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1986-02-03 Interview with Nicholas Pisacano, February 3, 1986 UKMC001:1986OH058 UKMC 021 01:41:53 University of Kentucky Medical Center Oral History Project Louie B. Nunn Center for Oral History, University of Kentucky Libraries Pisacano, Nicholas, J. -- Interviews Family medicine Social medicine Poor -- Health and hygiene Poor -- Medical care Deuschle, Kurt W. Pellegrino, Edmund D., 1920- Morris, Alvin L., 1927- Willard, William R., 1908- University of Kentucky. Medical Center -- History Nicholas Pisacano; interviewee Richard C. Smoot; interviewer 1986OH058_UKMC21_Pisacano 1:|16(5)|30(6)|44(5)|57(9)|74(9)|89(15)|108(2)|123(15)|154(3)|174(5)|200(10)|217(12)|252(5)|286(9)|313(3)|331(9)|354(6)|374(4)|389(3)|430(3)|447(9)|476(5)|509(8)|545(9)|560(6)|579(7)|603(3)|629(5)|655(9)|671(6)|692(2)|724(3)|743(11)|763(11)|792(1)|824(6)|846(8)|861(11)|876(10)|903(5)|919(11)|940(2)|961(8)|985(8)|1004(8)|1030(5)|1050(4)|1074(4)|1093(2)|1111(7)|1130(8)|1145(2)|1162(8)|1177(4)|1199(10)|1219(4)|1235(8)|1250(7)|1266(8)|1281(8)|1297(2)|1312(12)|1330(10)|1348(12)|1365(8)|1398(6)|1422(2)|1457(4)|1476(8)|1491(9)|1506(6)|1531(6)|1561(10)|1580(14)|1606(2)|1628(9)|1643(6)|1663(7)|1686(7)|1704(15)|1732(2)|1771(3)|1786(5)|1803(11)|1824(12)|1843(7)|1866(12)|1896(5)|1913(5)|1930(3)|1945(9)|1971(2)|1987(10)|2008(3)|2030(3)|2047(3)|2069(12)|2084(5)|2099(4)|2118(6)|2143(9) audiotrans UKMCoh interview SMOOT: Dr. Pisacano, to begin would tell me a little bit about yourself, your background, where you're from, when you were born, uh, your family life. PISACANO: Oh, I was born in Philadelphia, Pennsylvania and, um, went to medical school in Philadelphia, uh, after the war, World War II. And from there I went into a small, rural practice, very rural practice, in Roy-, in South Royalton, Vermont. I was a country doctor up in the mountains and, uh, but then I saw that it was time for me to leave there because I didn't want to raise my children in a one-room school- house atmosphere, so, uh, uh, I moved back to my hometown and moved back into Philadelphia and had a big practice there, a huge city practice. So I went from the mountains to the, to the huge city. In fact, my neighborhood had more people that, I think than the whole state of Vermont. But anyway, we, uh, I went back there and then I got involved in a very heavy practice situation, you know, you'd practice from eight in the morning till about eleven at night, uh, except for one night a week which we had off, one afternoon and one night off. Um, and then while I was there I got, uh, involved in becoming the medical director of the American Cancer Society and that's, uh, I got interested in, uh, in, uh, continuing education for the general practitioner because I was a GP in Philadelphia. And, uh, and did, we put on some real good programs for the practicing physicians of all, all specialties, even though I was a GP. And it was through, through the my efforts in the American Cancer Society that I met, uh, Al Morris. His dean, Al's dean, works at Pennsylvania as a profe-, associate professor I believe ----------(??), he was on the faculty. He was a very young man then and, uh, I went to, to his dean who was on our board of directors of the American Cancer Society to put on a program in the early detection of oral cancer for physicians as well as dentists and, um, and it's through the, through that process I met Al Morris and worked with him on several programs and I was really taken with him as a brilliant, young, um, dentist, uh, educator and we got to be close friends, then one day he announced that he was going to become dean of this new medical school in Kentucky and like a lot of other people, I asked him, "Where was Kentucky?" Not, not in a facetious way, because, you know, the Philadelphians more than anybody else are provincial. You know, if it's outside of Philadelphia, it's where is it, you know? And, uh, but anyhow, he came down here and I think he was only down here maybe six months or less or maybe between six months and a year and, uh, I came down to visit him, a friendly visit, and that, and at that time of year, had a dinner, I think it was out at the old Carnahan, I can't remember, the Carnahan or Spindletop. And, uh, in addition to meeting with him and being with him, which was really lovely, I met Ed Pellegrino and Bill Willard. No, Ed Pellegrino was-- I met here and then, uh, I got to be, uh, quite taken with Ed Pellegrino, too. I thought he, just my first impression, was an unusual person, highly educated obviously and, uh, a polished young physician. And, uh, I went back home, back to my work and, uh, which was really, as I say, really busy because I didn't take too many vacations. This was one of my few vacations to come down here and see Al. And, uh, the next thing, I got a call from Dr. Willard asking if he could see me and we arranged to meet, uh, and one evening in Philadelphia, when he was visiting, and we talked. And he told me about this medical center, uh, and the College of Medicine and, uh, as much asked me if I'd be interested in some kind of a position here. And I--well, I may have my sequence wrong. I don't know if Pellegrino came up first or Willard, but I think Willard did and then was followed closely, uh, by Pellegrino or vice versa, but anyhow I saw both of them in a short period of time and Pellegrino is the one that really offered me a job in his department, uh, and my understanding was that the job offer was to work in the Department of Medicine full-time, which would give you the first, I guess the first GP in the United States, no question about it, full-time appointment in the Department of Medicine with that sort of title and at the same time I would also do the continuing education through the, uh, College of Medicine and, uh, and that made a lot of sense. I guess when you think back about it, because continuing education, the biggest consumers of continuing education, which was very, a very new, uh, discipline in the--there are only about half a dozen people in the country doing this on a full-time or some kind of a dedicated activity, and, uh, it makes good, makes good sense and especially a state like Kentucky where we had to figure out ways of getting information to physicians as well as having a place for our physicians to come. And being a GP, uh, I think it made good sense to have a GP do it, because, uh, the biggest consumer would be the GPs. And, um, so to make a long story short, I did it and I got involved a lot in the whole community, all of the state. And, uh, at the same time began to be a teacher in the Department of Medicine, which had me really scared because I was a practitioner, I was not an academic and I remember, my remember those days, one of the things that fascinated me about coming as a full-time professor, a full-time academic person here, was that nobody worked, as far I'm concerned. I mean, at five o'clock people went home. And at five o'clock I was just on my way on my last house call, uh, not my last, but one of my last house calls in the afternoon to get back to the office for six o'clock evening hours. So that was, and then, so what'd I do? I'd spend a lot of time in the library trying to keep up with all the literature and, and make sure that I could at least be literate when I went to these conferences and it had me really nervous, but I think I, I held my own as far as a GP is concerned, because the one thing that was unique to my being there is, I'm probably the only guy that really saw a lot of patients, you know, in his active life and, and I came right from the full practice world. And, and I got very involved in teaching the senior medical students in the, in the medical clinic and, uh, and enjoyed it very, very much. And then I got involved in some of the other activities that most of us had to do, we had promotions committees, admission committee and, uh, and all things like this which became, it's almost a fun thing and there was a real spirit of camaraderie, which I have never seen anywhere since. I might not, before or after, and that-- SMOOT: That included, uh-- PISACANO: --guys like Kurt Deuschle, who was, who started the whole discipline in community medicine and Kurt was probably one of the most of the most imaginative, creative guys I've ever met, still is that way. Well, very often Pellegrino, Deuschle and I would meet after everybody had gone home at five or five-thirty and we'd si-, and I was, my office was about two doors from Pellegrino's and Deuschle's was down across the hall, down the hall from us on the sixth floor. And we would sit there and talk about a lot of things, but it was all creative stuff and excitement. It was just full of excitement. The place just bristled. Everybody, almost, almost everybody, I can't think of one exception right now, when you had a problem or you wanted to talk over something, everybody was eager to talk to you and to help you. It was just an unusual, of course, I guess it goes with starting something new and being part of a growing thing. Everybody created a ----------(??) went into each others, when needed. And we had joint meetings all the time, we, it was really a, most spirited thing I ever saw and it had to be the most exciting thing I've ever participated in as far as a massive, uh, st-, structure such as this educational component we were creating here. Uh, and I'm just randomly thinking now, just giving you random thoughts. I'm trying to push myself way back in those days. And so, uh, I got busier and busier and then, uh, uh, I then got involved in starting a whole new specialty of family practice, which wasn't in existence, it did not exist then. And I got very active with some, a few people around the nation on this and, uh, started to devote a lot of my activities to that and the right place for it because of the nature, if you read the, I don't know if you read that 1952 document that they published, wh-, the medical center. Did you read that? Did you read that? SMOOT: The one, the, that was published, uh-- PISACANO: Back-- SMOOT: --by the Kentucky Medical Foundation to push for the medical center? PISACANO: No, it was called The Philosophy of Education, written by I think it was Bill Willard. SMOOT: Okay. PISACANO: Uh, the justification of a, of a, of a new type of school and, um, it, it's a, it's a document that's worth reading. I can't, I don't have a copy of it, but you can find it, it's called The Philos-, it's called The Philosophy of the Whole Medical Center and the idea was to produce generalists, the undifferentiated physician. SMOOT: I've read that. PISACANO: Generalists. And somehow or other that sort slipped between the cracks between here and there a lot and, uh, so then, um, I got involved in some national activities. Now, I also got involved in the arts and sciences and became the assistant dean of arts and sciences under Paul Nagal, who was a great historian, by the way. SMOOT: Yes, I know Dr. Nagal. PISACANO: Yeah. And uh, at least by, by reputation and I felt so too, but I'm not a historian so I can't. But he--I was his friend and, uh, and I was assistant dean half-time. So I was, I really had one foot in the medical center and one foot in the rest of the campus. The faculty met on the senate council, became vice-chairman of the senate council and that's when he had the blip. Um, and I saw a lot, I saw a lot wha-, was happening from a different viewpoint, not just as a faculty person, not just as an outsider even, or not an insider as a faculty member but I saw as an insider on the senate council and getting some views of other people and--go ahead. SMOOT: Well, let's back up just a moment and bring you right back to this, because that's an interesting point. You had an entirely different perspective from most people but, uh, I'm going to go way back, if you don't mind, and, and just kind of fill in some gaps here. PISACANO: I'm just--I shouldn't be shooting off there. SMOOT: No, that's okay. Uh, what made you want to become a physician in the first place? I mean, was that part of your family background? Was that, were you pushed into that? PISACANO: No. SMOOT: Was your father a physician? PISACANO: No, no. I'm the first person in my family that went beyond high school. Um, no, I just wanted to be a doctor when I was a little kid and I went to college when I was sixteen years old and I got a scholarship to a place called Western Maryland and I went there, it was ----------(??). And um, went there, and then the wa-, --I was there two years and the war, about a year and a half when the war broke out and I, like most every boy my age, we all volunteered and I went in when I was eighteen and came out when I was twenty-two. And I had all my pre-med requirements just about wrapped up in those two years, but I had to do one course, physics, so I had to go back. They wouldn't let me in without that physics course, I still don't understand that to this day, as you can see. But anyhow, I finished, but it was--turned out to be a boon of my exis-, really one of the greatest things that ever happened to me because I went back, all I needed was physics, and they honored my scholarship again. They let me renew my scholarship and I took this year. This is not important to the history of the medical center, but it's just background. And, um, and so while I took physics, I, I--it was the only pre-med course I needed, I had everything else for a degree practically, so I took a lot of philosophy, logic, symbolic logic and a lot of English grammar and literature, so I became, wound up with an English major type of thing, and, uh, which I loved very much. It, but I had the time to do it, because all I had to do was physics and I hated physics, I might add. My roommate was a, is a, is a physicist, is a genius at