uh, they were all young and sitting around a table and we were eating dinner and uh, one of them said, "What's for desert tonight, Mom?" and Mom said, "Ice cream" and they all said, "Oh, great!" and I said, "Tell you what, guys, you guys are really crazy about ice cream, aren't you? Well, I'll tell you--I'll tell you what we're going to do. We're going to make life simple for Mom, she won't have to cook any more. From now on, everyday, breakfast, lunch and dinner the only thing you're going to eat is ice cream." (Smoot laughs) "What? You mean nothing else?" Well, of course you know what the result of that was. SMOOT: Um-hm. ROMANO: They wouldn't buy that. Everything is a balance--sure it's a balance, but if you're going to err, best you should err on the side of being a little more like God than being a little more like a person. Listen, you may not have ever had any life threatening situations yet, young man (Smoot laughs). I'm talking to you, okay? SMOOT: Yes. ROMANO: But I had a sledgehammer in my chest once. SMOOT: Hmm. ROMANO: It wasn't a heart attack, thank God, it was not an infarction. It was a-a myocardial spasm-- SMOOT: Um-hm. ROMANO: --but I thought it was a heart attack and when they rushed me into that emergency room, I wanted God to be there! No way could that person overdo this God complex. I want somebody with confidence, and capability, somebody I look up to. I'm down, I'm dependent. You can-- you know, you can overdo it, but uh, I'm not concerned about that. SMOOT: Um-hm. ROMANO: We've--the tendency has been to go in the other direction, you know, "Oh, call me Joe." Well, you know, in my office I'm not going to say call me "Doctor" if you call me Michael, but if you give me a choice I'm going to say, you know, in the office I like to maintain in front of my staff, et cetera, a professional relationship. I think it's in a--in your best interest uh--or say something like that. Okay. But I don't have to worry about that because if you look like you're Dr. Romano, you're Dr. Romano and you--you--you each--see the thing that's changed over the years in--in this facet of educating students is that there was a time when we tried to put them all in one mold. Everybody had to wear a white shirt with a dark tie and everybody had to have dark pants and dark shoes and shined shoes and the shoes had to be leather shoes. Okay. We tried to put them in a mold. We gave--we made no room for individuality-- SMOOT: Hmm. ROMANO: --and now I say to students, "Hey, I'll tell you what you need to concentrate on--be well groomed, but don't lose your individuality." That's the key, see. [Pause in recording.] SMOOT: I'm--like to ask you about the relationship, uh, between the physicians, dentists in the Medical Center and the people in the community. Uh, we've been talking about the attitudes imparted to the students and student-faculty relationships and so forth. What about the attitudes of the practitioner and the medical community outside of the Medical Center? How-- ROMANO: The town-gown situation. SMOOT: Exactly. ROMANO: Sure. Well, I've always felt that that's been exaggerated, that the rift, the gap, the frictions, whatever you want to call them-- SMOOT: Um-hm. ROMANO: --have been exaggerated. Um, you know, I'm--I may be a little uh, perhaps, but I've always found it possible to establish and maintain a good relationship with my colleagues in the dental community. Uh, I go to the dental society and I feel very comfortable. I've always felt comfortable, but on the other hand that's still a result of the 1960's and the 1970's. See, now we're in the 1980's and this whole business of town-gown is the--the--whatever differences there have been, are becoming exacerbated and I'm going to ask you, do you have any idea now, why they're exacerbated in the 1980's? SMOOT: Are there too many dentists--too much competition, costs involved, uh? ROMANO: That's it. Okay. So now let's talk about, again if we've covered the matter of students et cetera, let's talk about the milieu of the 1980's. SMOOT: Please. ROMANO: Okay. Um, I need to know from you whether you've heard this term or not, because I suspect that not too many people have articulated it quite this way. I have felt for several years now that we're into what I call an age where we're seeing the commercialization of health care--the commercialization of health care. SMOOT: I've heard that used in a variety of ways. ROMANO: Okay. SMOOT: How do you mean it? ROMANO: Well, I mean it that there was always a difference between the health professions and commerce and industry. There was always a difference. We often were compared and yet whenever anybody tried to look at it, the basic motivation, the basic structure, the basic thrusts of commerce and industry and the basic thrusts and motivations of-of health care industry--you didn't even call it an industry, ten years ago if you called it an industry people raised their eyebrows, particularly people in the health care field--but if you compared them both, there was always a uh--a comfortable difference. Okay--and the difference could be de-defined very simply--that in the world of commerce and industry, the