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1985-11-21 Interview with Howard Bost, November 21, 1985 1985OH244 UKMC 16 02:08:22 UKMC001 University of Kentucky Medical Center Oral History Project Louie B. Nunn Center for Oral History, University of Kentucky Libraries Bost, Howard L. (Howard Lee), 1918-2005 -- Interviews University of Kentucky. Medical Center -- History Medicare Kentucky Medical Assistance Program Hospitals -- Medical staff -- Recruiting University of Kentucky -- Presidents Hospitals -- Administration Universities and colleges -- Administration Hospitals -- Economic aspects Howard Bost; interviewee Richard C. Smoot; interviewer 1985OH244_UKMC16_Bost 1:|11(11)|21(1)|28(10)|40(4)|48(6)|59(1)|70(1)|81(9)|90(3)|98(7)|122(7)|136(10)|145(10)|159(3)|169(4)|178(5)|190(4)|209(11)|230(7)|239(5)|250(2)|264(10)|284(3)|296(5)|310(11)|323(4)|339(2)|346(2)|353(2)|362(2)|372(6)|382(7)|395(5)|408(3)|438(6)|449(6)|460(4)|471(2)|487(7)|501(1)|516(2)|529(3)|544(6)|556(1)|570(8)|588(6)|606(12)|622(6)|635(9)|647(9)|658(2)|687(6)|697(10)|717(7)|741(8)|750(1)|775(2)|782(1)|796(10)|810(5)|822(2)|840(8)|858(7)|869(8)|884(5)|893(12)|900(8)|912(10)|922(3)|928(13)|936(8)|953(6)|968(3)|982(9)|993(2)|1002(5)|1013(8)|1024(3)|1034(4)|1044(9)|1056(13)|1083(6)|1091(4)|1100(9)|1116(2)|1132(5)|1148(6)|1158(7)|1170(1)|1182(12)|1202(1)|1214(10)|1225(3)|1233(10)|1242(9)|1252(5)|1263(5)|1275(5)|1295(11)|1307(12)|1319(3)|1325(12)|1337(3)|1349(4)|1364(2)|1374(4)|1400(11)|1429(8)|1439(5)|1451(7)|1460(1)|1468(2)|1480(8)|1493(1)|1505(9)|1514(6)|1523(1)|1532(5)|1548(1)|1569(4)|1580(2)|1591(2)|1600(7)|1613(13)|1624(7)|1641(5)|1655(6) audiotrans UKMCoh interview SMOOT: Dr. Bost, the last time we had an opportunity to talk I think we had worked our way up through several subjects and left off with the relationship between the university itself and the Medical Center--the administration of the university and the Medical Center. Could you describe that relationship in its early stages? How well did they-- administrations get along? Uh, how well did they work together? BOST: Um, the whole medical school, uh, Medical Center development was uh, uh, entirely new and beyond the experience of the university administration and the--and the university as an institution and um, there was uh, I think uh, a considerable, uh, and lengthy uh, and sometimes difficult period of uh, uh, getting uh, to, uh, understand to uh--to--really to--to know the terrain that uh--that this whole development involved and the--the--the--there--there were many--many dimensions of this. Uh, uh, certainly the uh--the scale of financial requirements was uh--was different and beyond the university's experience and this was a particularly difficult point because the university had--had uh, uh, I--I would say uh, had a uh, relatively, uh--well, the university had almost historically been under financed let me say--from my perspective that was the case. I think that was a general, uh--general feeling and um, the--the question of whether the state and in--then the university could uh, afford a medical school had been a point of some considerable, uh, discussion and concern. So uh, the--the decisions that were made to proceed with the development, uh, were uh, I think, from the very outset, uh, viewed with some apprehension. Now, the um--there--there were--there were several other points, I think that--that affected the relationship in that early period. Um, the financing of the Medical Center plan, the--of course the Medical Science building and then the subsequent contracts for the hospital and clinical facilities and then later a separate contract for the construction of the dental, uh, uh, wing. Uh, these uh--these were projects that at that time and I don't know what the pattern is today, but at that time these--these were projects of the Commonwealth of Kentucky, the construction contracts, the contracts with the architects, the decisions about--that had to be made along the line in connection with the uh--the project and all of this were uh, decisions uh, of the commonwealth--the department of finance had direct and immediate, uh, responsibility and--and control over those. Um, the facilities were being developed for the use of the University of Kentucky, but the--the selection of uh--of architects, the approval of plans, the uh, frequent decisions that were required for change orders to--that would--to modify the facilities to uh, conform to uh, program projections, expectations and so on were decisions that had to be uh, made uh, and worked through with the--at the state level rather than with the university administration. (coughs) The um--the grant requests that we generated and developed for uh, participation in the financing of the cons--of the capital expenditures, uh, were, uh, again, Commonwealth of Kentucky. The uh--the--the uh, health research facilities program was one that we got uh, some substantial assistance from the federal level; so in all of those aspects and this was uh-- this was the first four years we were here we were in construction of facilities, we weren't--we didn't actually didn't bring the faculty in, you know, until pretty close to the fourth--third and fourth year. Uh, we didn't take students until I guess 1960 and we were here in '56. So in that whole period, uh, we were very substantially engaged in, if you will, staff work, uh, for the uh--for the--for the state. Uh, now, these--these matters were not uh, uh, matters that were concealed from the university. Uh, as a matter of fact, everything I think that transpired the university, at least the president's office, was fully appraised of it and was, in effect uh--in effect a party to it, but uh, again the subject matter was unfamiliar. The uh, whole uh--all of the range of considerations that came to focus around the decisions to be made and so on were matters that uh, were beyond the experience of the university administration and we had the uh--the uh--the knowledge, the uh--and we felt that we were uh, the parties most at interest in fact, directly at interest. So uh, this whole period was one in which uh, uh, we were--we were uh, uh, in a distinctive relationship from other parts of the campus to uh--to the university. As a matter of fact, during that entire period we were not engaged in conducting educational programs. Uh, we were engaged in the construction of the project. We were engaged in the--in the uh--in the planning, projection of academic programs, organizing programs, what departments will we have, how--how is all of this going to be, what sort of organizational configuration will we have--all of these kinds of questions and the recruitment of uh--of faculty--the selection of the key people in terms of department chairmen and deans and so on. Uh, these were matters that uh, were uh--that were different or involved a range of considerations that were different than the university was uh, for the most part engaged in--in dealing with students and--and uh, ongoing administration of academic activities--we--we were not--we didn't have any students, we weren't engaged in academic activities (laughs) in that sense. So uh, the uh- -the relationship with the university administration was uh, affected by all that, uh, I think very--very--very significantly affected. Um, when uh--when we got into--well, the other thing is that because of our--because of our program--its character and the newness of it and all--uh, there were just an incredible series of points at which exceptions had to be made from university general practice in the past where exceptions had to be made, uh, uh--wha-where distinctions had to be recognized and created and uh, this of course was uh--was not easy terrain to--to uh--to get over and, I think uh, that it had--it had the--the content for really serious problems. Uh, for the most part, the--the problems were dealt with, I think, in a very, uh--in a very responsible, uh, uh, comend--very commendable kind of way. There were certain points along the line that did tend to get hung up and these were sometimes abrasive, but not--not as a general characterization. (clears throat) I think that uh--that the president, uh, who, uh-- Frank Dickey, had an extremely difficult cross to bear during that time. This--the Medical Center and its development was--well, it made his life, uh, really--very difficult and--if not uneasy and uh, he was sort of placed in the middle very, very often and he had to made decisions that uh, were difficult decisions, uh, but he and uh, Dr. Willard, uh, developed, uh, I think, a mutual respect and confidence that really was the point that bridged the uh, difficulties. SMOOT: May I probe a little bit more deeply-- BOST: Sure. SMOOT: --in some of the problems that were being dealt with. For example, uh, salaries-- BOST: Um-hm. SMOOT: --at the university were very low at that time. I think the president made twelve thousand dollars. Uh, how--how were you going to approach physicians an-and bring them into an institution where they were going to be making such low salaries? Obviously you had to do something about that. BOST: Absolutely. SMOOT: How did you approach this problem--'cause these were not just the rules within the university, these were--if I'm not mistaken--these were state rules, were they not? BOST: Well uh, there were state limitations that-- SMOOT: All right. BOST: --about that period were considered to be constitutional and uh--but there--there had been some ways found around the uh--that in terms of uh, some court or uh, attorney general's rulings, court decisions and all. Although I don't know that--uh, I don't recall that there were cases that were in--in--being adjudicated right at that point, but um, there was, sometime later, uh, a clearer supreme court decision that uh, uh, perhaps stretching a bit, uh, reinterpreted the constitutional limitations to be subject to uh, uh, adjustment for changes in the value of money (Smoot laughs) and uh, what was once twelve thousand dollars was no longer twelve thousand dollars, but was considerably more because of changes in price level, um--but that decision as I recall it came after we really had gotten through the initial, um, problem of not being able to offer salaries, uh, above that limitation. They--we--we presented our budget, uh, again through the university, but to the state--our projected operating budget--and uh we, of course predicated the--the budget on uh, our expectations as to what, uh, would be required in terms of salary level to attract uh, competent people and uh, we made our--our case, if you will, directly to the state at that--and as to why this was required and, you know, what the considerations were and the uh--the consequences of not being able to uh, attract uh, competent people and uh--so there were always-- there were compromises made along the line--progressive compromises that tended to give us a little more leeway as we went along. SMOOT: Um-hm. BOST: Uh, so that we--without uh, you know, in one dramatic, uh, kind of breakthrough, we kind of pushed along and got uh--got what we had to have, not what we wanted, but what we had to have. Um, the recruiting went pretty well, uh--although we were ne--really never able to match the uh--the salary levels at--at other institutions. Uh, that we, you know, considered ourselves--that we aspired to be equal to, let