physics and thank God I had a roommate because I don't know if I'd ever gotten through it or not. He used to make me sit there and learn some things. But anyhow, then I went on to medical school in 1947 and graduated there and then of course our sch-, class was made up of all veterans practically. And Joe Hamburg was--and I were classmates all the way through medical school. And uh, we were, we were very close friends. We studied together every night. For four years-- SMOOT: Hmm. PISACANO: --practically we were together every night studying. So, uh, so when I came to Kentucky eventually, many years later, the year later we got him down here to join us. So he became the second GP in the Department of Medicine. But anyhow, ever since I was a boy, was interested in becoming a physician, always. I, I just never had any-- [Interruption in taping.] SMOOT: So you and, and Dr. Hamburg were together at, is it-- PISACANO: Medical school, we went all the way through medical school together. SMOOT: Hahnemann? PISACANO: Yep, Hahnemann, in Philadelphia. SMOOT: Okay. Then after that you went off to your do internship residency, Stamford, Connecticut? PISACANO: Stamford, Connecticut. And Joe and I interned together, too, Dr. Hamburg-- SMOOT: Right. PISACANO: --I call him Joe, we interned together and we were close friends and I went on up to Vermont to practice. I almost stayed in Stamford with, with, uh, not with him, but he stayed there and practiced and--but I wanted to, I had this yen to be a country doctor and, uh, went up there and then came back to Philadelphia. SMOOT: Okay. PISACANO: And Joe and I always kept in close communication and then when I went to Kentucky he said, "Where's Kentucky?" The same thing--(both laugh)--and, uh, then the next you know, after almost needling about it, he was down there a year after I was, got him down there. So anyhow, that's the story of Joe. SMOOT: Then you went to Philadelphia in 1955, uh-- PISACANO: Yes. SMOOT: --as a general practitioner-- PISACANO: Um-hm. SMOOT: --and worked with, uh, the Philadelphia Academy of General Practice. PISACANO: Right. I was, uh, active in that. SMOOT: Okay. And the Philadelphia Division of the American Cancer Society. PISACANO: Right. I was the medical director. SMOOT: Um-hm. PISACANO: That's how I got that CME experience and then, the Al, then met Al Morris as through that thing. SMOOT: Well, you've talked about a lot of your background already and why you came to Kentucky, uh, the efforts of, uh, Al Morris-- PISACANO: Um-hm. SMOOT: --as well as Dr. Willard and, uh-- PISACANO: Pellegrino. SMOOT: Dr. Pellegrino. PISACANO: Those three people, yeah, without question. Al Morris initiated the contact, almost, and I don't know whether it was directly or indirectly, but he initiated the contact because I came down here to visit him and, uh, and Pellegrino really did the pursuing and, uh, and, and, I, I really admired him so much that as I said then I began thinking, well, maybe I'm killing myself here, you know, really maybe it's time for a change, even though it was--the pay was abominable. I was, I was never a--I don't mean this to be on the tape--I never, I never was much to make money in practice anyhow. I never charged patients, uh, and I never had bill, I never sent a bill in my life. To this day, I've never had a bill head; there's not a bill head ever been printed with my name on it, and so I didn't charge patients that didn't, couldn't pay and I didn't send bills and s-, but I, but I made, but I was seeing people all day and every day and the pay down here was, uh, very tough. I had to borrow money the first month to live down here. But that's, that's enough of that. Uh, it just, but I thought maybe it was time for me to make a change physically. I was really getting, I could, I could, you know, it was getting to the point where I was really. So I just thought it would be just a good idea and it turned out to be a very great idea because it's, you know, it's good to change once in awhile because when you're getting really comfortable, that's when you ought to stop and look at things and, um, or not comfortable, get in-, into some kind of a groove or a niche, and, uh, and I really love practice. I really, to this day, miss my neighborhood, really do, seeing those people, and, uh, but I don't miss being battered around and tired and physically tired, I couldn't have, I'd probably have been dead by now if I'd continued. SMOOT: Hmm. PISACANO: So maybe it was a good move. But, uh, I also met people in this academic world I never would have met, you know, nationally. I have friends all over the country, all over the world, just talked to a guy, just write, just wrote my friend from Australia and you get to know people on a nice, close basis because of the position I'm in that I would not have been in if I'd stayed in practice. And, and so it was just a fortuitous stroke of luck, there was no great thought or planning, I can tell you that. That's the way life works, to me. Most of the good experiences are serendipitous anyhow, just happens that way, providing you're doing the right thing, nothing evil. SMOOT: Let me ask you, uh, about your first impressions at the University of Kentucky. When you came down here-- PISACANO: Yeah. SMOOT: --you saw Al Morris and, uh-- PISACANO: Um-hm. SMOOT: --then returned eventually. What were your impressions of the university at that time? PISCACANO: Well, coming from a big city and a place like University of Pennsylvania and Temple University and Villanova, uh, I thought it was a very, very pretty to me, a very pretty atmosphere and I, but I had the, I really got the impressions it was, uh, sort of a country club school. Not a country club school, that, that implies rich people, but I mean, uh, sort of a relaxed atmosphere that I'm not used to, I'll put it that way. And it really did, it really gave me that impression. And I saw that change rather rapidly when Oswald came too. That's when I started getting involved in the other university activities. SMOOT: Um-hm. PISACANO: He came in here full steam ahead and he bounced around and did, he really, uh, whether it was Oswald himself or his people, his administration or whether it was the times involved, all these things you have go along with the times too. SMOOT: Sure. PISACANO: Things changed rapidly here, for the better, the university as a whole and, but it was a friendly university because I, I, I'm not used to being, seeing people that friendly about everything, you know. Not only in the medical school and the camaraderie we had, but, but the university was, uh, a friendly place and I enjoyed, uh, being in the university atmosphere because I enjoyed meeting history professors and English professors and, uh, other administrators. At, as when I was then an active clinical I took care of, uh, my goodness, practically all of the vice-presidents around here. I took care of Ab Kirwan. Um, and a lot of people--is a physician so I got to really enjoy, it, it's just like a small community, that's what it was and, um, very impressed with it. And, uh, of course, then of course we had always had the great basketball. I never even cared about college basketball, like everybody else, till they came down here. And I got involved with the athletic board, so I've been involved in a lot of activities and it keeps you, it keeps your interest up and keeps your feeling good about the place. I've watched the evolution as, as this university's really to upwards and I might add and I know that I've watched this, uh-- SMOOT: Let me jump into something that you mentioned earlier. Uh, you, you talked about the fact that you were attached to the medical school and at the same time you were attached to the-- PISACANO: Arts and sciences. SMOOT: --arts and sciences. PISACANO: Um-hm. SMOOT: Now, I'll give you a different perspective. I've heard people say-- PISACANO: Um-hm. SMOOT: --from arts and sciences, particularly in the early days, they were fearful of-- PISACANO: That's right. SMOOT: --the fact that the medical cen-, medical center was going to be built, they were going to lose money. PISACANO: Um-hm. SMOOT: We didn't need it, uh, and you still hear that occasionally. It's, it's rare, but-- PISACANO: Um-hm. SMOOT: --occasionally you hear that, that sort of, uh, perception. What about your own perception, uh, between the relationship, uh? PISACANO: Yeah, well, see, my, I have this schmaltzy viewpoint and there's no question about it and there's no question about it, it's, it's not that. I say, you give me good, strong medical school that makes my arts and sciences better, and vice versa. I happen to think more vice versa, but you give me a good, strong arts and sciences general or liberal arts college, that makes the medical school stronger because there, there's still a basic sciences of all medicine lies in that arts and sciences, basically. I think there's no need for a Department of Biochemistry in a medical school. I think there's no need for a Department of Anatomy. A de-, you can have an anatomy section. I'm talking about, that ought to be done in the arts and sciences, to me, and that's heresy. You don't need, we couldn't, we had, we had a Department of Chemistry, Biochemistry, in, in dental school, I think there's one in the ag, wasn't there? There's one in the arts and sciences and one in the medical school. This is ridiculous. There should be a Department of Biochemistry, or d-, chemistry, that hits all these and then you have some concentration, some uniqueness to each of the professional schools and so therefore I say, my, my, again, it's that uni-, it's a unifying effect that's part of my nature, that's why I'm a family doctor and not, uh, uh, subspecialist, because it's a unifying principal. I think if, if, when you can act on the behalf of the whole and you're doing the right thing, then you take the parts and make each one of those as best you can to make the whole function better. But the whole is still greater than the sum of its parts. That's an old, another old cliche, but it's true. And, uh, so I really feel strongly that, uh, I, if I were the vice-, or the chancellor of this medical center, I'd do everything I could to make the arts and sciences stronger. And if I were the, the chancellor of the other side of the campus, in the arts and sciences area, I would do everything I can to make the medical school stronger, medical center. And, and that's the way I believe, but apparently that's thought as another wasted effort. SMOOT: Could you tell me a little bit about the original thoughts, philosophical commitments of the medical, uh, center as, as an institution? We, we've touched on it a little bit, but there, it was a very unique philosophy, I think, uh-- PISACANO: Um-hm. SMOOT: --in many respects, uh, that Dr. Willard and others had put together for the creation of the medical center and you-- PISACANO: Right. SMOOT: --and you were coming in and seeing this. PISACANO: Yeah. SMOOT: Uh, can you tell me a little bit about that from your own perspective? PISACANO: Well, as I, well, I can tell you it was, uh, I'm sort of maybe repeating myself, but-- SMOOT: That's all right. PISACANO: --the, um, it was an exciting time because there was a whole new philosophy of medical education. SMOOT: Um-hm. PISACANO: It was a unifying principal. SMOOT: Um-hm. PISACANO: They used the team concept which was doomed to failure apparently, but that's okay, at least the, but there's some other ideas there, like the idea of the community medicine-- SMOOT: Um-hm. PISACANO: --a Department of Behavioral Sciences, uh, but community medicine particularly, which serves, it was a unifying type of department. It took clinical activities and, and used them in the, put them application within the context of the community and, uh, and we had, uh, Pellegrino's philosophy of, of a good, producing good generalists, as well as subspecialists. SMOOT: Um-hm. PISACANO: Uh, all those things were exciting, but they went by the wayside in time. That's the, there's the tragedy. SMOOT: What did you think of the, uh, idea of everyone would receive a fixed amount of money, a salary, and then anything that would be made above that would go into a pool and be distributed around to various departments and, and so forth? PISACANO: You mean the current system of-- SMOOT: No, the old, the very old system where you, if, for example, if you were a surgeon and you were making, you could make a great deal of money-- PISACANO: Oh, I see. SMOOT: --but you had a limitation-- PISACANO: The old system. SMOOT: --set upon your salary, your income, and anything made above that-- PISACANO: Um-hm. SMOOT: --you had to give to the institution. Am I-- PISACANO: Right. That's true. SMOOT: --correct on this? PISACANO: Oh, yeah. Well, that's, again, it's got two sides. It's the one thing that, there's one factor nobody ever put there and that's human greed. You can't stop that. A guy says, look, I am responsible for three million dollars worth of income and he's only responsible for one million dollars income, we're getting the same salary. Well, if they think on those terms, you s-, it, it's, it's got to be doomed. Uh, if a guy comes in and, uh, understands that we're all working together at a comparable salary, whatever that salary might be. I think maybe salary could be adjusted a, a little bit one of those ways. Salary, but not, uh, once you start creating an, an overage that you can take a piece of, like the, the new system, uh, then it creates a whole different atmosphere and it's not conducive to good teaching either. We got community practitioners we can get those elements from, you know, because it's none of our business what they make, but we can learn a lot from them. Uh, so the whole--that's part of the whole disaster, I think. I, it may