whole beat was the dollar bill. The heart beat was earning money. SMOOT: Profit. ROMANO: Okay. And in health care industry or the health care fields as it was called, it was helping people. Now, in 1969, I left the warm womb of academic dentistry and I was recruited as president of a company and I went to Madison Avenue. I had a big office suite and there I was sitting in this big office with thirty-seven people as a staff, president of a big company. For the first two days I felt great. I accepted the offer where they--they made me an offer I couldn't refuse. They doubled my salary, all kinds of perks and benefits. The company was one of the main investors with Frank Sinatra, he uh, recruited me by flying to New Orleans and uh, picking me up in his Lear jet, called the Christina and flying me to New York and by the time I got there, he sold me. I left all those years, 1967- -I started in 1950--I left seventeen years of academic life in dental education. I had reached a point of becoming an associate dean at a school. Uh, most likely, had I remained in dental education I might have gone on to be a dean and I, you know, I was fairly satisfied with what I was doing and very happy--very happy and I was seduced into the world of commerce and industry and two days I was happy and the third day I realized, what have I done? I'm not used to this kind of heart beat. It's like a heart transplant. I've got a different beat. I'm not--I'm not tuned into this profit--money--everything, every decision, everything you deal with has to be resolved in terms of what's most profitable, how much money is it going to cost, how much money is it going to make us and quite frankly, although I worked hard and--and fulfilled my two year contract, I was very unhappy and very much out of my element. I-I'm mentioning this because I have had the experience, okay, in comparing the two worlds and there was a difference--vast difference. Well, what's happened now? Well, that difference isn't as great as it used to be because now in health care we have seen commercial interests loom very large and very important aspects of the health care and I'll say now, today industry. The for-profit hospitals are in the forefront of this change. Uh, when one thinks of the statistics it's staggering. Ten years ago the for-profit hospitals had something like four percent of the beds. Today they have 27 percent of the beds. It's predicted that by 1990, they'll have 50 percent of the beds and by the year 2000 they may have 80 percent of the beds. Now, that's major. That's profound. That's got to have an impact on everything that happens in the health center--this academic health center. In addition, there are two factors in my judgment that have- -are lead---have led to the commercialization of health care because we--we are a commercial enterprise at this point. I defy anybody to try to give a case against that statement I made. We are a commercial enterprise. We have to say, "No, I can't treat you, you're going to die, 'cause there isn't the money. You don't have the money and you don't have insurance. Oh, I might give you something to help your suffering a little bit, but this treatment that will cure you is too expensive and you don't have the money and I can't afford to give it to you." That's where we are. That's not good for a society like ours--a society supposedly that's based on humanism. All right. That's where we are. Now, how did we get there and where are we going? Well, we got there because first of all commercial interest saw that there was bucks to be made in health care and even at a time in the sixties when the established system of hospitals--community hospitals, government operated hospitals, academic institution operated hospitals--was still sound and viable financially, they saw an opportunity to get in there and make some bucks and there were people sitting down night and day everywhere in the world trying to figure out how to make bucks. Okay. So the advent, the--the--the--of--of the--the proprietary hospitals- -the for-profit hospitals--is a factor that's led us to where we are. And there's another factor--the federal government--with all good intentions, decided that if people needed health care they were going to get it, and Medicaid and Medicare came into being in the sixties. With all good intentions, but what did that do? It created a system whereby you just do whatever has to be done and whatever it costs, it costs, big Sam's going to pay. So we had this influx of the billions of dollars into our health care system and it's spiraled the costs. If you look at the cost of living increase in the last--uh, '65 to '78, I did a study--'65 to '78 is twenty-three years, is--is--uh, '65 to '78. It's thirteen years. During that thirteen years there was something like a 90 percent increase in the cost of living. Health care went up eleven hundred percent--staggering. Okay, so when you hear that health care costs have gone out of sight, you know, that--that statistic there blows you away. You know, you had no idea that it--that there was that much of a difference in the cost of living in--okay--uh, I did a study in 1969, took