me say, (coughs) um, but we--we were--we were very uh, I think, uh, committed to pitching our development at the top third of the medical schools in the country and the--we did--we made many, many decisions that were-- where one of the assumptions was, you know, to be in the top third you have to do thus and so. You have to be here and in on this--on this axis or whatever and um, our library development, our research uh, uh, development and--and the space that we provided for research facilities which was a very important consideration in recruitment and (coughs) uh, so that uh--that uh--and we were--we were making the--the case with the--with the state that uh--that, you know, with such an expenditure as the whole development entailed that uh, it really uh, would not pay off and would not accomplish what everyone wanted it to, uh, if this were a mediocre--or inferior certainly--program that uh, eventually--so I don't know that I'm answering your question adequately, but it was a--it was a, uh, kind of a long period of pull and tug and uh--and uh a whole series of uh, particular decisions that in aggregate, uh, represented or--or provided a substantially higher level of--of uh--of salary--faculty salaries--than existed in the university. SMOOT: Um-hm. BOST: There was some--there was some uh, reaction to that of course. I didn't uh--didn't really experience that first hand as much as I'm sure (laughs) many others did and I think in particularly the president. I'm sure he got it uh, more than anyone really, but uh, the--the point that we made and I think that it ultimately was uh, recognized to be valid and that was that uh--that the--the effect of establishing a higher plane for faculty, uh, remuneration in the Medical Center would uh--would uh, provide leverage for uh, a higher level for the university itself and I think that ultimately was in fact the case and- -and maybe equally important, uh, was recognized to be the--the ultimate effect of it. SMOOT: Um-hm. BOST: So that it did work out, but it was uh--at the--at the point in time that we were developing it was a very, very difficult issue. BOST: Of course we had a change in administration after Dr. Dickey decided to go elsewhere. Uh, Jack Oswald came in and had an entirely different sort of style uh, in administration. BOST: Yes. SMOOT: And this affected the, uh, administrative style of the Medical Center staff as well. Was this a positive, negative sort of uh, change? Uh, can it be put in those terms? Perhaps it's not fair to put it in those terms. What were your impressions of the changes? BOST: When he came in, uh, we were over the hump. We were in operation, we had established the levels at which we needed to--to be in terms of uh--of budget and salary and we had--we in fact were in operation. I forget the year that he came in, uh, '64-- SMOOT: I think '64. BOST: --'63, something like that. SMOOT: Sixty-three or four, Um-hm. BOST: Yeah. Well, see we had been in operation for--for three years at that point and the hospital had been activated. We were--we were uh--we were in--in essentially full--full activation. SMOOT: Um-hm. BOST: Uh, so that uh--that when he came in, uh, I think, his perception was that the Medical Center was uh, if anything too far ahead of the rest of the university (laughs) and uh, he began to uh--to look for ways to tighten the screws a bit and uh, I recall, uh, some budget requests that he--he took a more, uh, severe view of than the previous- -the previous administration had because the previous administration pretty much had felt that--that if we were--if we were successful in uh--in convincing the state of the need for the funds and this came over and above what the university was--would normally expect, you know, this didn't really take out of the university and that was a very important, I think, uh, uh, aspect and--and attitude on their part. If--if the--if the Medical Center had not gotten the level of support that we did in fact get, I don't think it would have added to the support of the university. Now, it's true that the--that the appropriations that were made for our operation--not for our capital, uh, facilities development--but for our operation--the appropriations were to the University of Kentucky, but the uh--the state, in the executive budget showed a separate page for the Medical Center and uh, this was uh, a reflection of uh--of the--our budget request and the discussions that we had had with the state and the--and the outcome of all of that process so that uh, it was--even though nominally--a part of the university appropriation, it was in fact, uh, recognized to be a, uh--I won't say separate, but a-a distinct part thereof. SMOOT: Um-hm. BOST: The lo--the money; however, was never line item let me say and we were never--we never sought that. We--we were very--we-we were very, I think all along the line, very uh, insistent that we not, uh, you know, that we not uh, separate from the university. This--this uh, period that I described was not a desire on our part to pull away from the university. We--we uh, thought that the Medical Center development being a part of the university was--was a very important, uh, mutual advantage and we were--we were convinced that the Medical Center development and the success of the Medical Center would uh, be of a great benefit to the university and uh, we never sought in any way, you know, the separation. As a matter of fact, the--the uh--the recent separation of the Medical Center as a distinct campus--we never--we never pushed for that. There was some--you know, there were--there were some places that had that pattern, but we didn't uh--we did not see that as being, uh, an element that we wanted to establish here. So we were not out to pull ourselves off from the university-- SMOOT: Um-hm. BOST: --and uh, uh, we wanted to have a uh--a strong and uh, important, uh, influence and impact on the university and I think in some respects we did. Although I would say that we did not have--that--that uh, some of our aspirations in that direction were never really--never realized as to the extent that we had expected. SMOOT: Dr. Oswald also changed the way that the um, Medical Center would approach Frankfort and we touched on that. BOST: Yes, he did. SMOOT: Um, was that something that was needed? Was that something that was good for the uh, Medical Center? BOST: Well, I don't think it was good for the Medical Center. The immediate impact was that it uh--it uh, um--it reduced the latitude that we had. There's no doubt of that. Uh, at that point, the state had enacted a sales tax and there was a lot of new money in this state and uh, the university got a significant, uh, increase in its allocations and there was a period of real change and growth and expansion here in the university and uh, that was the point in time that uh--that this happened that you're talking about--that the Medical Center was really kind of absorbed back into the university in--for--in terms of its uh--its relationships with the state. Um, so that uh, it wasn't uh--it wasn't a period when--in which there was a shortage of funds and a question of, you know, who gets cut. That wasn't the kind of period that it was, but uh, President Oswald clearly saw other priorities in the university than the Medical Center and uh, uh, instead of our being able to proceed, uh, with some of the directions and some of the--I--perhaps I shouldn't say directions at--at the rate of--of uh--development of program that we had projected, we had to curtail the rate of development. We were not able to add faculty as rapidly as we had projected as a consequence of-of that. SMOOT: Um-hm. BOST: Uh, I recall that we had projected positions for which, uh, uh, there was not money after he had made some changes in our budget requests, uh, and uh--he did not want the positions taken out of the budget because this would have been a very negative reaction, you know, there would have been a very strong and negative reaction if there'd been an actual--actual, uh, curtailment, uh, in the Medical Center at a time when the university was getting a lot more money so he insisted that the positions stay in the Medical Center budget although there were not--there was not money to cover them. These were vacant positions that we were expecting to fill and uh, we had only a portion of the money required to fill those so he re--he insisted that we keep the positions in there and very often the positions did not fill as quickly as they were projected to fill, therefore there was some unused money and we were covering more positions, uh, than there was money for. In other words, the--the money was used for those that filled when the appointments were made and uh, uh, he--in effect he was--he was anticipating that there would be some unused funds and cutting down at the outset, you know, the--the amount that was available--this uh--this kind of uh--and--and later on there were some positions of course that would become vacant and these were vacancy credits and we were paying kind of a--I don't know; in the College of Medicine it was called Russian roulette and it took a long time. It took uh, ten years to uh, work that out of the system and get to the point that we really had sufficient funds to cover what we were budgeting and got bar and that was a consequence of that initial--initial step that uh, President Oswald took. SMOOT: Um-hm. What about Dr. Singletary? How's his relationship with the Medical Center been? BOST: Well, I think that uh, more than uh, the previous presidents he has come to uh--to--he--he's become familiar with the--with the operation of the Medical School and its programs. I think he has a great deal more, uh, knowledge and uh, appreciation of the--the programs in the Medical Center than--than was true at an earlier time. Um, also, I think that uh--that Dr. Bosomworth has--has worked, uh, much more closely with the president's office than did Dr. Willard. Um, I think that that this in substantial part a reflection of the character of the period and the activities which they had--were concerned with in their respective points in time when they were here. Um, I uh--I don't--I don't want to uh, express criticism of the university in--in terms of the Medical Center development. I think that uh--that um, the university has--has played its--its role in all of this very--very well and uh, uh, I think that it--that the outcome of it--with the programs that came to, uh, exist and their--their uh, level of operation and success--testifies to the fact that uh--that it--the--the decisions that were made along the line were, uh, valid and uh--and were--well, without those decisions I think that we would not have the--the outcome that we've had let me say. Uh, I think that- -that this whole period of relationship has gone as well here as any place that I know of where there's been a comparable situation and uh, uh, I think that with all of the issues that have presented over this whole period that uh--that there could have been, uh--almost normally would be more difficulty than--than has existed. SMOOT: Hmm. Let me, um, ask you about the budget. You've been very much involved with the budgetary formulations and decisions in the Medical Center. Has the Medical Center been adequately funded over the years? BOST: I would say reasonably so--reasonably