be, I'm, again, I'm not bright enough to tell you what it is, but, but maybe this new method of paying people is probably--it creates a lot of, uh, could create a lot of problems. There's good and there's bad to say about both. Um, if, if a person comes and see--what they don't know, I would have a contract for everybody that comes in the, a, a, a medical school, and the contract would be this, say look, don't tell me what you can make on the outside, because you can stay the hell on the outside and do it. Don't, I don't want to hear that, but you want to come here as a professor or associate professor or assistant professor, we'll give you this much money, and if that's going to cause you any discontent, do me a favor, don't take the goddamned job. Right now. Okay? Oh, we might have some type of bonus operation, but not for, not so much, we've got to be some productivity. In fact, I'd have minimum productivity. If you don't do this, you're out. And, uh, uh, but, they don't come in here, they always come in here with the idea that if I can make x dollars and I can make y plus that, I get a piece of that y. I think that creates a lot of problems. SMOOT: Hmm. PISACANO: But that's only a personal opinion. To me, a person is, is, uh, I'm, I'm so old-fashioned in my thinking and, uh, but if I really believe that if a person decides to become an academic person it's like, uh, it's like, now, I don't mean you should take the oath of poverty, no but you have to be ready to be committed to that world and from that world and from that world you're not going to be the richest guy in town. You can still do well in the medical, because there's not a guy over there that's going hungry, but, uh, and that was one of the things, the arts and sciences salaries were here, down lower than the, than the, uh, medical center because the marketplace demands that, but the outside marketplace, the guy can make twice that, then I say good, go to hell on the outside again. So you have to say that, I, for the security and for the comfort and the enjoyment of being in the academic community, if that's what a guy enjoys, that costs me x thousand dollars a year in income. You see? SMOOT: Yes. PISACANO: And, uh, let me tell you, it's sort of nice to be able to do like some of these guys, run over to the library, sit there for a couple hours, read. The busy practitioner can't do that, he has to read at ten o'clock at night maybe. You see what I mean? He doesn't have that luxury. Well, that luxury costs money is what I'm trying to tell you and that money is, you make x thousand less than the practice guy. And until they really realize that, then they'll never solve the problem, but then once you give them bonuses and, and percentages, they start to get greedy again. SMOOT: Um-hm. PISACANO: There are some salaries over at that medical school which are, I think, extremely high for a medical school. Personally, I mean, they're not high for physicians maybe, but then they made that choice. You know, they sit in meetings all day and brag--bag brown lun-, uh, brown bag lunches, but don't see that guy out there doing that. He doesn't sit in meetings all day. He may go to one once in a while, but he's out there hustling. SMOOT: Um-hm. PISACANO: So he's making twice as much as you are, but he's also working twice as hard as you are. SMOOT: Um-hm. PISACANO: He's got responsibilities like an office, front office, not over here, everything is neat and laid out for them in little rows. It's like, it's like growing flowers--(coughs)--you're on your own as opposed to the florist who, who arranges them and, and, and then they're all plucked and cleaned and all, that's a little different. SMOOT: Um-hm. PISACANO: And academic people have to know that that's, it's a different world. SMOOT: You came here, when you came here you came as, uh, director of the division of continuing medical education, is that correct? PISACANO: Right. Um-hm. That's part of my job. SMOOT: That is part of your job and then the Department of Medicine-- PISACANO: The Department of Medicine, the other. SMOOT: Okay. PISACANO: I worked in student health, I worked in the outpatient, medical outpatient department and, um, did CME on a, on a shoestring. I mean a shoestring. SMOOT: Can you tell me a little bit more about that, what it was like? PISACANO: Oh, it was, that was exciting too, there were a few of us in the country doing it and I, I went around and learned from those guys that were doing it and still my good friends, a lot of them, and, uh, and they were the granddaddies of continuing medical education and they taught me a lot. But they all had fairly good budgets, we had, we bummed money from departments. We, for instance, we had a guy here, Warren Wheeler in pediatrics, really a great man. He was interested in continuing education so he, he provided even the budgetary requirements for a lot of things. He provided us, me secretarial help for a program in pediatrics, he'd get, let me use his department to mail the, the programs from, you know, because we had very little budget to work on. Now it's a big operation, it's a big money maker, uh, and thanks to family practice as a specialty, by the way, we made it a paying thing because we required, see, we require it. You can't just volunteer to do it. But it was exciting. Again, it was something new. Now, it's become just a big business. To me it'd be alm-, to me, now it's, it's very unexciting, you go to the meetings, I don't even go to meetings anymore, but you read their stuff, it's the same old garbage repeated, you know. And, uh, in fact, it may be even beginning to wane a little bit as a popular discipline, but when we were in it, it was brand new. Again, I can only name about seven guys that were doing it, eight guys at the most at the time I went into it. But we, we did pretty well here. We, uh, we, uh, uh, brought in a whole new concept of continuing education. I used to bring a program down at Danville every month and we even pretested and post-tested them to develop that technique and then Danville is an excellent medical community, had very conscientious physicians and they welcomed this. Uh, we'd bring a different guy each time, talk about different things of clinical interest. It's an unusually good medical community, very, very conscientious, you know. And I sat through their medical meetings and their death conferences and reviewed their stuff, they were really, were extremely--if all physicians were that conscientious, all communities, it'd be great. And, uh, and then we also started a new technique where we'd bring in the, some general practitioners from around the area who, and community where went to, we established a little professors day, with Pellegrino, and he would sit there cold and they'd present cases to him, problems cases they've had from their practice and everybody would listen and learn at the same time, while that physician was getting, let's say, a good, academic, free consultation, you know, by discussing the case and we, we established that whole concept, we called it professors day. And it was fun, then it became, eventually I think to me, and I'm glad I'm not in it now, it would be more just keeping shop, yeah. SMOOT: Um-hm. PISACANO: But it was, that's the way it started. SMOOT: You later became, you mentioned chair of the Department of Hygiene and Public Health, assistant dean in the College of Arts and Sciences, we've touched on. PISACANO: Um-hm. SMOOT: Uh, Department of Hygiene and Public Health. PISACANO: Yeah, that, that was the department, in the College of Arts and Sciences and, and when I became assistant, uh, to Paul Nagal, um, I, one of the first recommendations I had was to wipe out the department. There was no need for a one man department. SMOOT: Um-hm. PISACANO: And in fact, the department had no academic credibility either, it was just a, it was a course is what it was and shouldn't be a department. It, it used to be they had students that went be, but since we had this medical center here, we needed it, so we changed the whole thing into a, a two-hour elective from a two-hour elective to a three-hou-, excuse me, a two-hour required course for most of the, all the college-- SMOOT: Um-hm. PISACANO: --into a three-hour, uh, elective and we changed it, Introduction to Human Biology and Health, no hygiene, oh, yeah, this now Introduction to Human Biology and they're still teaching it. SMOOT: Um-hm. PISACANO: I've had twenty-eight some odd thousand students go through that class, but it's, it's a liberal arts approach to, uh, introduction to human biology. It's a liberal arts approach to the introduction. I mean, what take, took, takes me a lifetime to learn I can't translate into a three-hour course, but I can throw some principles out and just excite students about the human body and also maybe give them some, a few little tips on what we know about how to keep good health or preserve good health or, you know, like the risk factors in heart disease, cancer, it's a fun thing. But it's fun for both the student and myself because we always are oversubscribed and we have to keep students out of there. SMOOT: Well, that's been reflected in the awards you've won from teaching. PISACANO: Well, it's, yeah, that's, awards are--I, I appreciate it, I mean, I don't mean that to be deprecating about awards, but awards I've found out that some of them lose their value when I see the people get into popularity contests and some of the professors that received those awards thereafter takes away from mine. So, uh, that's--but I do appreciate students and students appreciated it, I think. And, uh, but it's a fun thing and, but anyhow that was an interesting little evolution, too. You know, from a Department of Public Heal-, Department of Health and Hygiene and we had a community medicine department here and all that stuff, so we just made it the way it should be, a liberal arts course. SMOOT: Let me go back again to the, uh, original members of the, of the team that was put together by Dr. Willard to administer the medical center. PISACANO: Yeah, the administration was Bost, right? SMOOT: Howard Bost. PISACANO: Howard Bost, Carl Delabar, and maybe you can help me with some of these names. My memory's not that good and I can see who's sitting in those meetings. Then he had, uh, various people in departments, Bob Straus, um. You're talking about the pure administration now? Who else was there, in the pure administration? Although Bob Straus headed a department, he was also, acted in the role of administrator along, sort of like a little, tiny kitchen cabinet, you might say. SMOOT: Um-hm. PISACANO: And I think, I remember every Monday morning, it was the, the department chairmen used to meet with Dr. Willard and, and the administrators, Carl and Bost, and we'd meet in a room and just talk over things. What some people called reading Dr. Willard's mail. SMOOT: Alan Ross, was he there? PISACANO: Well, he was, he was there in and out, but he was not part of the, uh, he was part of the behavioral sciences, as I recall. SMOOT: Right. Biostatistician. PISACANO: Yeah, and I don't know, was he a regular or not? I remember seeing him, but I don't think he was with--maybe my memory's wrong, you better ask other people about that. Now, that's pure memory, I mean I don't. He wasn't, he wasn't exactly a major influence if he were there, to put it bluntly. He might have been to Bill Willard. But it was sort of to just sit around and listen to the mail and talk over some things. SMOOT: Um-hm. PISACANO: See, that's another thing I don't, I don't go for is just having a meeting to have a meeting every week, you know. And, you know, I'd rather ad hoc it, if I need you, I'll call you. SMOOT: That's, uh, similar to some impressions that I have received from the change over to the committee system, where some people said, well, it was so much more efficient before we had the committee system and now, that was one person's impression. PISACANO: The committees is, is, is, is even a more degeneration of this-- SMOOT: Um-hm. PISACANO: --to me and that's why they spent a lot of, I was used to say taxpayers' money, but now you can't say that because it's now, they've got different incentive system, but they waste more time with committees. SMOOT: Um-hm. PISACANO: Uh, and there's nothing wrong with committees, but it should be, the committee, committee should be very small, two or three pe-, three people to have an odd number and maybe five at the most, using people when you want. I'd use everything on an ad hoc basis. SMOOT: Um-hm. PISACANO: For instance, if you need a--even though you have almost a standing committee, I'd still use them as an ad hoc. You've got a standing committee, let's say, on, uh, on promotions. SMOOT: Um-hm. PISACANO: Well, we've got twenty guys coming up and we want to get some work done, then we call the committee and have them meet. Don't say you meet just because there's a meeting, just to have a meeting. And that's another thing, and they, those awful brown bag lunches, that's the most, you know, it's bad for your digestion and bad for what you want to do. SMOOT: Let me ask you a sweeping question. Uh, how do you think the medical center was-- PISACANO: Yes. SMOOT: --and, as a functioning institution, in its early days? In other words, how did it impact upon local and state and even national or regional medical practice? Did it affect standards? Did it affect competition, all these sorts of things? PISACANO: Well, I really can't speak too much about the competition because I'm not in practice and, but as a, as a national institution, the first, oh, I would say the first five, six, seven years of that was absolutely unbelievably attractive to most people in the country, but they were still betting on the come. This was not saying