a sabbatical and I did a study whereby I studied the impact of the federal government on health care compared to air travel. Now, immediately when I talk about this to anybody the first question in your mind is, what do you mean air travel? You're comparing apples and uh--and pork chops (Smoot laughs), okay? SMOOT: Yeah. ROMANO: But you're not, you're comparing apples and pears because the reality is that of all the endeavors in our society you can make the most valid comparison between health care and air travel. Both of them deal with the service--a human service. Both of them are manpower intensive and the manpower is striated from the highly skilled to the highly unskilled. Somebody's got to clean out those airplanes and the- -the toilets in the airplanes. Okay--and the same thing with hospitals. Okay, so from highly skilled to highly unskilled--thirdly, both of them are technology intensive. Fourthly, both of them depend on the federal government or they wouldn't be there; and lastly, both of them deal with life and death--air travel on a minute-to-minute basis, health care on a day-to-day basis--a valid comparison. Okay. Now, when I looked into the increase in costs in 1978, when I was preparing for the study, uh, I found that if you take twenty-eight things that people buy--from, you know, food, clothing, housing, transportation- -um, and you compare the increase in that period of thirteen years, at the very top of the list is telephone service. The increase was very small compared to the cost of living increase. The bottom of the list was health care--out of twenty-seven, twenty-eight things. Second on the list was air travel. Air travel--the cost of air travel--increased less than the cost of living in that thirteen-year period and in addition to the cost being contained and controlled very effectively, the quality of the service was increased immen-immensely. In 1965, to go from New York to Los Angeles it took you seven hours in a propeller airplane and you vibrated all the way. In 1978, you could go jet in three and a half hours. So look what they accomplished. It--it's been amazing and I was so impressed with what they accomplished that I said, I've got to look into it and I said, the greatest factor in both instances has been the relationship with the federal government so; therefore, let me look into it. What did the federal government do in health care that they didn't do in air travel or vice versa? What--what--what's been the difference and the results were--were quite interesting. The results--I can give you the six-month study results in uh, three minutes. The government supports both of those activities. It subsidizes them, but it subsidizes them in a markedly different way. In the case of air travel, the subsidy is given in a way where it cannot be abused by the provider of the care. They have the whole air control system. If that was added to the price of your ticket--that air control system--it would cost you a mint. It would-- it would quadruple the cost of the ticket if the airlines had to pay for the air control system. It's all paid by Uncle Sam. Can the airlines abuse that? Can they have more air control than they need? Because the Federal government's paying, let's have seventeen people here at the tower instead of five people. There's no way you--you abuse that. They build airports--they support the building of airports. SMOOT: Um-hm. ROMANO: They support research and development--mostly for military-- okay. They give you weather data. All things that do not allow the provider or the consumer to abuse the government subsidy and therefore the costs have been controlled and the quality of the service has been improved. Remarkable--no abuses, very little if any abuses. Now, how did they do it with health care? They gave the money to the--to the provider at his or her terms. Okay. You go and you get the care and then whatever you say it costs for the care, the government provides-- direct payment to the consumer and to the provider. Now, well of course there was abuse--with no controls. That's a, a very interesting point here, you know, see that uh--it made the difference. So what did I say now were the factors that created the commercialization of health care? First one was the for-profit people coming into the field. The second one was Uncle Sam made it very profitable to be in the health care field by the way Uncle Sam supported--the government supported--health care. Okay. The third thing that had a fact--had uh, an impact is, of course, the advent of technology. You're talking about now, costs that are out of sight for certain kinds of treatment. Incidentally, sometime you and I--off the--off the record--may talk about what we need to do to offset all of this. How can we still--the government still supports health care and not have the abuses? That was part of my study also. SMOOT: I'd like to do that. ROMANO: Yeah. So these are all the factors. Okay, the technology that created the commercialization of health care and today this Medical Center has to look at itself as though it's a--it's a--it's an industry, it's a business and what we do, everything we do