so. I don't think that the Medical Center has uh, uh, you know, failed to realize, uh, important, uh, elements of potential because of under financing. Now, there have been--there have been, uh--there's been a chronic situation as there would be in almost any organization that there has not been money to cover all the things that uh--that uh, would be good to do or even-- even that you might feel are important to do. Budget has been tight, at certain points tighter than others, uh, but I don't think that the uh-- that the program has--has suffered seriously because of underfunding. SMOOT: Um-hm. BOST: It has--the uh--the greatest, uh, factor in the financing of the Medical Center is the patient care program in the hospital and uh, the--the developments that avoided a serious--uh, almost uh, fatal, uh--underfunding of the whole development--the developments that avoided that were the developments of uh, governmental financing for indigents and for aged. Those two developments more than any other single factors have meant the difference between, uh, a viable situation financially and--and one that would have been uh, totally over committed and uh--and uh, I think seriously compromised. SMOOT: Um-hm. BOST: If you just look at the--at the amount of uh--of revenue that is--that is uh, realized by the university hospital from payments for care from those programs over the years and you'll get some idea that it's--it's a tremendous amount. It is as much or more as--than the state appropriations for the whole--whole operation. SMOOT: That was one of the original intentions, was it not? BOST: It was--it very definitely was and uh--and uh we had a very substantial, uh, role and contribution in that--in the development of those programs, both the uh--the medical assistance--Medicaid--program in the state of Kentucky, uh, which we got developed before Medicaid was enacted federally, uh, and uh, which became I--it became operative about the time we were beginning to provide (laughs) care over here, uh, and later, uh, the program for the aged which, uh, of course is a tremendous source of financing for--not just University Medical Center- -but of all the whole health care system. SMOOT: This has changed a lot though, hasn't it--the-- BOST: Yes. SMOOT: --relationship of indigents, uh, within the state and how they are treated in the Medical Center--not just here, this is a national problem? Um, could anything have been done to avoid the problem that we face today in terms of caring for the indigents and, uh, others who have less means available to take care of themselves in terms of health care? BOST: I didn't quite understand the first of your question? SMOOT: Indigent care-- BOST: Yes. SMOOT: --has changed throughout the country. Um, you see more hospitals turning away indigents-- BOST: Um-hm. SMOOT: --saying that we cannot afford to take care of them. Uh, more of a commercialization, I suppose, a reflection of the commercialization of the medical health fields, uh, as one person might--has put it to me. BOST: Um-hm. SMOOT: What could have been done to avoid the situation that we have now because its--you see the problem at our Medical Center and at other medical centers around the country. Uh, you were intimately involved with the development of these programs in Kentucky--Medicare and uh, so forth. What could have been done to avoid the problem that we face today in terms of caring for the indigent? BOST: Well, I think the--the--the-the basic question is uh, is uh-- that of governmental responsibility, I think, for those who cannot, uh--who cannot pay for the care that they require and uh, perhaps the establishment of governmental responsibility could have been extended further. Uh, I--I personally never--never accepted the idea that--that hospitals, uh, were created and existed for the purpose of meeting the indigent care problem. My--my view of the hospital role was of uh--of assembling the resources and organizing the activities and so on to meet the health care needs of the entire population and uh--although they could do some, uh--they could perform some role in--in shifting money from one group to another that--that the government was in a better situation to accomplish that kind of spreading of the risk and responsibility than--than hospitals. For all--all hospitals can do is take it from the rich sick and give it to the poor sick, you know, its- -its--that's uh, kind of a Robin Hood operation. I don't think it's uh, socially--very advanced, uh, concept. For one thing, the problem of indigent care is not distributed equitably, it's more severe in certain areas and regions and certain population groups and parts of town that it is in others and so it doesn't get distributed equitably unless you take--unless government is involved, but uh, um, the tremendous increase in the cost and price of health care is--has uh, been the big factor that has exacerbated the problem. We might have--we might have curtailed the cost increases in health care more effectively than we have, I think. Um, although that's a very difficult operation and again, no one could do that but government and government was not uh, very, uh, effective or competent in approaching that--that particular problem. Um, I would say that--that with respect to the university hospital it was never--it was never, uh, my or our concept that that hospital was being constructed or existed for the purpose of uh, providing health care for the poor. That hospital in terms of the very creation of it, the question of how big it should be and what it should contain and all was dictated by uh, the needs for the--for clinical training of uh, health professionals. SMOOT: Um-hm. BOST: That's the only reason it was there and it did not represent the state's approach to dealing with indigent care. SMOOT: Um-hm. BOST: And uh, in fact, the uh--as I contended many, many times in many settings the--the most effective use of state dollars to meet indigent care was not to put it in university hospital, but to put it in the federal-state matching context and purchase care, you know, for--for people that required it in hospitals where the care would probably not cost as much as it would in the university hospital. So the--the university hospital never developed with the mission and the role and the purpose of meeting the indigent care needs of the state. SMOOT: Um-hm. BOST: And uh, uh, this was the basis--finally the basis--on which the policy was modified to uh--to limit the--the--the extent of indigent care being provided by the hospital. This is necessary for the hospital to exist. I think if the--if the hospital were a, uh, government charity hospital that it would not uh, be viable today. I think it could not continue to exist. [Pause in recording.] BOST: --think of this sort of broad mission that we--we were committing ourselves to is the--is the development of uh, what we called an office of state and local services--state and local services and this was a uh, uh--Bob Johnson was our--our man that we brought in for that and this was not a--a--a public relations operation. We were--we were beginning to involve ourselves and our developing institution in health affairs in all--both the--on the state level in many, many facets of the--of the health affairs at the state level and in many local community situations and uh, I don't know whether Ed Pellegrino has spoke about Morehead. Did he speak about Morehead? SMOOT: He just touched upon it as a place where people were starting to move out from the Medical Center. BOST: Yes. Well, there was--there was no--there was no hospital, uh, in Morehead and uh, we began to work with a group there that-- citizens--that were interested in developing a hospital and uh, one of the Catholic orders became interested in it and oh, uh, Bob Johnson was very active in that setting and then Ed Pellegrino later was and as a result we developed a uh--a rather remarkable program there. Uh, it was uh, analogous to the Hunterton program in some--many respects and uh, we recruited--we recruited medical staff for them. Dr. Willard made several trips to recruit medical staff for them and uh, as a result of that whole development and--Morehead probably has the greatest concentration of specialty skills and of the care and the level of care that's available of any place in Eastern Kentucky and there was nothing there before we started working. SMOOT: Hmm. BOST: And we were--we were engaged in many--many uh, other situations that did not develop in the same--to the same extent that that did, but--but our--our effort to begin to use our development here as leverage to upgrade the whole picture in--in the state was a very th- -uh, uh, deep and strong commitment. Another--another bit of evidence of that is the establishment in--in our, uh, College of Medicine of the department of community medicine and uh, Dr. Willard brought Kurt Deuschle here. Uh, this was a--this wa--again was a question of--of involving, uh, and extending the influence of our programs and our development here into outlying situations to--not only using them for educational purposes, but of having an impact on the general level and stimulating their--their development. Uh, much of this was--it was directed at Eastern Kentucky because that was the greatest underserved area, but it was not at all confined to that. We had extensive contacts with Trover Clinic and with other places in south and--and uh, not extreme western, I don't recall, but Bob Johnson was involved in uh--in communities, uh, in all directions of the state and we--we saw our commitment really to be--to have an impact and a--and a positive influence on health care in the state of Kentucky and it was that--it was that, uh, common objective that was at a notch above, you know, just our own, uh--our own nest so to speak and uh, that--that I think was a--was a very important factor in--in uh, attracting faculty and in terms of influencing as kind of a select--selection factor-- SMOOT: Um-hm. BOST: --in who came and what uh--what uh--how--how a program developed. The selection of Ed Pellegrino him-himself--I spoke of that to you before our tape started--was in fact a reflection of that very attitude that we were looking for not only strength in a--in a chairman of the department of medicine in the conventional academic aspect. We were looking for uh, an orientation and a--and a commitment to health care in a broader sense with a general community--community dimension--not a, uh, provincial community, but a--in generic sense--a community concept of--of development. So we were--we were--many of us were looking at the Medical Center as really a platform from which to move the general pattern and level of health care. SMOOT: Were you using more or less idealistic sort of sales pitch? BOST: Yes, absolutely. SMOOT: Okay. BOST: And this--this--this was--this was a, I think, a very important, uh, element in our ability to attract faculty and particularly the faculty that we attracted. We did not have the most money. We were not able to top the salaries and we were looking for bright, able, well motivated, uh, younger people and, uh, this was--this was what we had to--we had to offer. We had the--the setting and the challenge and the potential and, you know, that-that I'm sure that it attracted and stimulated some and it may have, uh, you know, had