here's an, here's something that's do-, you, there were, there were things being done which had a real promise for the future, but like a rocket it lit up the sky, but also like a rocket, it fizzled pretty fast, too, in, in speaking in elements of time. And, uh, and, uh, this is, this--I was trying to explain before, it plateaued, which again is part of the natural history of any new institution, new movement, there's a plateau effect. But we never got the secondary rise that we should've. I think from the plateau we've actually gone downhill, we've declined. So whether the medical center, it's, it's here, it's a, I guess a permanent, if you want to use the term, permanent fixture and I think it's done a lot of good for the community as a whole, Kentucky, I really do. There's no question about it, upgrades, a medical school upgrades community, regardless of what it is. But it's also, it can be a white elephant, in many ways. Uh, and it has, uh, the question you have to decide is, how much social responsibility must it adhere to? I'm talking about taking care of sick people. Not tertiary care, that's, that's understood. But what else should it do? Well, it's teaching students, we're helping produce doctors, we're doing the right thing in that sense, but at a very high cost. And the question, should there be one medical school or two medical schools in a state of this size? I think there should be one medical school, but it's too late, we've got two of them, uh, and both are doing good things now, but you can still do good things with one institution and with maybe a lot less administrative cost, regardless of what they tell you, you know. Like I say, we, we should unify right here, why do we have sixteen thousand departments of chemistry when we can do good with one? So if you can't unify internally, how are they gonna unify statewide? But that's, I'm speaking as a taxpayer now, but as far as, it, I think it's elevated education in this state. I think it's elevated medical practice. I think it's, uh, promoted research to some degree, uh, but I also think it did not live up to its, it didn't fulfill what it I think it could have done. I think it didn't live up to its fullest potential-- SMOOT: Um-hm. PISACANO: --for various reasons. SMOOT: In the early days, what departments would you point to in particular, or could you do this, evaluate those departments, say this department was really outstanding, this department was, was going someplace perhaps, uh-- PISACANO: Um-hm. SMOOT: --this one was, was perhaps not as strong as it could be? Could, could-- PISACANO: Well, the Department of Community Medicine always stands out in my mind because it was the first one in its country and at the very beginning the, the philosophy that Kurt Deuschle, uh, espoused was really good and, uh, and it was, it was something that was done. And it, but it, uh, when he left, it just fell apart. And, and the whole community effort, community medicine effort, is, is not as popular as it was in the country, too. I'm talking about, it's a different, uh, different than the original thing, so I think that was the number one department, uh, and behavioral science, we had the first Department of Behavioral Science in the country and now that's an unpopular department among medical students. In fact, they often use the prefix BS 101 or something like that. And, um, so behavioral science is, in its proper context, is still very, very vital, but it should not be the tail that wags the dog, okay? And students look at it in a different way than they should. Uh, community medicine, as I say, it's lost a lot of its popularity in the country. SMOOT: Um-hm. PISACANO: And, uh, for various reasons. The times we were living in, it was a new idea, but now, now a lot of these things are already accepted or rejected and so it becomes almost, uh, an anomalous structure. The Department of Medicine here, in the beginning under Pellegrino, was very, very strong and very well-regarded. Uh, I don't know how it's regarded now. Department of Surgery, through Ben Eiseman, who was a nationally known figure, who was I think very strong. We had some excellent people of, who have gone on to national leadership posts around the country and, um, I can't, I, I imagine that department is not as strong as it was because they were having a hell of a time getting a chairman. If it takes you a couple of years to get a chairman, that makes me wonder about it. But I don't know anything about it. Um, the other clinical departments, pediatrics, uh, had some excellent leadership and still does, I think. I think pediatrics is, uh, is holding its own from what, from my, my outside viewpoint. [Pause in recording.] SMOOT: We were talking about departments, uh, yours-- PISACANO: Yeah, well, I think the Department of Psychiatry never was a strong department, in my opinion. But I don't think psychiatry is strong in many places in this country. In fact, psychiatry is a, I don't know, it's a, I don't know what its applicability is to a medical school except they ought to be taught some of the principals. I think if you get the DSM-III and read that, you've got enough. But that's, uh, sort of off the record. SMOOT: Let me, uh, let me ask you about the success of the University of Kentucky Medical Center graduates. Have the graduates been, uh, at a level that they should be? Have they gone on to, uh, make themselves a success? PISACANO: That's a good question, yeah. Well, we've had a few that have made, you know, fairly good national reputations, you know, and that's not the, that wasn't, that's not the aim of the medical school. The aim of this medical is to produce practitioners and in that sense, we've met our goal. We're meeting our goal, producing practitioners. SMOOT: Um-hm. PISACANO: Um, you-- they have to decide what they want to do. You can still do both, but do you want to be Harvard or do you want to be a, a Minnesota? Minnesota produces practitioners uh, in, uh, at least in family practice, they are a great producer of practitioners that go out and take care of people. Or do you want to produce, um, a bunch of research scientists? There's nothing wrong in doing that, but for a poor state , if not the poorest state, I think any money we spend, we ought to have that translated into health care delivery, as much as we can, with the idea that a research base is very important in an academic institution. SMOOT: Um-hm. PISACANO: So I think we're meeting our, I think we're meeting some, some of those goals inadvertently. And, um, but I think they have to make some determinations of direction in that damned administration, I really think they have to. SMOOT: Um-hm. PISACANO: There's, there's, somebody ought to say, what is our direction here? What is our, what are--set our priorities in such a way, say x percent of our effort, or not percent, but a certain amount of effort will go to research, a certain amount of effort will go into, uh, pure teaching and the others would be, other in the service. Which of those things we going to, how are we going to work it out? What kind of a student do we want to have come out of this place? We want to have a student who's--originally we said the undifferentiated student. That was another popular word that's a cliche now and doesn't mean a damn thing. But to produce a student who can be adaptable to, to any specialty, including family practice as a specialty, and if we decide that we want to produce more of the clinician types, general internists, family physicians, general pediatricians, then let's take that direction and go. Let these people, there'll still be a quantity of people who want to go into research and do academic medicine. But, uh, they ought to state those and follow it. Right now it's chaos. SMOOT: Do you think that the medical center has received, uh, the type of support it should from the state? PISACANO: Oh, yeah, I think so. I mean, given this state. SMOOT: Um-hm. PISACANO: You know, everybody wants more. Nobody gets enough. But I'm looking now as a pure taxpayer, I think it has done very, I would guess it's done fairly well. And, uh, somebody asked how much money the medical center, the hospital, made in the last year, profit. SMOOT: Um-hm. Do you think that, uh, certain individual governors have been more helpful than others towards the medical center? PISACANO: I don't know that much about the outside politics. I would guess that in the early days it was Breathitt, Combs. Uh, the governors were more helpful, I think they've become less helpful as time went on to a certain degree. I don't think needed, I think they needed that early thrust and early, early, uh, seeding, but I don't know how much. I really don't know that much about how much the governors really did control legislature. SMOOT: How about the general administration of the university? PISACANO: What, to-- SMOOT: The president of the university? PISACANO: As being behind it? Oh, I think especially, yeah, I think, again in the early days when the medical center was, needed support, moral and, and administrative and what have you, uh, let's see, Dickey was the president, I believe. SMOOT: That's right. PISACANO: And, uh, he was very supportive, as I recall. Now, that might have been words, but I think he also put it in action and I think Oswald was supportive and I think Singletary was supportive. I mean Ab Kirwan was interim, you know, he was-- they made him president after he was out, but I would say that the support has been about evened frankly. SMOOT: Yeah. PISACANO: I think it, I wish it would be more for certain areas of the medical center, like family practice, um, and I think it will be, by the way, with the current president. I think he understands; I know that Dr. Singletary realizes that, that the keystone of the health care delivery system is now the family physician. And if he knows that, then if we can get the, the chancellor to appreciate that, then maybe the dean will put things in action and I think the dean has an idea about it, but I think it takes some administrative, at second, the second level. SMOOT: Hmm. PISACANO: And obviously the president can influence the chancellor and the chancellor can influence the dean. Regardless of what they say, and all their denials, that's the way it works and, um, I don't know what else, I'm lost in my question. SMOOT: Well, let me ask you about the relationship between, uh, the University of Kentucky and the University of Louisville. There's been a lot made of that over the years, uh, in the early stages of the development of the medical center here-- PISACANO: Um-hm. SMOOT: --of course they were, there was a lot of rumbling from Louisville, wait, wait, we don't need that, why doesn't the state just support us? Of course, at that time U of L was not a state supported-- PISACANO: Right. SMOOT: --institution. But how about the relationship over the, your own experience? Have, have, do you, any, uh, uh, relations with U of L, any contact with U of L? Uh, or did seek any? PISACANO: No, I, I don't know. No, I don't, I see them as two even though, let me go back. If, knowing what I know now, but it's easy to say that; you know, it's easy to look back and, and say what, what you would do today. But the sensible thing would be, is to throw in a lot of--make Louisville a state school back in the late fifties, whenever it was, make it a state school and throwing all that money into it, you'd had a first cl-, you could have had a first class institution. That's, you know, for a lot less money. SMOOT: Um-hm. PISACANO: But that's, that's not given, that's not a choice that we have now. There are two schools and I, I think there's a, I think there's an innate rivalry there and I think there's a innate competition and I would imagine they still are competitive, but I, I don't even re-, I don't, I just, you know, have gotten into the line of thinking, like most people, there, there's a school there and there's a school here. I wouldn't do one, hurt, I wouldn't want to hurt either one of them. Uh, so I didn't, you know, I, I think it, since we have two schools, and we're stuck with two schools, um, I think we just ought to try and make both of them as, but I would, I would rather see one school emphasize one thing, another school emphasize one thing. The credit all shines back on Kentucky. And I'm not picking any particular area, let's suppose like, if we're going to do transplants here and, and in Louisville, the heart transplants, my God, let's all help them. SMOOT: Um-hm. PISACANO: That doesn't mean we shouldn't do any here. But let's let them bask in that sunshine and help them, let the state support them in those areas. And if we're going to do certain things like, uh, some other discipline and we have some good people here, then let's be known for that. In addition to the, the basic elements of teaching medical students, which had to be strong wires, but I think there could be a working relationship that could be salubrious to the state, but more important, salubrious to the people, the health of the people, but people don't like to--there's, there's an anti-unifying principal in, in, in these things, it's too competitive, compe-, competition to me is very healthy when it winds up, uh, uh, with something a unified whole benefits. But competition can be also destructive and I think we're almost, uh, more in that, in that mode than we are in, in the healthier competitive cul-, the thing that produces a unified whole. SMOOT: Um-hm. PISACANO: Since we can't blend the two universities, the two medical schools into one, we could, but it would probably be almost as expensive to do that how than it would have been than if we had not started out that way, but since we assume and make the assumption we'll have two separate medical schools, then let's see