has to be equated to dollars and cents. How unfortunate and yet, we needed it--we needed it. We got a little too fat and sassy and comfortable and greedy, and competition, in the final analysis, is the best way to purify a system. Now, we're going to see a pendulum effect. We're going to swing from the humanism to the commercialism, but when we have enough of the commercialism, when enough people are disturbed at things like--I just saw on television in the last week or so on the morning show--about people being let out of the hospital before they were ready to be let out and dying. Okay. Now, just imagine, the media is on to this now. What a beautiful system to have in this country. When you talk negative about the media, that is so stupid. Look what a beautiful system we have. Watergate would've never come to where it was if it wasn't for the media. Even the president of the United States could--can't really get away with murder, in a sense. So we're going to see the commercialization of health care get worse and worse or better and better, however you look at it, whichever side of the coin you want to look at, but more intense, more of a factor and then we're going to realize that we have ruined a good system and we're going to turn it back because it's an essential system. You have to have it. You know, you could almost have--you can--you can almost tolerate an educational system that isn't that good. Okay. You can tolerate one that has deficiencies. How long have we known in Kentucky that we're at the bottom of the heap? You know, one guy got up and said--at some meeting last week--won't be long now that even Puerto Rico is going to pass us by (Smoot laughs). That hurts--okay. How long can we tolerate this? We're tolerating it, but when it comes to the health care system- -hey, that's your little skin, buddy, and my little skin. Okay. The motivation here not to tolerate and to close your eyes to a system that's faltering is intense, so I'm not worried. It's going to get worse before it gets better, but it's going to get better eventually. Eventually we're going to go back to a system--we're going to--we're going to reshape the system. We're going to develop it--redevelop it--slowly change it back to a humanistic technological system. That's the answer. If we were good enough to go to the moon and that--that's awesome, but what's even more awesome than getting there was seeing the first step on that moon instantaneously from there to here on earth. That--well--that blew my mind. If we are good enough to do that, we're going to be good enough to--to get the best of technology and help it in saving, uh, human lives and prolonging lives and uh, minimizing suffering and uh--and still do it with the--the appropriate amount of humanistic, uh, motivation and feeling in-in health care. I'm--I'm an optimist about this whole matter. SMOOT: It almost seems contradictory, doesn't it, the-- ROMANO: It does. SMOOT: Are there any other things you'd like to discuss? Uh, any other, uh, matters you would like to address this morning? ROMANO: Well, I want to talk a little bit about academic health centers as a last point--the--the real big, broad picture. If one wants to understand the-the future, uh, one of the things that helps you of course is to kind of look at the past and if you can define some-some basic trends, concepts in the past and they're really basic, most often they will apply to the future and it'll help you in extrapolating the present to the future. Now, if we go back twenty-five years--let's go back forty-five years--we had medical schools. Most of them were just free standing, privately owned institutions and as you know, through the efforts of a number of people, um, we saw that they became part of universities and the--the academics, uh, in medical education became part of the academic system and it wasn't and then as part of--of universities, medical schools needed hospitals and they would have arrangements with community hospitals and most of them were on that basis twenty-five years ago, but it was not easy because they couldn't control the program in that hospital so that it would be what they needed to teach. In other words, the type of patients, the type of systems that you create in hospitals, um, weren't really the ones that the academicians felt were in the best interests of the teaching program, so we went through a period where medical schools started to build hospitals as part of universities. Then if they were going to build a hospital, well, we ought to have a College of Nursing and then, well, there is a dental school here on this campus also. It's at the other side of the campus, but we do have a dental school here. Well, let's put it all together then. It needs a new building, it's been there for fifty years, so twenty-five years ago we saw the evolution of Medical Centers--academic Medical Centers. Well, in recent years you've seen this Medical Center kind of differentiate into a health sciences learning center, a cancer resear-research center and just from a practical point of view of mouthing this, you know--the cancer center at the University of Kentucky Medical