an opposite effect on others, but it did bear very importantly and basically on the outcome. SMOOT: Something I found very interesting was that there was a limitation on how much people could make. Uh, there was a salary and that was all you were supposed to make-- BOST: Yeah. SMOOT: --at least in the early stages. BOST: Oh well, we set up--the whole handling of professional fees in the hospital was--was--was colored by this and I don't know whether you may have had opportunity to look at the Physician Services Plan, but this--this was the plan that we formally established that uh, all of the uh--the--the payments for professional services went into a fund. It did not go into the individual's pocket and uh, this was a fund that was uh, used in our budgeting for total programs and uh, was not necessarily reserved for the clinical programs and though there was a very great, uh, measure of idealism in this. Actually, I think that-- that uh--that this may date it (both laugh). SMOOT: Well, it was unusual for the time, as well as-- BOST: It was unusual for the times. It was not as unusual for the times as it would be today-- SMOOT: Yes. BOST: --because the uh--the kind of uh--of uh, individualistic self-interest, uh, of bottom line mentality that has come to uh--to predominate was--was less, uh, the case there and at that period there still, I think, was uh--was a, uh, feeling that health care was a special area and a special purpose that uh, there was--you spoke about hospitals, uh, turning away indigent persons and so on, the--the idea that health care, uh, was something that, uh, was not there for the purpose of making money or providing uh, uh, reward, but rather was there to uh, meet needs. That was still the prevailing attitude. SMOOT: However, there were people that dissented from that attitude from the very beginning, were there not? BOST: Well, yes. Uh, I think we had less than our share of those people though because, I think, the recruitment and the--the whole process and the--the considerations, the dialogues that went on tended to turn off people of that--uh, of that bend and tended to attract--and that was the reason that for some considerable time we had a remarkable degree of uh--of uh, coherence here. We had a degree of--of uh--I won't say consistency, but uh, of--kind of uh, uh, intellectual compatibility or orientation I should say rather [microphone interference] than--but there was an element of uh, compatibility that uh, has, I think, increasingly been diluted as we went beyond that initial period. SMOOT: Was the original idea--the original plan--for--for salaries and things, was that--probably too strong a word to say subverted, uh--what happened? I--I'll back up and just rephrase the question. What happened to the plan? What happened to the idea? Was that a uh, reflection of the changing attitudes of medicine throughout the country or was this something that had happened within the Medical Center itself? BOST: I think we stayed on a strict salary. This was the term that was used--strict salary system--longer than almost any place in the country. Um, the uh, increasing cost of health care, the increasing, uh, remuneration of physicians particularly, but other health professionals, uh, made it--put increasing pressures on this kind of strict salary system and uh, the uh--the difficulties of keeping pace in terms of, uh, being able to offer, you know, not top the market, but offer enough, you know, to--to make it possible for a person to come, uh, became increasingly difficult and the--the ability to use the professional earnings as an element in uh--of remuneration for faculty, uh, you know, finally overturned it. SMOOT: Um-hm. It came down to a vote, I--I've heard, went from Plan A--the original plan--to Plan B and uh, by that time, by--when it came down to the actual vote there were only a couple of departments that opted to retain the original plan. BOST: Well, the vote came kind of late. Actually, the--it was all over by the time the vote was taken. The situation--the die was cast. By that time we had another dean of the College of Medicine and his attitude was, you know, for--to-to change it and to put everybody on an incentive and, you know, so it--it had already lost uh, uh, administrative support-- SMOOT: That was-- BOST: --in that period. SMOOT: That was quite a change I suppose from-- BOST: Oh, yes. SMOOT: Dr. Pellegrino to Dr. [Kay] Clausen. BOST: Well, Pellegrino was not dean. SMOOT: Oh, I'm sorry--okay. BOST: But uh--so uh--but Clausen was uh--Pellegrino was--was--had, had strong commitments to the uh, strict salary approach-- SMOOT: Yes. BOST: --and uh, had a uh--a very important influence earlier. Um--I developed the Physician Services Plan which was the--the whole device and mechanism and all for uh, handling professional fees and this, uh, was--well, it--it played a very important, uh, role in the early period. I think one of the--one of the, uh, effects of that was that again, an indirect one in influencing the selection of people who decided to come here. SMOOT: When did that actual change take place--the-- BOST: --not--not until, uh, oh, I don't know, '70--mid seventies I believe--in the early seventies perhaps. You know, this was a good deal later. SMOOT: Um-hm. BOST: Now, the so-called PSP--Physician Services Plan--was the--was the pattern throughout our--our period of development and uh, reaching maturity, I would say. SMOOT: Um-hm--hmm. BOST: It was a whole different philosophy and a very, very, uh, distinct philosophy. I--right now in--in hindsight I think most people would say a very idealistic philosophy, but it is that quality of idealism and the--and the breadth of uh--of a view in terms of mission and commitment that is the most distinctive quality of this whole period and whole development and I think you'll see that in individuals, you'll see it in many, many dimensions as you uh, develop more insight into the whole period and all, you'll see indirect effects and permutations of that in--in--in many manifestations. SMOOT: Seemed in a broad sense to change then from a--from this--a very idealistic institution to a far more traditional-- BOST: That's right. SMOOT: --institution-- BOST: That's right. SMOOT: --and would you say this was an inevitable sort of uh, a development? BOST: Perhaps so. I--I think that uh, any development of this character tends over time to take on the coloration of its surroundings. SMOOT: Um-hm. BOST: It's a pretty natural phenomenon, I think. Uh, the uh--the dilution that occurs, uh, with the expansion and growth of program and bringing in outside people, you know, who have not been a part of the initial development. Uh, this--this--and--and then the departure of key people, you know, who were committed to it. This--I say is a kind of a dilution of it. That--that is, uh, no doubt a, uh, predictable- -the uh, extent to which it happened and--and the--I--I don't think that it--it's--it's without some continuing elements of influence and I think that it becomes, uh, um, you know, some part of the tradition and--and distinctive quality of the institution over time, but it uh-- it doesn't predominate as it did in the early time. SMOOT: As a medical economist, you've looked into, no doubt, the so- called growing commercialization of the health care professions-- BOST: Um-hm. SMOOT: --health field generally speaking. Um, how is this affecting medical education and what is this--in--from your own perspective portend for the future? What do you--what do you see as the immediate future of health care and the, uh, developments of medical centers--how are physicians being educated-- BOST: Um-hm. SMOOT: --how is this commercialization affecting them in their education and their attitudes? BOST: Well, I think it has an unfortunate effect. I think that uh--that uh, at some point there will be a reaction to it. I think perhaps we can already see some indications of this. SMOOT: Um-hm. BOST: Um, the uh--I think the--the--the ultimate--ultimate story will or ultimate outcome will uh--will hinge on whether the commercialization of it--how that squares with the aspirations of society in terms of health care. If, as we see I think increasing evidence that it tends to uh, leave, uh, many people, uh, out, it doesn't square with our--our, you know, with--with social conscience or--or equity considerations, uh, then--then there will be, uh--it will build up a constituency--a growing constituency that ultimately will create a--a swing of the pendulum in the other direction. SMOOT: Um-hm. BOST: On the other hand, if it does serve to meet all the needs and take care of all the problems, why, then of course it'll carry the day, but I--I don't myself expect that. I think that uh--that--I don't trust markets that--that uh--that--that much. I think that uh, markets tend to pile it higher where it's already high and low where it's already low and uh, this--this in the health arena is not an adequate res-- outcome. So we--we will have more people, uh, who are disenfranchised in terms of access to health care and we will have, uh, emergence of double standards--double--double standards for health care--for those who have money or much money and those who don't and, uh, I think the question of how that reconciles with our--our uh, attitudes--social expectations, aspirations--is--is going to be the ultimate determinant. SMOOT: Um-hm. BOST: But if--if uh--if we're going to have uh, you know, some reaction to this and if we're going to have some--some real change in the other direction, I think that the medical schools and medical education is the--is the--is the--the most, uh, important grounds, you know, for that to uh--to uh, breed and come about, because it--this--this is a- -this is a change in attitude, change in orientation and--and the young will first, uh, see this and will first become, uh, you know, motivated to--to--to bring about change and uh--it won't be the people that are out and well established that will affect the change in that direction. It will be the young--the young health professionals and--and anyone who is concerned about uh, the problems that may be existent or--or developing increasing. Uh, I think that they have to look to medical education and health professional education as an important area for this to be, uh, uh, you know, understood and the--the study and uh--and concern with it to be implanted and cultivated. SMOOT: You've worked with--in a variety of, uh, settings with the state. Uh, we've talked in our previous session about your work with the development of Kentucky's Medical Assistance program and that also that you worked on the governor's Advisory Council of Hospitals in 1966. Uh, could you tell me a little bit about that? You were cited an award by the Kentucky Hospital Association for you work with this particular, uh, council, uh, and I believe you have touched on the points of this-- this-- BOST: Well now, that's--that's--that probably is the Medical Assistance Council-- SMOOT: Okay. BOST: --financing hospital care. SMOOT: All right. BOST: I was a member of the initial council and I was chairman for about, uh, fifteen years or so, um, but um, I uh--I was involved in a good many things at the state level, uh, pretty much most everything in the health arena from--up to HMO's. Um, I was also very much involved in the development