what we can do to work together and help each other in our own strengths. Okay? That doesn't mean you build the strength here so this one is weak here, but, uh, I, I think again, long as the state is reflected to, to receive the benefit, that's the important thing. But people don't think that way. SMOOT: What could be done to make people think that way? PISACANO: I, it's so, then we need a strong legislative component to it, governor and legislators say, this is the way it's going to be. Now, the next question is how much does the state really have to say about it? How much money they kicking in? You see mean? I, I'm from the old school of you le-, whe-, guy who pays the piper should call the tune to some degree and part of that tune should be let you guys do it yourself but do it right and if you don't do it right, then I'll have to come in and do it for you or see that it gets done. So I think, uh, a strong fiat from the, from Frankfort, that includes the legislature, might be able to accomplish it, but I don't know if you can govern human behavior that way because even if you do that, there'll still be greed and rivalry and negative competition. That's the way human nature is and the only way you can change human nature, like we did in family practice, we could not prevail upon the reason of people, using reason as a force. Now when you appeal to people on the basis of reason, it takes reasonable people. I can't give you a rationale if you're not a reasonable person. Well, we failed to reason in family practice. So then we had to use legislative force, which is the people. And that, and that's when politics is not a dirty word because that's really meaning the people. When, when, when an institution or whatever it may be, fails to live up to its social responsibility, basically, on its own, then I think maybe it takes a fiat. Okay? And the third element to that, since I'm a student of Machiavelli, and you may be too since you're a history major, the third element is when reason fails, you use politics. When--I mean, in, in the, the do good now. I must watch it because that can turn into a corrupt thing too and when politics fails, then you use violence, which is revolution and blah, blah, blah. SMOOT: Um-hm. PISACANO: Well, there's no need for that in, in our thing, but, um, I think that's the way I would do it. I'd say, let's reasonably decide how we're going to get these two people to live together, like Russia and the U.S., same damn thing, here we go again, how do we decide. What's the rational approach to this nuclear arms thing? What is the rational approach to living east and west? And since you can't appeal to, you, apparently you guys are not doing it rationally, there's, you're not getting along, then we're going to try something here by fiat. We'll say, you're going to get this budget, you're going to do this and, or else. We'll take your money away from you. And, uh, short of that, I don't know what else you could do. Uh, but you must always put in that equation, human greed, uh, a desire to be first and not equal, which is fine. I, I happen to be one of those. I don't want to be second if I can be first and I don't want to be equal if I can be first. I'd be willing to be equal if it, the common good is served better and that's somebody with some brains and not myself, I don't have that much brains but could figure out what is it that we can do here on a co-, a shared basis that's going to be good. There's some things I don't want to share. There's some things you don't want to share. But good, the state benefits. See I mean? And, um, suppose we, suppose we amalgamated both basketball teams into one, we'd beat the hell out of anybody, wouldn't we? SMOOT: I would think so. PISACANO: Huh? And, uh, but I say there's no need for that right now, let each have a good team if they can have. That's--see, I'm not talking about taking away from one schools basketball team so the other can be good, number one. But think about it, if we did amalgamate the basketball teams, we would be number one. At least in my book we would be, I don't how anybody could beat us. SMOOT: I don't either. (laughs) PISACANO: It, it, what are you looking for? See, what, what's your goal and, uh, our goal is not be number one basketball in the country. It, since we have basketball teams, we hope that one of them will be number one. But if our goal was to be number one in basketball, there's a way of accomplishing it. Put the two schools together and say this is the university of, uh, this is the Kentucky state team, you know, commonwealth team, and, uh, if you could get away with it in the NCAA. Uh, but you could do that simply by a legislative fiat, help the two institutions to get into one and, uh, then you'd fight who's going to be the coach, right? SMOOT: That's right. (laughs) PISACANO: So it's, it's the old story. SMOOT: I'd like to ask you about the development of family practice as a specialization. PISACANO: Well, the family practice was an idea several of us had as a specialty and it was born because of, and this is not schmaltzy, but it was really born of a social need. As medicine, as the medical explosion so, they call it the medical explosion, knowledge explosion occurred probably from World War II on. The knowledge just, just, just multiplied. And, and it created as a necessary effect, a lot of subspecialties. You needed those, and we still need them, but in this process of the subspecialty creation, there was lost something and that was the unified look at, of the patient as a whole. And, and we were losing the baby with the bathwater as the old expression goes. So some of us got together and we figured what need is a generalist specialty that takes all the good things of general practice, eliminates the deficiencies and creates especially where the family would be our center of attention, even though the family might be a single person. And looking at that and then, uh, getting the necessary elements to develop that. And we thought, uh, it was a good idea, so the ten of us not together and wrote up a, uh, made up a corporation called The American Board of Family Practice, Incorporated and we, uh, we owned that and we figured that family practice was a specialty it needed a board and a certification process and needed a three-year training program, minimal, originally we were even thinking of four years, residency program. Well, we were beleaguered all the way. We were had our own general practitioners were against it across the country because we're talking about, you know, when you have to do something sometimes. If we'd left it to the people, there would not be a specialty today. If we left it to the people there wouldn't be a free America today, we'd be a British colony. So leaving to the people is, new and innovative things is I think is not too smart, but leaving to the people to determine things for you sometime when you present them with some stuff is very useful and we use those Machiavellian, in the benign sense, the Machiavellian tactics. So we, we formed this board and our own medical society, The American Academy of General Practice, booted us down. See we had to have a sponsoring group to get this specialty. They turned us down one year a hundred and one to one; then next year they turned us down a hundred and two to zero. I mean that's a resounding defeat or series of defeats if you ever saw one. But we didn't lose heart, some of us did, but we stayed in there. And I was the founding secretary and I did all the, the paperwork and, uh, it became really as cause now. It became really, to me, more than, not just something that ought to be done, but the, it sort of got you mad. I was a little younger then, had a little more steam than I have now. And, and we, uh, uh, went to, uh, the American Board of Internal Medicine and now you think about the history here. We asked them to take us on as a subspecialty board. Well, that way we wouldn't have to go through all this sponsoring group of another group. So they, it would, it would replace the general internist with a family physician and all the rest of internal medicine was dedicated, in addition to family practice, their subspecialties, which makes a lot of sense, especially today. It didn't then, to them, and they through us out and, uh, and then as time went on, we finally prevailed upon our own people in the academy to, to get interested in this. Through a lot of political persuasion and so forth, uh, the year after they rejected us unanimously, they decided, and we did a lot of leg work; you can imagine the work we had to do, that the academy decided to throw in their support for us as a board that there ought to be a specialty of family practice. And then once we had the academy behind us, which was then the largest specialty, uh, the largest medical group outside the AMA in the country. We, uh, we had all that political strength, but it still took us years of harassment, hold back and enemies from the outside who were against the idea, some philosophically against it, some just pure prejudicially against it. And, uh, it took us from 1965 when the academy did finally approve it, till 1969 to get, uh, the American Board of Family Practice. And Dr. Willard even was the chairman of a committee called the Willard Report, which justified family practice, but that was a political thing. Uh, I know it doesn't sound like it, but we had the thing all laid out this way and he authored, he was the chairman and author of the report, uh, the Willard Report, which we selected the people for and I was his, I was working with him then as assistant vice-president. And, uh, so it finally came about in 1969 and I might add that the dean of this medical school then was Dr. Jordan and he was in Chicago the same day we were, this committee was meeting to approve the specialty. It was a big thing, I called the, used to call it the Congress of Medical Education and so, I'll never forget, his, he was against family practice and I'll never forget when I went up to him in the hallway there and I said, "We just got approved, you know, Bill." And he said, he said, "It'll never succeed." That was his comment, not even congratulations. And, uh, much to his, uh, with all due respects to him, we not only succeeded, we're now the second largest, and have been in the last ten years, the second largest producer of medical specialists in the United States. And it was, it's got a lot of painful elements to it, I won't go into, but it's good. It was a, it was born out of adversity, which makes, which makes it stronger. Uh, I for one, talking about history, is I don't forget as much as I can, I remember, I may not remember details, but I remember the pain that goes with the details sometime or the comfort whatever it may be. And the pain or the pleasure in, in using that, I, we always still very, ever vigilant and watchful that we don't get hit on the blind side because we're getting a little comfortable sometimes. So we're always doing innovations. Family practice has made many, many firsts in medical history. Number one, our board was the first board ever to require recertification, so our doctors have to be recertified. They take a test every six to seven years. The certificate expires if they don't, uh, and they have to take a test to be recertified, plus they have to do other things. We look at office records, they have to have three hundred hours of continuing education in a six year period. All that, and so we're the first to do that. And now, several other boards are doing it and, and the, it in, within a decade, every board will be doing it. The second thing, we had the first multidisciplinary board. We have on our board a psychiatrist, an internist, a pediatrician, a surgeon and an obstetrician. So we had, we got a multidisciplinary board. That's by our choice also. Third, we, uh, uh, well, I guess that's the, they're the unique things. I'm trying to think what's unique, the recertification and so forth. Um, oh, the third thing is, we had no grandfathers, you had to take an examination to become members of the board. All the other boards before us, when they created a board, they'd say, well, look, we're here, we're, we're, we're members, they never had to take an examination, the first ones, but from here on, everybody else take an exam. No, every one of our people were certified as diplomats are certified by virtue of the passing examination. SMOOT: Hmm. PISACANO: And, uh, and we've done many interesting things in examination techniques that were innovative. We're gonna, we're starting to write up some of these things now for publication. But we're, we're rolling along, we're, but we're going to-- I'm going to try to avoid with this board the things that happened to this medical center. Number one is complacency. Number two, maintain, uh, a high administrative, uh, strength and philosophy and to keep it from ever sinking. And, and the third thing is you have to be ready for social changes that affect you. Some of these social changes can affect you adversely and some cannot and some may be helpful. Now, the new, the new economics of medicine out there, uh, that, uh, such HMOs, private corporations and all in our, are in our favor, they're all seeking family physicians, so therefore, it makes sense for medical schools to have strong family practice departments to produce a, a good number and a reasonable number of family physicians to meet those needs, which are now almost demands. SMOOT: Um-hm. PISACANO: And then people say, well, maybe these, these private things won't last long. They may not, but they're, they're making profit, that's true. But if a company can make profit and give you, and give you high care, high quality medical care, at the same time, make sure that there are physicians