Center--you see, we're running into a little problem here, but there's more to it than that. At this University Medical Center, until ten years ago, all of the units of this Medical Center were governed by the university. How interesting that the Cancer Center is not governed by the university, it's a separate entity, has its own board, it has its own foundation. The university gave it space--ground--they raised the money for the building. Sure, it's related to the Medical Center programmatically, but when it comes to the way it's governed, it's--it's an individually governed operation that's part of this Medical Center. Let's go to Louisville. Louisville, in their thrust toward what I call the me too' it--Me tooism, they had to have a university hospital. Oh, of course in the seventies when they became part of the state system--well, U.K. has a university hospital, we have to have one too. Me too! Me too! And they're pretty powerful there in Louisville. Don't underestimate the power of the Louisville axis and they had a university hospital, but it cost so much to build it--you know, they started off thinking they were going to build a hospital for forty thousand--forty million dollars. They ended up spending a hundred and twenty-five million dollars. That's a slight overrun. (Smoot laughs) By the time they built it, the funding of health science education was starting to hurt and they weren't going to be able to afford to run it. They didn't have the money to run it and what did they do? They proposed--and at first it sounded out--outrageous--that they give it to Humana and have Humana run it for them, with all the programmatic, you know, tie-ups that you needed. Well, I for one said, oh, that'll never fly. How are you going to have something built by public funds, belongs to the university, is on university ground and you're going to give it to Humana? Well, the arrangement is going to be that they're going to pay rent--no way! Humana runs it. So there you have now, a health sciences center with a hospital--the major element--with governance of its own. Now, this whole matter of having health related institutions in one physical environment, but each with their own governance is not new. If you ever get to Houston--have you been to Houston? SMOOT: No, I haven't. ROMANO: If you're near Houston, go to Houston. If you're interested in medical education, if you're interested in health care--go to Houston. Twenty-five years ago, right after World War II--forty years ago--in the late forties, at one point there were two medical schools and three hospitals that were going to rebuild and some bright visionary got the idea, well, why don't we all rebuild new buildings in the--in the same area? We'll go to the outskirts of town, buy cheap ground and all build and this--we can help each other. We can interrelate in so many ways. We can have a symbiotic relationship. It sounded great. There are- -there is now literally three square miles with sixty some buildings of all kinds. There are five medical schools all in one area. It'll blow your mind if you see this huge area on the edge of Houston--that's the Houston Medical Complex--and that's the term. Health centers--academic health centers--are going to be called academic health complexes. We're now a complex. That's the next generation of word. You may not have heard that from anybody, but that's where we are. SMOOT: It has something of a double entente to it, doesn't it? ROMANO: That's right--and it's true, but we're a health complex because within this complex there's a cancer center, there's a burn center, there's a medical school, there's an academic health center and we're going to see more and more facilities related to health build here. Our hospital may be turned over to proprietary--I wouldn't doubt if Humana owns it ten years from now--wouldn't doubt that at all. So, that's where I see the evolution--okay--from where we were, to where we are, to where we're going. For all good reasons, health facilities need to be close to each other and for all practical reasons--there's no reason why they all have to have the same governance. They have enough in common, they need each other. Being close to each other is a great help to all of them--to all parties involved--and you're going to see more and more of this. Occur--it's occurring here and we're going to enter--we are now entering the era of the commercialization of health care characterized by health complexes. SMOOT: Hmm. ROMANO: Period and amen. SMOOT: (laughs) And thank you very much. ROMANO: My pleasure. [End of interview.] In Dr. Michael Romano’s (Professor of Department of Community Dentistry and the Department of Restorative Dentistry 1984-unknown, Director of Learning Media 1981-1982) second interview, Dr. Romano discusses the insurmountable challenges to the original philosophic goals of the Medical Center, and the effect that had on the Medical Center’s development. He also describes the strategies and perspectives he takes in dealing with students. In addition, Romano discusses systemic challenges to the health care industry and considers the future of the health care industry. insert here