of the Medicare lo--Medicare program at the national level. Those are really the two major activities that I had that were sort of outside the Medical Center although I--I--I feel that they are not really tangential. I think that they are central to the uh, success of the--of the whole development as any other single thing that can be identified. SMOOT: You had an opportunity then to work with--not only with the executive branch, but also with the legislative branches of government on the state as well as on the national level. Um, it has been pointed out, of course--it--it's easy to see the changes that take place in the governor's office. Much easier to see those changes than it is to see changes in the legislature. Uh, have the changes that have taken place over the years in the Kentucky legislature, uh, had effects upon the Medical Center here? BOST: I expect so. The legislature did not really, uh, have much involvement in any depth back in the period in which we were developing here. There--we--we were, uh, in a so-called strong executive state and the governor and his staff and his uh, development of the governor's budget--the executive budget was the--really the whole process. There were legislative review and legislative ultimate consideration and action, but uh, that was not an area that uh, uh, we got deeply engaged in. Uh, the governor usually had the political, uh, power to secure adoption of his budget and his program projections and that was--that--that happened consistently throughout our period. I guess it's only the last uh--with Governor Brown that the legislature and the legislative committees really began to have a much more important participation. It will make it--it will make it more cumbersome to work on matters of public policy, I think, to have work with a lot of legislators and a lot of legislative committees. The uh--the strong executive made it uh, much more manageable and I think we were perhaps a beneficiary of the fact that uh, we had that type of state government during our developmental period. SMOOT: Um-hm. Let me back up and ask you if you could, uh, compare the administration, uh, briefly, I don't--don't have to go into great detail on this--but compare the--the administrative styles of Dr. Willard and Dr. Bosomworth. Say that they're under entirely different circumstances, I realize that changes had taken place-- sweeping changes--in the university as well as in the state, but can you--can you compare them? Would you care to com-- BOST: Well, there were important, uh--there're important differences, but some very definite similarities too. SMOOT: Okay. BOST: Dr. Willard, uh--his style, I guess you could characterize as being soft-shoe. He didn't have any flamboyance in his makeup. He uh--he didn't uh, threaten or--or uh--or exploit his relationsh--he didn't threaten people and he didn't exploit people. Very remarkable, uh, to have a person who has the--the qualities of effective leadership and also one of not being, uh, you know, pushy, uh--and uh, he--he had a quality of kind of deliberatli--deliberateness. He wasn't impulsive- -he isn't impulsive. Uh, he inspired the--a great deal of confidence, I think, in the people that he worked with. He gave them a great deal of latitude. Uh, he uh--he led by example in many respects. Um, he put a lot of--he gave a lot of attention to his selection of people and having uh, selected them, then he--he really didn't attempt to uh, control them in any narrow sense at all. He gave them a great deal of--of latitude and a very great deal of support and I think that--that uh, if people didn't quite do what he expected them to that in part his effectiveness was that if he hadn't hurt their conscience-- SMOOT: (laughs) Yeah. BOST: I don't, uh--he didn't have--you know, he wasn't a tough administrator in any respect, but he was articulate and there was never a great deal of uncertainty about what direction he wanted to see things move, you know, uh, but he--he left a lot to the individual in terms of their own style and their own, uh, you know, how they--how they do it. He didn't try to--to uh, run their show for them at all, but he was very effective in uh--in the continuing contacts that he had with people and just kind of uh, uh, drawing them out in terms of where they were and where they were headed and what they were thinking and what their objectives and purposes and so on that they had in mind were and how it was going and--and he would bring in points that was--he was aware of in, you know, the broader context as it related to their activities and--and uh, he was a--he was a very effective administrator in--in a kind of a gentle sense of, you know, keeping, uh, some element of coherence in the whole, uh, composite of activity. Um, he uh--I think he enjoyed a very--a very great respect on the part of--of uh, people that--that worked with him and for him. Um, Dr. Bosomworth, uh, uh, is also not a tough administrator in the sense of uh, pushing people and uh--and all. I don't think that Dr. Bosomworth comes to the job with quite the same, uh, breadth and depth of uh--of orientation that--that Dr. Willard did. Dr. Willard had more influence on things around him and the whole setting that he was in-- wherever he was. Uh, I think Dr. Bosomworth is considerably affected by what the setting is. He's--he adjusts--modify, you know, uh, adapts more than Dr. Willard usually did. Uh, Dr. Bosomworth isn't as--as inclined to be as uh--as much of a, uh, a crusader as Dr. Willard was. Of course it was a different period and different--different, uh setting, but uh, uh--Dr. Willard attracted strong people I think. He--he attracted a certain type of person--uh, the people who--who were--who were exceptional in some--some respects and uh, I think that Dr. Bosomworth has of necessity had to work with the people that are--had al--were already here in very considerable part, you know. He hasn't had the same--the same, uh, opportunity, the same ability to uh--to carve and shape-- SMOOT: Um-hm. BOST: --as uh--as Dr. Willard did. Nobody, again, would have of course. Uh, as time has gone on I think Dr. Bosomworth has tended to assert himself more as time has gone on. SMOOT: Was he uh--well, I--I'm curious as to the selection process for the successor for Dr. Willard and it seems that uh, Dr. Bosomworth was a recognized--was recognized as a very strong candidate very early to succeed Dr. Willard. Is that so? BOST: Well, I think so. Uh, uh, he had--he had gotten involved in--in the hospital and he was interested in the general picture in the Medical Center to a degree that other clinicians were not. SMOOT: Um-hm. BOST: Uh, and uh, uh, he had worked with Dick Wittrup, uh, in uh, general financing program, a development and program operation in the hospital and knew the--the terrain perhaps better than any other person locally. SMOOT: Um-hm. BOST: Uh, I think that uh--that there was never any great contention, that I was aware of, about Dr. Bosomworth's selection. He didn't really threaten anybody and uh, so there was--there was just no, you know, no real--and--and uh, he was young and obviously able and so the uh--the inclination not to bring in somebody from the outside that would be an unknown quantity and that would upset things, you know, this is always a--apprehension on the part of many. [Pause in recording.] SMOOT: What do you think has been the impact of the Medical Center on the local community, then the regional and statewide communities-- socially, economically, in terms--certainly in terms of health care? BOST: Well, I think that it--it is now and will increasingly be, uh, an impact related to the, uh, uh--to the graduates of the health professional programs as they feed into the--the health care system of the state and settle in communities and so on. I think that that will--perhaps already has come to be the principle, uh, impact of the Medical Center and I believe that the people who have gone and completed the programs here and gone into local communities, uh, take a uh--to varying extents and really this is the kind of thing you can't, uh, document or really measure anyway, but I think that their attitudes on questions and issues and behavior and so on may be uh--may be uh, uh, different than their predecessors, than uh--than uh, others in the community and that this--this--this is a subtle impact that I think it's very important, particularly in the health arena. Just last--last evening, uh, I was meeting with a medical advisory committee--I'm the only non-clinician on the committee--and uh, dealing with uh, whether or not uh, Blue Cross should pay for certain essentially new kinds of services that are developed and uh--and uh may be quasi experimental or, you know, transplants, this and that--the whole range of things- -and uh, at the meeting was a--was uh--a member of the committee was a man who is one of our graduates here and one of the issues, uh, being discussed was the issue of uh--of a monitor that can be worn by diabetics where they can test their own blood sugar and uh, if it goes up at certain times or after certain activities or mealtime or whatever--they know what it is and they--they--they know then how much insulin they require and should be taking. It's a way of uh--of uh, monitoring medications that is far more advanced than, you know, where they just take a, uh, set dosage at set intervals and uh, in a way this is kind of preventative measure because to the extent that you can improve the--the regulation of the medication you can avoid progressive damage which is essentially irreversible, you know, and uh, the attitudes of the members of the committee were--were interesting and some thought that this was, you know, kind of a, a luxury kind of thing and all, but the--the graduate of--of our program uh, was uh, very effective in pointing out that this was a pa--a preventative kind of measure that could improve--potentially improve--the health level of a group of people that are already, you know, diabetics. They were particularly subject to illness and illness expenses in the future and uh, that--that we don't have, you know, a lot of ways that we can spend money to prevent difficulties. We usually spend the money after the difficulties are here and that--that attitude is--is what I--to me an illustration of the kind of uh, influence and impact that can--can come from a program where the educational program that is feeding people out into the mainstream delivering health services. Um, the department of behavioral science represents a--a component in the formation of a health professional that undoubtedly is having, uh, uh, effects in subtle kinds of ways, uh, and so the--the--the impact is really a very elusive, uh, uh, question. Now, the--the impact in the earlier period- -before we began to have substantial numbers of out--out--graduates from the programs--the impact, I think, was uh, one of very significant stimulation, of uh--in the arenas of health affairs, whether uh, financing of health services, whether areas of uh--of maternal and child health, areas of rehabilitation--care for rehabilitation. Uh, I was on the state commission for rehab, for a while and--and uh, Dr. Willard was on many of these kinds of uh, activities--uh, uh, home care programs--uh, various uh, elements of change and, uh, development in--in health