to get continuing to get recertified and kept up-to-date and give them all the educational advantages they have, the American people are going to improve, the health of the American people is going to improve. And that--we're getting to the point now we're going to actually pay, you might say, to keep people healthy. You see? Which isn't bad for the patient. And at the same time, I still think it can be done for not any great increase in cost. Um, uh, so, uh, family practice is, is the keystone specialty in all this. And I think if it's done right and if we are careful and mind our Ps and Qs and maintain a high degree of competency and excellence, then I think that we will remain the keystone. And, uh,and that's what I'm reaching for. I think the same principal could have been applied to this medical center. Okay? SMOOT: Um-hm. Would you, um, then, I think it would be fair to say that one of the great achievements that has taken place here at the University of Kentucky Medical Center has been the creation of the American Board of Family Practice. PISACANO: Yeah. It was not actually at the medical center, they had nothing to do with it. Believe me, they had nothing to do with it. As a matter of fact, the medical school basically was against it. We did it here, I did it. SMOOT: Um-hm. PISACANO: I don't like to say I did it because it sounds awful, I and my colleagues. But the center was here; the headquarters are still here, you can see. SMOOT: Yes. Sitting in the headquarters. PISACANO: We've had opportunities to move, good opportunities, given free rent in prestigious universities, but on a personal reasons, I just like Kentucky and I stayed here. SMOOT: Hmm. Um-hm. PISACANO: So, Lexington moved its board several times; can move it tomorrow if I want but-- SMOOT: But you're not going to? PISACANO: I have no plans to, no. I, you know, I like Kentucky, I like living here and I like many things about Kentucky. I like the university and--but the credit does not go to anybody in that medical school, I can tell you that right now, or the medical center. SMOOT: Um-hm. PISACANO: Or the state. I think they should be proud of it, because it's the second largest specialty in the country, but then again, I'm speaking from a very different vantage point. You know. SMOOT: Do you see the relationship improving between the--say the university and the-- PISACANO: And what? SMOOT: --American Board? PISACANO: Oh, we never had any bad relationship, they just were against, they have never been supportive of a family practice specialty in any particular way that was helpful to us. SMOOT: Um-hm. PISACANO: As far as creating a department in that medical school, they were just the opposite. We had to fight to get a department in that medical school, although I was not in that department. But we fought, had to fight for it, so that's why I say, not only give them credit where credit is not due. Sure they have a department now, but they got it by legislative fiat. That's nothing to brag about. Now, if you want to brag about something, what-- if they want to make it so that they've got something to brag about, they can start giving it some fiscal and moral support and make it the one of the best state school departments in the country and it can be done. But that's still-- I don't know what they're going to do with it. But as far as family practice is concerned, the university has nothing to brag about whatsoever. SMOOT: Well, let me ask you, what do they have to brag about, over, over the years that you have been associated with the-- PISACANO: What, who? SMOOT: Well, the medical center. PISACANO: The medical center? SMOOT: Uh, have they had-- PISACANO: They, they had at one time, they had at one time one of the best dental schools in the country. SMOOT: Um-hm. PISACANO: Back in the days of Al Morris. SMOOT: Um-hm. PISACANO: And they were--people were excited about it. But again, like the, like the medical school, it was probably more of a rocket than it was, uh, uh, a steady climbing, you know, spacecraft and, uh, we had, uh, we did some innovations in nursing education, and which, uh, I know what happened, I know nothing about nursing so I can't comment on what's happened there. The pharmacy school still enjoys, I think, a national reputation. They've have some excellent administration and excellent, uh, teachers over there, well-known, I know in pharmacy. I know that. SMOOT: Um-hm. PISACANO: But I can't tell you where it ranks. I would guess it ranks still very high among the state schools, among the schools in the country. Uh, the medical school, uh, it's, uh, it, it, it's joined the, uh, ranks of, uh, average. I won't use the word that, and, um, and that's a shame because I think we had, uh--I use the analogy that it was like the, it was sort of like our, um, um, our halcyon days is the proper term, but people use the term, um, um, the one I used earlier, the Kennedy like sort of-- SMOOT: Camelot. PISACANO: The Camelot, uh, and it, a lot of Camelots are just temporary, they're little social quirks that happen and, and they happen in any society. You know, there's a, they go in and out, they fizzle. SMOOT: Um-hm. PISACANO: And they're flash in the pans, like a lot of baseball, football players are. I read a story you, yesterday corning back on the airplane about some guy who was the hottest high school player in the country many years ago, went to Auburn and quit after one year because he wanted to go out and now he's, he's thirty some odd years old, back in school again, says he wants to be a coach and he's playing with a small, tiny college, thirty-eight years old, but, uh, he blew it. See, he was a fizz. He, he was a, like you, you can name athletes that, you know, where are--the quote, where are they now? We don't even know. And what happened to Camelot? The Camelot was doomed from the start. It wasn't built on a solid rock foundation, it was built on a popular idea that people grabbed right away. It was a fad. And when they do that, it is doomed to failure unless you build in some things in that fabric which keep it solid. And I think if you build anything, as we're trying to do with family practice, and make it a solid entity, being able to withstand those tempestuous winds of fashion, then we can, uh, we'll all be okay. I don't think the medical center quite did that. I think the medical center is a, is a, enjoyed medical school, I can tell you, I, and I know that, I say the pharmacy school still I think is outstanding, from what I hear. Again, I'm not a pharmacist. Uh, but I, in the circles I travel, the national circles that this, this school was at one time the hottest medical school to me among the state schools in the country and it is not now. And I want to know why. What can we do about it? What can we do to make it, to revive that Camelot fever or to revive that, uh, you can't revive halcyon days, but you can create new, new halcyon waters and, uh, I think, I think it can be done. I happen to think, biased as I am, and if I were, and I know I really believe if I were sitting on the outside, and this is hard for anybody to believe this, and I wouldn't ask you to believe it either. But if I were sitting over there, I'd say the way to do is build strong foundation in the keystone specialty called family practice, which is the unifying specialty. You keep that strong, and that's your core, all the other stuff will be good, but then you can even start to do some outstanding work in some very subspecial, sub-subspecial or super special area and I would really help all I could to do that, providing you gave us a good strong keystone. I go back to my analogy; that we've got to good cake before you can have all the fancy icing. But, uh, I'm not even sure we've got much icing anymore. Uh, but we need a good cake and family practice is that cake. That, that makes the other departments, clinical departments look better, they get stronger and then all your subspecialties get, look better and then your super stuff, like pancreas transplants, even look better. You see? SMOOT: Um-hm. PISACANO: But that's my philosophy. SMOOT: Well, can you point to institutions-- PISACANO: And that's why I'm not running the medical school or the medical center. SMOOT: Can you point to institutions where that is the case? PISACANO: Oh, sure. You've got some outstanding state schools, like Indiana, Minnesota, that are just outstanding, I mean, and they're- -anywhere an institution God, I'm sure they have their weaknesses and they have some super strengths, but generally across the board, they're strong institutions and they produce, for the state, what they're supposed to be doing, they're producing practitioners for the state. Um, I was just trying to think of, oh, the University of Florida is even starting a, it is, has even a good, uh, production of, uh, let me just try and think. Shut that off for a minute. I'm just trying to think of institutions which are outstanding in doing, producing practitioners, because you know, a medical school basically is to produce practitioners. SMOOT: Um-hm. PISACANO: Basically. I don't say you should produce all practitioners. God almighty, we need our academic people. But you're talking about a very small percentage. See? SMOOT: Sure. What I was, I think that that adds validity to what you were saying. Uh, you can point definitely to institutions where you have-- PISACANO: Oh, sure. SMOOT: --strong family practice and it's worked for all the departments-- PISACANO: For the good of the school. SMOOT: --of the institution, for the state, et cetera. PISACANO: Yeah. And again, your administration would be the guiding, the administration could guide that. The administration of the medical school and medical center could see to it that once you got a good strong family practice department and then they could really start concentrating on some other things to get some unique reputation in. SMOOT: Um-hm. PISACANO: You know, like transplants or some other ex-, extremely interesting studies. And, um, but that's just, again, that's a philosophy and it doesn't necessarily mean everybody believes in it. In fact, I can't think of too many people that do. Certainly not here. SMOOT: Hmm. How do you think the university medical center has done in terms of helping the state, particularly in Eastern Kentucky, in developing good medical care for the people of Eastern Kentucky, uh, providing practitioners for that part of the state, working with the hospitals in that region, et cetera? PISACANO: I, I don't, I honestly don't know the answer, I'm serious, I don't know the answer to that question. I would guess, as one who resides in this state, that it's certainly improved the care. I think you ought to ask some of the practitioners down there. But, um, I, I, I just really feel that it has to have improved, the presence of this medical school, has helped Eastern Kentucky and other areas of need. Now, I don't know if it's met any goals or if they had any goals to meet certain needs. I don't know. But I, I, I just feel reasonably sure they have. SMOOT: What about indigents? PISACANO: About what? SMOOT: Indigent care. PISACANO: Well, I guess it's improved there, too. I don't know what the indigent care was before the medical school started. I have no idea what the, I'm talking about percentage because I don't know what your population. You have to know all your demographics and I don't know those. Uh, but I think there's a, uh, I think that indigent care is a separate problem from the medical school, frankly. I mean, not that it's not part of their problem, but I think that now that, I understand this, what do they call this system where they can get the indigents, medically indigent, certifiably medical indigent get care, when they call a certain number for a physician? SMOOT: I know what you're talking about-- PISACANO: It's, yeah, it's supposed to be, it's by the Kentucky State Medical Society and I think that's, I think that's the only state in the country does that. I think that's admirable. So if you were an indigent person, I mean, not just trying to look for a free ride, and you could not afford it, you could still call a doctor and get one, which I think is, I don't know how that's working, but, it's, the idea is excellent. SMOOT: Um-hm. PISACANO: I got my own solution to the indigent problem and it has nothing to do with the medical school or medical center and so--not a solution, my own proposal and, and I'm going to put that in print pretty soon. SMOOT: Oh, really? PISACANO: Well, it's, it's calling on physicians each to g-, to tithe, using the tithing principal, and, uh, and not, not 10 percent as the tithing is, but maybe, uh, I ask them for four hours a month. Every physician in the country, except the young people just starting out who need to get their debts paid off. I'm talking about from ten years out, on. If everybody gave four hours a month, four hours a month, either to the care, if, if you're a clinician, the care in some, the free, to indigent care. You got enough people in this town; you could have that clinic open all. Let the state provide the facility, we provide the care. Not we, but my clinician colleagues. There are enough people to take care of a lot of indigents. It'd be a lot cheaper for the state, by the way, and it'd be a lot more noble for the profession. And then those, those people who don't practice, like some of the professors and administrators would have to give four hours equivalent in money towards the physical support. That, you know, four hours of your salary a month, whatever that is, which is what, it's one-tenth of a week, of one week's salary a month, uh, which would be four-tenths of a week of salary in a, in a year, I mean, you'd have to figure out a year. Whatever it is, give the equivalent in cash, which would be deductible, for those people who think the, think that way, and say, here, buy bandages, buy this for these people or you can give other services. We can lend administrative services. Maybe an administrator is going to say, I'll help, I'll spend four hours a month running this place, helping you run it or ever, whatever, some equivalent. SMOOT: Um-hm. PISACANO: If everybody that's out in practice, ten years or over, which I don't have the exact figures yet, how many people are out ten years and over out of medical school and it must be at least three hundred and some odd thousand, United States, how many would there be in Kentucky? I don't know, but we could find out soon enough, just take our, you know, what, who's practicing in Kentucky and what their a-, when they got, when they graduated from medical school. If they all contributed, and it's a tithing principal, because tithing is 10 percent; I wouldn't ask them to do that. If every one of us did something in-kind or in services, we may not solve the total indigent, but I'll tell you, the indigent problem would become a minor thing. Then the state could even add a few bucks, if they needed it, because we can't all afford to build a clinic building. But you know if the state would build us a clinic in, in certain areas where it's accessible to a patient-- SMOOT: Um-hm. PISACANO: --you can use the old, you don't even need county seats, you don't need a hundred and twenty in this place, you, maybe ten around the state. I don't, again, I'm not, I'm talking off the top of my head now, the figures, and those were manned by, you do it by your physician population, say we've got a thousand doctors in this area or five hundred doctors, that's two thousand hours a month. Right? Let's suppose only half of them can give actual service, but will give it in-kind. That's a thousand hours a month doctors would be giving to a small area of people. And that really should take, on the outpatient now that would not include hospitals because you can't give them, that's somebody else's problem. But if the, if the physicians would give that four hours service even in the hospital area, that would take care of the physician's bill. I'm talking about the physicians' responsibility, but institutions have to do their share, but that's where the state could come in. SMOOT: Um-hm. PISACANO: And it, and I not an economist, but I'll bet you it makes damn good economic sense, but it requires one thing, you've got to give. How much is four hours a month? How much is, how much is, uh, how much does that come to? Forty-eight hours a year. Forget, give them, I even ask for forty hours and my proposal is ten mon-, is, is so that they can have vacation thrown in there. Forty hours a year. You take three hundred thousand physicians, and that's a very modest figure, I'm figuring it over ten years, multiply it by forty, you come to 1.2 million hours a year and that's the United States, but, I don't know what it'd be in Kentucky, but you could figure it out. SMOOT: Um-hm. PISACANO: It wouldn't maybe take care of everybody and not every case either, because you need hospitalizations and you've got long term things and all that, but it would certainly solve a lot of--at least then I can have four hundred thousand doctors going to bed every night saying well, at least we're doing something as a profession and, and I doubt if anyone would go hungry because of it. I doubt if they'd have to give up their third Mercedes for it. You know what I mean? I doubt, but that's more heresy. [Pause in recording.] SMOOT: What you just mentioned to me, about the plan to propose some giving on the part of doctors, physicians to, to help indigents, reminds me of a, of a question that I wanted to ask you concerning the social concerns of physicians. Uh, you know, this goes back to the original philosophy of the medical center here at the University of Kentucky, uh, to bring in behavioral scientists and all these other people to-- PISACANO: Um-hm. SMOOT: --to instill in physicians more of a social consciousness than might have otherwise been the case, what they were getting in more traditional medical centers around the country. And now you see today the rise of proprietary, private institutions, uh, even moving into public institutions, taking them over-- PISACANO: Um-hm. SMOOT: --running the show, you know. PISACANO: Like, like Louisville. Um-hm. SMOOT: I'm just curious as, from your perspective, what, what does all this mean? What, what does this entail? Why is--have we done this? PISACANO: Why have we done what? SMOOT: Why have we gone-- PISACANO: Privatization is being used. SMOOT: Well, yeah, but why have we gone from a time before the medical center even, when private institutions like the proprietary hospitals-- PISACANO: Um-hm. Right. SMOOT: --were considered so awful, so terrible, we've got to get away from that, we have to have public institutions. PISACANO: Um-hm. SMOOT: Now, it seems that we're almost going back-- PISACANO: To private. SMOOT: --to private. PISACANO: Well, because the private thing is still a private. People seek still, people still want their own whatever it is. SMOOT: Um-hm. PISACANO: The, the private hospitals failed because they just, poor administration again and poor management. SMOOT: Um-hm. PISACANO: I mean, almost wasteful and then along comes some guy and say, hey, I look at that, I could give all those services and better for a lot cheaper if I knew how to manage this place, if they let me manage it and so they tried it and it worked. You can give better management, better delivery with better than had been, so then, then the pendulum swung towards the privates now. But the privates are forgetting something and, uh, and I think I've got a, I've thought about this quite a bit. The privates are being derelict in their duty to educate, help educate physicians, because now we've taken away the funding base for graduate medical education, residency programs. So these, these private corporations and I won't name them. Uh, I've been to one, I tried to get to talk to one of them not far from here, to help do its share and, and I've met with nothing but, uh, being relegated to, to talk to this guy to talk to somebody and finally wound up talking to nobody and I'm just saying, I think they have a responsibility, number one, socially. I mean, morally, forget social, they have a moral responsibility since they're taking and they're making money. There's nothing wrong with that and I say, God bless you, but I think you owe something back into the system. That's why my four hours a month, is something we owe back. I think it's a very great privilege to be a physician. That, even have, being able to become a physician, regardless of what you're doing in medicine, I don't care if you're running an insurance company, whether you're working as a dean or an associate dean or professor or whether you're out there in the fields working hard. Uh, I think we all owe something back to it and I think those people do too. Their tithing principal would be, you help us educate these physicians and then looking at it from the business sense, forget the moral, forget the altruism, you're only casting your bread upon the waters, you're now training your own people to take, continue to work in your factory, training your own employees, future employees. And if you want to train your own employees, what do want to do? You want excellent employees. You want, you want those guys to produce well, because if you don't then somebody's going to set up a system over here that's going to beat you. So you've got to have excellence, to use that old, another cliche. At the same time, you get loyalty and everything else when you train a guy well and so the guy comes out of the residency, subsidized by my private corporation, I would say, you know, I owe them something and they're a good company to work for, I wouldn't mind working for these people on a salary base. You know, I, I enjoy medicine, I'm making a good salary, they're giving me time for my continuing education, they're giving me vacation time, they give me retirement benefits or whatever it may be and you work your tail off and then get, of course you've got to work under certain standards too. We can't let you goof off. You're going to have peer review and all that stuff in there. And the system starts to feed itself, you see? There'll be weaknesses from time to time, but you do thing, you do with anything else, you plug them up. SMOOT: Um-hm. PISACANO: Or knock them out. Uh, so if the private corporations would do that, they would be so popular with the, with the public. Because say, hey, look what we're doing for you people, we're providing the funding, saving your tax dollars. You know what I mean? And now you don't have to go to a hospital and say there's a certain amount of this money we're going to tax you on. No, no. We're, we're making profit on your sickness. So then you say, well, how do we, what happens if we start making people well? They can make a profit on wellness, because health is, is, is a right, but it's also a privilege. SMOOT: Um-hm. PISACANO: And I think the consumer, if you, I hate to use that term to another damn cliche that I'm using. But the, the patient, the person has equal responsibilities, too. You want to be healthy, it, you can't get it without cooperating and being a compliant person, doing what you, doing your share and if it takes some of your tax dollars to, to produce certain things, then let's do it, you know. And anyhow, now if somebody in, in the, in the, the community hospitals have any goddamn sense, which I don't know why they haven't done this yet, they can say, okay, we've been mismanaging, we're going to do our, let's look at their management methods. What are they doing? They're making profit, we're always in the red. They're always begging for money, community hospitals, you know that, big drives and charity drives and they have these little thermometers outside the hospital and all that bull. You don't need that if you manage as well as the private corporation does, do you, if you're making money. And what are you going to do better? You can say, use your management principals and now it's a community hospital, since it is a charitable, basically a charitable institution, perhaps we can do it without the profit that means it's less money for the patient. But you do have to put some money back into research and development and all those things, but you can still make a little bit of money. Your not, aim is not to make money, your aim is to just be one inch into the black or a dollar into the black. SMOOT: Um-hm. PISACANO: And all the extra money you make, you put back institution, in the institution, maybe a new operating room, the finest operating suite there is, the finest rooms we can have. I'm talking about health, I'm not talking about luxury rooms, you can get those, and let the people pay for that if they want luxury, but say, now we can provide more services for the indigent with this extra money. Do you see what I mean? Instead of back to share-, stockholders. The stockholders are the community. You see what I mean? SMOOT: Yes. PISACANO: And I don't know why some dumb guy, a smart guy hasn't said, what the hell? This company over here is making a fortune because people, the stockholders, are getting dividends, what can I do to make my hospital run that way? Now that--the message is there, but I don't know what the hell they're doing. SMOOT: Um-hm. PISACANO: But it takes, but I think these private corporations are derelict if they don't give something back into the profession that's making them their money. SMOOT: Um-hm. PISACANO: So a lot of it, I don't get upset and decry, I think it's all going to work out if it's manipulated, and I don't mean manipulated in the bad sense, but is governed, administered well. SMOOT: Um-hm. PISACANO: See. But, uh, again, these are thoughts of a heretic and they're not, they don't quite go along with the guy who wants to make all the money or doesn't want to do any work. See? SMOOT: You've said on several occasions that you, that you have certain ideas that would be considered heresies within the profession or whether the private sector or-- PISACANO: Um-hm. Yeah. SMOOT: --public institutions. Why are they heresies? What, what's so wrong with, with, uh, these kinds of ideas? Why, why-- PISACANO: Because it disturbs people. My grandfather had an expression that, that the precedent is the terror of second-rate men. You can say people, he said men. And if you do something that establishes a precedent it scares people even more that it would as the precedent. But it's nothing that's really, uh, precedent so much as, I think in my own mind, only my mind now, I'm not saying this because I have a Schopenhauer philosophies of the world is my idea and I see it only as I can see it through these two eyes and this brain, but it makes sense to me. It makes sense to me. It may not make sense to people who are smarter than I am, have more knowledge than I have, then, then it's heresy. It may not make sense to the guy who doesn't want to think about it rationally, but it may, it may put out four hours a month out of his pocket or so much money out of the stockholders, back into the training of physicians, you see? Then it becomes heresy. Heresy is something that you, that you don't think is right. It's not heresy to me, it's common sense. Thomas Paine, you know, you know that too, Thomas Paine's was, his common sense was common sense and it was also heresy. Uh, he was called the dirty, little atheist and he's neither dirty, little or, nor atheist, but, but, uh, he was, you know, he was no hero. There's no Tom Paine's birthday, because he was really a heretic. But, I like his heresy, you