services and I think we were--we were very active and very uh, uh, uh--I won't say we had a determining effect, but I think we provided a very significant stimulation in the consideration and development. I think that Kentucky was relatively laggard when we came in and I think that this stimulation was badly needed and uh, I think that it did have some very important--very important effects. This--in the Hospital Association--the whole program and activities of the Hospital Association--were--were markedly upgraded, uh, after, uh, we came in and some of our people began to participate. Perhaps we didn't have as much effect on uh--on uh, the, you know, organized medicine and its--KMA [Kentucky Medical Association] and so on, but we did have in--in nursing, we did have in uh--in hospital arena, uh, and several other arenas. Mental health for example--mental health was a, uh--we had a tremendous development of--of community mental health centers in Kentucky. Uh, I chaired the state Mental Health Commission--planning commission--when we blueprinted, uh, this whole development. You know, we were going to get people from institutions and provide more community services and community support and provide, uh, mental health consultations, uh to a whole, uh, broader constituency than--before you had to be, you know, a very severe before you came to any service that was available from the state programs and uh, this was uh, you know, tying in the community programs with the public schools and with behavioral problems in schools and a very much broader, uh approach-- orientation--to dealing with--with uh, mental health problems of varying degrees and characters. SMOOT: Hmm. BOST: Uh, yes. [Pause in recording.] SMOOT: In a programmatic sense, we had a significant impact-- SMOOT: Um-hm. BOST: --and Kentucky is no longer as laggard. It--Kentucky came up on many scores--uh, mental health, uh, hospital care, nursing home care. Uh, uh, Kentucky gained a lot of ground in that period of the--of the sixties and I think that our involvement, uh, uh, contributed importantly to that. SMOOT: Um-hm. What about on the national level? BOST: Uh, well, I've mentioned Dr. Willard's involvement on the national level in terms of the standards for medical education--accreditation of medical schools. Um, I was involved in uh--in the whole problem of financing care for the aged and uh, I served as uh, executive director of a blue ribbon committee that uh, had three Noble prize laureates and former secretaries of HEW [Health Education and Welfare] um, and uh, got a report out that influenced the legislation enactment by Congress of the Medicare legislation and then I took a leave from the university and became, uh, deputy director of the Medicare program throughout its uh, activation and uh, Medicare had a tremendous widespread influence on the standards in health beyond Kentucky as well as within Kentucky. Independent laboratories for example were virtually unregulated in many, many states and standards were set for independent laboratories that up--very definitely upgraded really very lax standards for nursing home care, for hospital care to some extent, uh, eliminated a segregation in hospital care overnight. While the public schools- -segregation in public schools--took I don't know how many years and still, you know, is partial, but segregation of uh--of patients in hospitals was dealt with by Medicare. It isn't recognized or very rarely admitted, but in Lexington, Kentucky in Good Samaritan Hospital there was the colored ward and--and the white ward (laughs) and this was a pattern that existed throughout the South and many other places and Medicare eliminated that. Well, this is really getting aside perhaps, but I think that and--and I know, I--I am--I'm quite certain that in terms of my own involvement in that situation that I would not have been involved in it had I not been in this setting and in this process and in this, you know, oriented as I was here. SMOOT: Um-hm. BOST: So, a side effect perhaps, but it--it really gets--it gets to the same point--if the--if the point is recognized to be the broadest one of the public interest in health care. SMOOT: Had that been one of the original intentions, the--the-- BOST: What? SMOOT: --the end of s--ending of segregation within the hospitals or was that something that just occurred because of the program itself? I'm curious since you brought that point up (laughs). BOST: Oh my, no. It was--it was--there was strong resistance to that. Oh my, no. That didn't go through unnoticed. No, no--no, the--the- -the issue of course had been perking along and becoming progressively front--the front burner--the Civil Rights legislation and all this was in the period, you know, when it was focused up very--very definitely, but the--it--the--the position that the program took in sticking by the--the guns--John Gardner, I don't know whether you know John Gardner who was head of Common Cause for awhile, before that he was the chief executive of the Carnegie Foundation. SMOOT: I've heard of him. BOST: Well, anyway he was secretary of HEW at that time. SMOOT: Yes--okay (laughs). BOST: And uh, uh--no, the--the--it took a lot of courage to uh--to accomplish that, but um, this was a--this was a period--I think we were very--I--I certainly feel very fortunate that this was a sort of an activist period when we were coming on with this development. It was a period of uh, of change and it was a period which was conducive or certainly receptive to uh--to uh, actions that tended to have a wide effect, you know. You wo--everyone wasn't just working for themselves, you know, their own uh, uh--their own interest upmost as the ultimate, central point in view and uh, so it--it--it provided an opportunity for engaging in uh--in uh, activities and uh, for efforts that--that could have a very wide effect and uh, I think that uh, others like myself were, you know, looking for this kind of opportunity and this--this development, uh, offered it and provided it in--in abundance. SMOOT: Hmm. It--what about in the seventies? Of course you--you were very active in the sixties--obviously were--that was a very activist decade. Uh, you were here in the seventies, you were seeing the fruits of what had occurred in the sixties. Uh, mixed emotions? Uh, were you pleased with the results? I'm not sa-- BOST: Well, I--of course ambivalent uh, about uh, certain things and trends that I saw developing. It was a period, you know, in which values were shifting somewhat and uh, it was not a period that--that offered, I think, the same kinds of opportunities that existed earlier. Uh, I became, uh, involved in a project in Eastern Kentucky for the Appalachian Regional Commission and uh, although I didn't take a leave of absence from the university, I had--I devoted a very considerable part of my time and effort to that development. It was about a, oh, Southeastern Kentucky there were fifteen, twenty counties involved in it and we tried to up--tried to really uh, plan and upgrade the health capacity--the capabilities--for delivering health care in that whole area and made some important--we had more home care programs in Southeast Kentucky than existed in uh, all the tiers of the loc--lower South, you know. We had more than the total of Alabama, Mississippi and Georgia and Florida and uh, I don't know where all. We had quite a remarkable--and--and most of those programs still are operating. SMOOT: Um-hm. BOST: They're not as--they're not uh, as expansive and they're not developing as they did in that period, but uh, um--well, in the--in the seventies, uh, uh, I did not see the same kinds of opportunities that I had earlier and uh, so personally I uh--although I continued to--to uh, function, I was functioning on a--on a increasingly curtailed level and basis and uh, I think, uh, perhaps by that time I was beginning to get a little frayed too (Smoot laughs), all worked out. SMOOT: You retired in 1983, is that right? BOST: Well, not--not-- SMOOT: Not-- BOST: --not--not fatigued, I've been rested a little bit, but I--I don't have the uh--I don't have the--the same, uh, well, you know, the--I don't hear the fire bells that I did. SMOOT: Are they going to come back sometime, do you think? BOST: I would hope so. I think they will. I think that the--the challenges are still there we just are not, uh, at this phase of time looking for them and uh, identifying them and uh--and uh, pointing them up. They're--they're submerged. SMOOT: Are there any other subjects you think we should touch upon, uh, today concerning the Medical Center or your own involvement with the Medical Center? BOST: Well, I--I--I don't know. There's uh--uh, I hope you have gotten the--the uh--some feel for the uh, range and character of decisions that--that uh--and issues--that presented in this whole planning period. The whole question of, you know, what departments will we have. Uh, we gave some serious consideration to--to a new configuration of organization within the College of Medicine by uh, organ systems, uh, rather than by uh, traditional disciplines, but that just uh--I--I mention that only to--to--and some others can give you more depth in that than I could--but uh, uh, the uh--the range of questions that have to be decided is just beyond anything that anyone would ever realize or can ever quite, uh, uh--that nothing is decided, you know, you really have to decide more things than--questions that you take as--for granted, you know, you--you only deal with things, you know, a few things, uh, ordinarily as you go along and in that kind of a period you--everything is open for--for determination and requires some--some conscious consideration and uh, that--that added to the--to the excitement of the period, but it also added to the demands of the period and uh, uh, more things were decided in the first few years than will be decided in the next uh, twenty-five or fifty. It's uh--it's almost as uh, you know, the--the uh, you know, in that embryo period more things decided about uh, a person's physique and uh, character and personality and physical attributes and mental perhaps than--than ever is again decided, you know. It--it--that's where the whole thing gets uh--really its kind of shape and--and direction. That's uh--of course we were not--we were not out to uh--to--to totally have a--an innovative program. We were pro--proceeding with a great deal of pragmatism, but we were also and I think we had a--we had a uh--some uh, receptivity even commitment to reform as we went through this range of questions that require consideration and uh, I don't know, I don't think we maybe did as well as we might have in terms of uh, uh, departing from the conventional, traditional patterns, but uh, we did some of that and uh, could have done more and perhaps should have done more, but uh, uh, that--that is a--is a, is a phenomenon, certainly a process that uh, in a period of that character has a real--just profound dimensions. Uh, one other thing that I might comment on a little bit, I think it deserves some--some uh, specific uh, uh, focus and that is the recruitment process. Uh, this of course is another one of those uh, uh, seminal sort of aspects that uh, uh, you know, cast things differently and they will never be the same again, you know, and--and everything that happens after that, you know, tends to some extent to have been influenced by that initial decision. You--you--you bring in uh, a certain, uh, person as the head of an important area and after that the whole program and pattern is--is uh, forever influenced. Um, a lot of attention was given to recruitment and uh, it was kind of a, uh group affair. Dr. Willard did personally, uh, the groundwork for almost all of the key recruitment. He would get names of people from uh, suggestions of possibilities from his contacts in the medical education field and he was broadly based in the medical education field, particularly because of his uh, role on the Council of Medical Education and he would get uh, wind of some bright, promising person someplace, you know, and he would--he was always accumulating lists of people, you know, that uh--just kind of intrigued him or, you know, he thought, you know, he might have interest in and his approach to this was a bit different I think than perhaps, uh, most people in a similar position. They might call someone who was, you know, a dean somewhere and say, you know, who have you got that uh, might be a professor of anatomy or this or that, you know, have you got somebody, you know, who's sort of coming along and looks good? I don't think he did very much of that. He uh--he did a lot of kind of uh, broad uh, stalking before he actually got down to recruitment and he usually--when he-- when uh, it came to the point that we were recruiting for uh, chairman of uh, biochemistry or physiology or whatever, you know, uh, he would uh--he would have accumulated, uh, quite a few names of people and then of course he would be receptive to suggestions that might come in, (coughs) but uh--and then--then he would find uh, ways of narrowing these down a bit and then he would usually go on the road and in connection with other trips he was taking here or there he would drop in and contact these people--not--not to the point of really recruiting them at that point, but just to kind of uh, get the feel. Did you get--did you talk with him about this? SMOOT: Briefly. BOST: Well, I--I--I am really second hand source for this. SMOOT: Oh, not really. You-- BOST: But, you know-- SMOOT: --you participated (laughs) in it. BOST: Uh, then uh--then there would be--he would--he would narrow this down and make some approach to those that he kind of selected out as the ones that seemed to be most attractive or most uh, promising and uh--and uh, then following this of those that really kind of bounced and he bounced with, uh, they--we'd have several who'd be invited in and he would uh, schedule a couple of days here and they would go around and talk with the various members on the staff, you--there--at that time there were four or five of us (Smoot laughs) and uh, we would talk about various aspects. We would try not to talk about the same aspects, uh, and uh, they would, you know, meet the president of the university and some--if there was any kind--a department on the campus- -there was a, you know, in this--if it were, uh, microbiology then it would be somebody over in biology, you know, or something, you know, on the campus. Uh, biochemistry would talk with the chairman of chemistry on the campus. He'd have a whole schedule for them, you know, a couple of days and uh, uh, then uh, we would have a--a dinner at his home and his wife served thousands of people I would say and there'd be often virtually all the staff would be there and the invitee and--and this would be, uh, oh uh, anywhere from ten to twenty people for a meal-- buffet--and then we would sit around his big living room in the evening and spend two or three hours just really having an open discussion with this person, drawing them out on this or that, you know, in a group and then we would uh, afterwards have a kind of a staff meeting and compare our notes and reactions to them and so on and uh, if uh--if the person uh, uh--if there was general consensus, you know, if they were a person we wanted to follow up then there would be a return visit by that person with his wife and, you know, looking at housing and this and that, but uh, there was a lot of--I th--I would say two things--I think that--that there--that this was not a kind of an extemporaneous process, it was a pretty uh, um, orderly, involved kind of uh, activity and--and uh, uh, there was--there was a lot of participation in it, uh and it wasn't uh, uh--very, very rarely was it a--was there a precipitous decision on it. Uh, the decision was his. We didn't- -maybe we did have a vote on one, but that was unfortunate, uh, but his--he--he made the decision, but we were all, you know, speaking, expressing our opinions and reactions and so on and uh, uh, it was um- -well, I think that--I think that uh--that the people who came knew what they were getting into. They--they--we--we--they--they knew they had the--the flavor and the sense of the whole situation, uh, perhaps much better than people or--frequently have. I think that that the initial people who came in had it to a, uh, much greater depth than the people who were later recruited by departments who came in, you know, that later when you got down the line in departments, you know, people would come in here and they wouldn't know anything about the general pic--but there was a real effort made to give everybody the whole picture, to give them the whole philosophy, the whole orientation, the, you know, the--the risks and the problems as well as the--the pluses and uh, so that--that there were not many decisions made that went off the track either because the person--we didn't really know th--what we were getting into when we brought the person in. We usually sort of had-- and--and had a pretty good idea of what they were, what their interests were, what their general, uh, approach would be and so on, uh, and they had a very good view of what they were getting into. So, you know, this--this was a very important--I--I think that--that recruitment sometimes and in some of the other developments went, you know, that the--whoever had responsibility for the development called some crony and get somebody in here on the scene, you know, and everybody--well, who's this--well, this is--for the first time, but this was a--was a, uh, participatory kind of aspect and uh, everybody came to feel a part of it. That was the real--I'm fumbling a bit--but this was the--this was the--the unique, significant telling part of it was that--that people who came in felt they were really a part of something that was- -that was broader and--and--and, uh, uh, you know, what they were doing was important, but they were a part of something that was larger than just their own, uh, zone of activity. SMOOT: Hmm. BOST: And that--that process of recruitment, uh, I think, was a fundamental--had fundamental import for the sort of cohesiveness or--or coherence is a better word that we had here for quite a long time-- early it did. Uh, we had a--a group that, you know, were really--not on exactly the same wavelength--but the rapport and the feeling of being uh, uh--belonging to something of imp--of significance that was broader, you know, this--this was--added to the, to the meaning and the--and the uh--the excitement and--and it had a tremendous motivating factor--people worked very, very long and hard, much more than people now do for more, uh, and--and this--this didn't come hard. It was not uh--it was not real punishment because there was a--this--this strong sense of being a part of something of significance, uh, you know, is a very gratifying feeling. It's a very--in itself is a very, uh, unique period. I've had a lot of people who were in this period tell me that it was a--of their entire period of their life, you know, it was a--it was a time that--that they really felt, uh, uh, good about what they were doing and the--in a congenial setting and--and it was really a high--high point for them. I think that's true for a good many people and uh, the recruitment process was a basic, you know-- SMOOT: Basic facet of that certainly. BOST: --basic part of creating that. SMOOT: Hmm. Didn't always work though. Now, I--I've heard that (laughs) particularly in--in regards to the first chair of surgery. BOST: Oh, yes. SMOOT: That-- BOST: Yeah, Eiseman didn't- uh- SMOOT: Never bought it, it seems. He-- BOST: No--no. Uh, I always felt somewhat let down because, you know, he--I remember his words, you know, he was talking about this and he really said too much. He said, "This is pure gold," you know, he really wanted to be a part of it and all and this was just absolutely without any depth or-- SMOOT: Well, he saw it as gold in the strictest sense of the term. BOST: I guess. Well, I--I just--maybe I just didn't understand him. (both laugh) No, no, he didn't because, you know, we had the PSP plan-- SMOOT: Yeah. BOST: --and the surgeons were one of the ones that really were most resentful of that, but uh, he did build a strong department. SMOOT: Oh, unquestionably. BOST: And uh, he had some very good people that he brought in. SMOOT: Yes. BOST: But uh, uh, there were--there were a few, yes, that didn't--but uh--but to characterize it I think it uh--it was remarkably coherent. SMOOT: Yes, I don't mean to point to the exception to the rule-- BOST: Yeah--right. SMOOT: --and say, well, there it is. BOST: You know the cliche, the exception proves the rule. SMOOT: Right (laughs). BOST: Uh, but uh, let me--let me suggest that if you haven't talked with Bob Johnson you might want to because Bob Johnson really was in the--he--he had the full time job of--of bridging between the health care system and the community terrain and the state and health and the Medical Center. That was his role and this again is a tangible expression of this uh, philosophy that I spoke to you. It might sound otherwise as a cliche, but there are numerous, uh, very tangible uh, evidence, I think, of--of the--the--the depth and reality of that, uh, and I think that--that more than anything else it was that general attitude and orientation that bridged the kind of contentiousness that existed locally and in the state when we came into the situation because we had in a relatively short time we had won the, you know, people thought that we were not only sincere, but that we could and would help and that that's what we were here for, and this went a long ways and uh, so I think that in terms of relationships that--that uh--that general attitude tended to uh, provide a footing for relationships that existed, you know, between the Medical Center and the state and the Medical Center and all of these specialized, uh, health constituencies and uh, many outlying leadership in the state. Perhaps we did the--the least successful job within the university itself on that thing. SMOOT: Um-hm. BOST: Uh, now, this was--this was uneven at least. Uh, in some areas it went--it went well. As we proceeded there were increasing people on the campus, uh, who became involved in common activities with us and so on. I think of Tom Ford and uh, uh, some others, but uh, um, we did not have the uh--the, well, there was--there was uh, um, microbiology was weak in the university. I don't know whether any one has spoken about this general area, but that was a--that was an--an obstacle in a way. It--I don't mean to comment negatively on the people, there was just an unfortunate situation. We