see. Jefferson was a heretic in is own way, and only he happened to be at the top of the ladder and, uh, but I think the heroes are again, the unsung heroes are the Torn Paines, as well as the Jeffersons, not the others who just sort of ride the crest, but, uh, so it's heresy, no matter what you say. SMOOT: Um-hm. PISACANO: You know, Jesus Christ was a heretic, right? And all, all, any, well any religious reform leader is a heretic, but, but if you're a Christian you look at it, well, that's common sense to them, but to, to the Jew it's not common sense. You see what I mean? It's all according to the way you look and from what your vantage point is and if you're sitting there and it's costing you four hours a month or it's costing you some money from your stockholders, now it's heresy. Although there may be a few that will say, you know, I think he's got an idea, let's do it. But I'm saying, don't look at it as heresy, look at it as casting your bread upon waters. Look at it as you people call the bottom line, since you're bottom line man, which I detest that thing, but look at it as a bottom line, it's going to make you money, it's going to make you heroes. You see? And who's, who's, who's getting the benefit out of it? You are, but you can say, I'm also taking care of a lot of those sick people out there who can't afford to be, the facilities. It's not going to be a, any kind of a panacea, but goddamn it, it's, it's a good shot of penicillin when you've got a dose, see? SMOOT: Yes. You've worked with a variety of community activities, uh, for example, the--I would call, it's, well, it's more professional and community, Kentucky Mental Health Association for example, uh, Pan- American, Southern, Kentucky Medical Associations-- PISACANO: Oh, yeah. Um-hm. SMOOT: --you've been affiliated with that sort of thing. Uh, what other civic boards or these particular ones, that you could tell me about, uh, where you feel like you've made some sort of contribution or. PISACANO: Nothing, hardly at all. SMOOT: That's really not your forte; you'd really prefer not to-- PISACANO: No, I don't think many people do, one or two zealots, like I am for family practice, in those organizations who do a lot more than I ever could hope to do. And not that they're not worthy causes, I just, I, I as an individual contributed relatively nothing. SMOOT: Um-hm. PISACANO: Really. But to my own specialty, I would say it's different, in my own specialty. But those, sitting on there's not much--that can be frustrating too, you know, get some, get, you can get bogged down even in well-intended. In fact, the worst people to get bogged down are well-intended people, blind, uh, blind zealots. And, uh, and sometimes they get off on some kicks that, see, there's got to be a little touch of realism and, and in some of those there's got to be a little touch of idealism in the other groups, you see? I, I like to paint, throw in a little bit of, uh, color in their canvas over here, the corporations, of some idealism and on these other people, these, one of the do-gooders. I like to throw in some real realism and somewhere in there is a, is a happy color. SMOOT: Yeah. Yeah. PISACANO: Um-hm. But, uh, I've done nothing that, would be worth talking about. In fact, embarrassingly so, so I really should think there should be more done. SMOOT: If you were going to write a history of the medical center, what would you point to? What, what specific things, uh, individuals, uh, events, uh, achievements, uh, points that, that be greatly proud of, perhaps points that you would not be so proud of, uh? PISACANO: Well, there, there are elements to all those. SMOOT: Sure. PISACANO: But I would look at it from the one thing we said in the very beginning, to me as an individual, not as a citizen now, and almost with a smile. I'm smiling as I think about it. It, it, it fits the historical patterns right to a tee, just another notch in his-, in the belt of history. And anybody that knows history would see it that way, you know. But with the one other thing that you can still modify future history at t-, at now. SMOOT: Um-hm. PISACANO: You can always modify future history right now. But that takes a little foresight. You know, Prometheus brought fire and he got punished for it and, um, but there's no Prometheus, there're no Prometheans around. One good Promethean could say, okay, we fit the historical pattern. All right. Now, here I want to come along and do this and grab it, well, no, that if you're drawing a, you know, diagram I'm talking about. SMOOT: Um-hm. PISACANO: If you're drawing it, we, we, we just flashed right up like this and then we plateaued and then we've been on a steady decline. Now, what I'm saying, I can't change this curve roll, but somewhere in here, somebody ought to fire a rocket that puts it back up here again. SMOOT: Um-hm. PISACANO: And, uh, so the interesting thing about the whole medical center as I read my history, as I read the classics, I read anything that's any of import, it's the same old world. You know what I mean? Same, somebody said, life is one goddamned thing after another. This is the same damn bell shaped curve that fits everything else, nothing at all unique, nothing at all to ruffle your feathers about, except that you still got a chance for something here. That's, that's my feeling about it. SMOOT: You, in other words, you can still make a difference, wise-- PISACANO: Oh sure, hell yes. And I think the difference is through developing a strong family practice training, in this state--fulfill your social responsibilities. I'm not going to have a social responsibility, I'm not, I'm not a liberal, as you probably gathered, but I do believe that there's a strong need to fulfill some sort of, and of course, the, you know, the people can be a pain in the ass, too. The so-called people. And I don't wait for people to change anything, I wait people to back me up when I propose a change or I wait for people to, to fight the change, but I, no initiative stuff and we don't, we need somebody with some initiative and foresight, a Prometheus, and ready to suffer the consequences, but he can look back. Prometheus looked back, looked like, had given the world fire. What would we do without fire? You know, to, to use the illusion and, uh, we don't have that. And I think that, uh, so I, I don't know what I, I really just don't look at that as any, any different also. And I say, if you show me that you, if you told me that, the exact history of this medical center, when I got all through I'll say, so what's new? To use the, and I can show you that in books, call it the Roman Empire, you can call it, uh, the German Third Reich, it went like this and, and, whatever you want, whatever you wanted to use, any movement, social movements particularly, they get modified, which is good sometimes and, or they fizzle out. The Camelot allusion is a good one. Oh my God, you, everybody wore their hair like Kennedy. I remember they all had the Kennedy style, really. And some of them still do. SMOOT: Um-hm. PISACANO: You know, it's that Kennedy thing and every--the whole world, they began to play touch football because they saw him playing touch football one time, which is a lot of crap, always with photographers, you ever notice? It's funny. And the rocking chair. He got a rocking chair in his office, he had a bad back. SMOOT: Right. PISACANO: But he had this rocking chair. Isn't it funny how it just shows him all alone with his son, they forgot the photographer was in the room too, you know what I mean? Come on. But then rocking chairs became popular, see what I mean? And this kind of stuff, I'm, it's, it's, but it fizzled. First place, I don't think it had that much substance. Lot of, lot of rhetoric, holy shit, lot of talk. And that's all I'm doing, but I think we can put this into substance, I want to make something into action and then to probably massage modified and that's okay, but don't let it fizzle. The idea should not fizzle. To help your neighbor and to produce physicians to, to treat people comprehensively is not an illusion and it's not, uh, it's not, uh, a temporary thing, it's not a will of the wisp, something should be here forever. So I'm giving a major talk, I think, down in Alabama in another two months and it's, it's going to be on the, the reconsecration of medicine. They asked me to talk about what I want. I said, "You sure anything I want to talk about?" Anything you want to talk, you can talk about baseball if you want. I said, "I'm going to talk about reconsecrato medici." Because a guy named, I don't have the b-, I got, I had a series of lectures here, uh, by, uh, the great, uh, uh, surgeon from Harvard gave, uh, a series of lectures and they put them into a bo-, and they put his book into, and one of his lectures is called consecrato, the consecration of medicine, medici, physicians and I read that, that was a very outstanding thing written back in the late twenties. Harvey Cushing his name was, very famous. And I--mine is going to be reconsecration, only in Latin, reconsecrato. See, to me we ought to stop and pull back a little bit and I'm practically giving you my whole thoughts for that talk. I haven't done anything yet. Is that it's time that we reconsecrate ourselves so that we can be held up in the public's eye, the, the John Q. Public and say, boy, he's a doctor. I don't want people bowing and scraping to me, but to say, but when you walk into a room there's a respect. Why? Not because I went through medical school and I, I've got three Mercedes Benzes in the garage, but because they know that I am talking care of people and I'm doing my duty and I'm a good doctor and if I get called right now in the middle of this cocktail party, I'm going to go and you're going to be sitting on your ass drinking. That's, see what I mean? But we haven't, we got the, it's time for reconsecration and this-- family practice is one way to do it, plus all the other research. Don't get me wrong. Never, never have I ever said don't have subspecialties and don't fortify those, but their, their way of doing it is wrong and, uh, it goes back to this medical center, again, why don't we reconsecrate ourselves to, to the 1960s. It's, the medical center, not the sixties. Although I, that did have a strong influence, you know, but why, why don't we reconsecrate ourselves? Maybe it's time the medical center reconsecrated itself. In fact, that's what they ought to do for their goddamn twenty-fifth anniversary instead of spending money and having little shindigs. See what I mean? SMOOT: Um-hm. PISACANO: But that's more heresy. Go over and tell your Bosomworth that and see what he says. You can give it and that's it. SMOOT: Let me ask you if there's anything else you, you think that should be touched upon? PISACANO: No, but you've asked me so many questions, you've stimulated my own thinking. SMOOT: Great. Well, I'm happy I did that, I hope you get more. PISACANO: Well, I've been sitting here racking my brain up. They called me the other day and said, I want, want a title, so I thought of that title and this is a, it's a big annual thing that I really am so scared because so many great, great physicians in the country have given this address down there. And the, the catch of it is you can talk about anything you want, doesn't have to be medicine, and then I began to think, my God, I've got a lot of my things, but this is, this is the pattern of my thinking, which you heard. And I got to start re-reading some of my Toyndee, I've got to find time to do that, because it'll just stimulate me to thinking in that pattern again. And as you could guess, I can't quote you one word of Toynbee, but I can, I think I've got, he's left a stain, you know what I mean? SMOOT: Yes. PISACANO: And I can't tell you what that, where that came from specifically, but it's there and, uh, if, if I could go back and re- read that, and that's how I give almost all my talks, I, I don't write anything, I just read two or three days before, start reading nights till three or four o'clock in the morning and get really stimulated, some things that I thought about six months ago or a year ago or even last week and that's the way to do it. But I have no other thoughts unless you provoke something. SMOOT: Well, maybe I could provoke something some other time, I'd rather go back and, and take a look at we-- PISACANO: Sure. SMOOT: --we have here and, uh, if I could impose upon you again-- PISACANO: I'm so glad they got a history, a person who loves, not loves, but probably really is, I don't know if you love or not, that really has a feeling for history true, true history, not-- SMOOT: I was going to say, I don't know if I have the right feelings about it. PISACANO: Oh, I think you do, sound like, well, you do; if you love it, then you've got the right feelings and that, so I think that's exciting. SMOOT: It is for me and I appreciate it. PISACANO: That's, that's something they could have screwed up again. [End of interview.] Dr. Nicholas Pisacano (General Practitioner, Department of Medicine; Assistant Dean of the College of Arts and Sciences; Director of Continuing Medical Education at the University of Kentucky Medical Center and Assistant to the Vice President at the Medical Center, 1962-1978) discusses his medical education and background before coming to the UKMC as the first full-time general practitioner. Dr. Pisacano reflects on the early years of the UKMC as a new and exciting time and he speaks highly about the community medicine dept., the first in the country. He also discusses his role in the creation of family practice as a specialty and explains his philosophy of family practice being the foundation for all other specialties. He also shares a proposal for how physicians could care for indigents. insert here