couldn't, uh--we couldn't accept the standards that existed and uh--and we had to disassociate ourselves, uh, and it was partly standards, partly a general--a general, uh, attitude and philosophy that was different and uh, there--there were- -there were perhaps other--other opportunities or--or--or possibilities of--of bringing parts or individuals in the university into, you know, our activities and we didn't really--I know I didn't--I--I feel some, uh, what remiss I guess in not going out of my way more to try to do that, but uh, we were--we were pointed beyond the university and uh, and we felt like that uh, our real, uh, impact and our real uh, concerns were out where health needs were and people were working with health needs a little more specific than the university was quite uh, uh, focused on and so that's--this made it--provided an excuse anyway- -for us not--not doing more in--to cultivate the involvement of the university community in our--in this whole period and activity and all. SMOOT: Hmm. BOST: Um, but uh, this--this development of this Medical Center was uh, you know, a part of a broader thrust throughout the--in American medical education to uh, incorporate medical education into universities and uh, that was a, you know, viewed as a very important, uh, pattern for--for the future and we--we accepted that. We were not resisting that at all. We were not looking for isolation and independence at all. I think perhaps that might have been misunderstood, uh, by some, I don't know, who thought we were trying to pull apart. I don't really--I--I think that Frank Dickey knew better and uh, I think others came later to recognize that was not the case. SMOOT: Um-hm. BOST: Actually the separation, I think, into a Medical Center campus was not uh, uh, was not--that was not a Medical Center triggered uh, development. I don't think that came as a result of the Medical Center's insistence or pressing for it. I think it came for other reasons. SMOOT: And clearly, geographically speaking, nothing's really changed. BOST: That's right (Smoot laughs)--that's right. SMOOT: Any other subjects you would uh, care to touch upon? BOST: Well, I--the--there are--there are other things that--that uh, I hope that others are giving you in terms of uh, curriculum and philosophy about uh, students and uh, grading and selection of medical students and uh, the uh--one thing that I ought--perhaps might comment on is uh, that uh, there was hope--at least on the part of uh, of uh, Brick Chambers and some of the original, uh, advocates of establishing a medical school here--that--that uh, philanthropy would be an important source of uh, of support and funding and all and uh, this did not materialize and really was not much of a pattern in the period in which we--this all occurred. Now, there is, you know, some--with the Markey Center over here being dedicated recently just indicates, uh, some real change in that--in that respect, but uh, uh, there was a--there was a vision of uh--of uh, almost a--a private development here and that the medical school and the Medical Center development would uh--would uh, be uh, you know, with the local hospitals and the local medical profession would comprise much of the faculty of it, you know. It was a much more integrated kind of uh, of uh, pattern than in fact developed here. As you know, with relatively minor exceptions all the faculty were brought in from the outside here and uh, um, the uh- -one consideration in that certainly that was in my thinking all along at that period was that if we were--if we were going to do clinical teaching in the local hospitals for example and depend on those as our, uh, resources for our educational programs, that this would involve us pretty much in--in accepting the status quo and uh, our aspirations and our--we felt like our--our destiny was uh, uh--required, uh, you know, an exemplary kind of development and so we had--we--we proceeded in a way that was not uh, totally separate, but was essentially independent of the uh, local health--so in that sense this was not a community development. Uh, to have gone that route would have made it far more provincial, uh, and would have, I think, have blunted the kind of impacts that we talked about later in terms of stimulation of people, you know, coming in that--that were new in the situation and brought to it, uh, new energy if not new ideas and new--new initiatives-- SMOOT: Hmm. BOST: --and uh, so that was a departure from the original concepts of uh, the kind of medical center it would be. There are medical centers that are on that general pattern. The, you know, the Houston--there's a--Houston, Texas is an example of that, you know, where the--uh, the- -the university and the community almost have no boundary lines, you know. It's pretty much all one smear--spread or whatever. SMOOT: I've heard it's quite an interesting place to see. BOST: Yeah. Well, it would uh--it would not have been nearly as highly structured and as highly organized as we sought to make this, uh, and we--we felt like we needed--particularly if we were going to be successful in uh--in producing a health professional whose attitudes and orientations were, uh, broader and perhaps different in some respects than the status quo and uh, we did seek to do that and I think that part of our idealism, uh, was perhaps naive in that. I think we've, you know, tended to gravitate back in the other direction as time has gone on. SMOOT: Well, it's hard to say what might have caused that though, isn't it? You can't say-- BOST: Well, yes, I think it is. It's uh, um-- SMOOT: Forces well beyond the power of a department of behavioral sciences to-- BOST: That's right. SMOOT: --contend with this. BOST: Oh yes--oh yes--yes, right. No, we--we set out--and I don't know whether Pellegrino or someone has talked with you about it--but we set out to have a--a really, uh, distinctive clinical program--program of clinical teaching. There was to be much less, uh, demarcation between disciplines, uh, much more of a group approach to clinical responsibilities and clinical teaching and so on and uh, a team approach and uh, this uh, materialized only in a very limited fashion and this was always a source of some disappointment to me, although I did not have direct uh, involvement in it. It still was a source of some disappointment because I felt that--that such an approach would produce a uh, a health professional who would, you know, who would be able to function, uh in--in the world of tomorrow in a much more effective way than uh--than the products of traditional medical education-- SMOOT: Um-hm. BOST: --programs. So that was a source of some--some disappointment, but um, I uh--I don't know how you could characterize this whole development. Um, I think I used the term--this--this was a community oriented, uh, program, but I--I have to define that. Uh, It--it wasn't community in terms of integration in a provincial sense, but a community in terms of its uh--its orientation to health affairs and health activities in a--in a community. There was a publication back uh--of a national group and I've forgotten now what the name of the commission was, but it was health is a community affair that had uh, uh, the whole philosophy of uh--of public interest and uh, and community involvement and community programming and org--community organization in dealing with the health problems and health needs of, you know, the entire area--all elements of the population. The--this was a--this was an approach to meeting health needs that uh--I won't say it was in vogue, but it was--it was the--uh, the thing that attracted a lot of interest and I think uh, tended to capture significant parts of the orientation here and of Dr. Willard's personal orientation. Health--provision of health care was not a money making activity. It was uh--it was an activity that uh, um, was really a--for--for the individual recipient, but also for the community and uh, you can't--you can't really, uh, be able to deal with the needs of individuals unless you have the whole community, uh, somewhat structured and organized and focused. It just won't be there, you know. SMOOT: Um-hm. BOST: It's like emergency service. The millionaire driving down the road, uh, isn't going to have that emergency service unless somebody already has, you know, worked it out and organized it and financed it and it can go out and get him, you know, uh, uh--and you just can't proceed on a--on an individual basis and have, you know, the kind of provision for health needs, uh, whether emergency needs or perhaps more, uh, mental health needs and many other chronic kinds of problems that we have. You--you have to--you have to take a much more fundamental, um, broader based approach to it and if you're going to take that kind of approach then there are certain identifiable attributes that people going into that profession--that's going into that kind of an--a setting--need and we were kind of reasoning backwards, you know. If--if these are the attributes that are needed in that kind of situation, then let us develop a program here and a curriculum and a faculty that will inculcate those attributes and attitudes into the people that will go out and help move that picture along and that was, see, the general--the general uh, uh--I think the general, uh, uh, approach to curriculum. It wasn't, you know, what will make the greatest scientist. Uh, so in that sense, uh, uh, our whole development here was not a research oriented development. It wasn't to try to, you know, to find the--you know, develop the greatest lab--laboratory, people, it was to develop the health professional that could go into this community approach context for meeting multiple health needs, and work most effectively with the resources that are there and the other disciplines that are involved-- [Pause in recording.] SMOOT: --all the more reason that Dr. Willard uh, put such emphasis on the Department of Community Medicine. BOST: That's right. Yes, that--this is--this is a manifestation of that and uh, again, it goes back to his uh--to his uh, formation and his--his concern with public health. Now, public health not in a narrow sense, you know, of uh--of uh, uh, pure water and ma--and environmental, communicable diseases, but public health in a--in a generic--in a real proper sense--public health--and he came to this with a public health orientation and uh, this was really the--the context out of which various parts and phases and segments of this whole development, you know, were spun and derived and distilled-- SMOOT: Um-hm. BOST: --and uh, that uh--that--that is m--I think was really the--the basic character of it. SMOOT: Is there anything else you'd like to add? BOST: I don't think so. SMOOT: Thank you so--so much on behalf of the Medical Center and the library for spending time with me, Dr. Bost. [End of interview.] In his second interview, Dr. Howard Bost, a founding member of the University of Kentucky Medical Center, discusses conflicts between the Medical Center and the university administration, particularly in budget prioritization. He compares different university presidents, their view of the Medical Center, and the different payment plans used by the Medical Center. Bost also discusses the Medical Center’s impact on the community and recruitment of staff. insert here