A MEDEX Magazine Series
Seattle 1969
Seated with the newly formed MEDEX Northwest team under the insistent fluorescent lights of a small conference room, Richard Smith stared at the stack of applications on the table before him. Eighty men had responded to their outreach at military installations across the country. Eighty veterans were looking to translate their battlefield medical skills into civilian careers.
So many lives, so many stories, Smith thought. How do we choose? After all, these fifteen will define this new profession.
“Okay, we need to be systematic about this,” Smith told the team. “Four primary criteria: medical training and battlefield experience, of course, but equally important are adaptability to civilian practice and community integration potential, especially in communities facing physician shortages.”
Ray Vath nodded. “And we need to screen for judgment. Can they recognize their limits? Will they resist portraying themselves as doctors? Can they develop an appropriate professional identity?”
Vath picked up an application from the top of the pile and studied the photo of a young corpsman with a serious expression and close-cropped hair. Three tours in Vietnam. Bronze Star with valor. Extensive experience in field trauma care.
“The technical skills aren’t the issue,” Smith said to Vath from across the table where he sat reviewing another file. “Most of these men have performed procedures that would make a third-year medical student faint.”
Vath agreed. “The question is: Which ones can adapt to civilian practice? Who among them can handle working within a structured healthcare system rather than independently in the field?”
Smith tapped his pen against the table, thinking. “And which ones can integrate into these small communities? That’s just as crucial.”
“I’m finding myself gravitating toward the Special Forces corpsmen,” said Vath, picking up another application file. “They’ve had the best training and performed the most independent medical work, often behind enemy lines in the mountains of Vietnam.”
“They’re also the most creative,” Smith added. “When you’re miles from support with limited supplies, you learn to solve problems in unconventional ways. That’s exactly the mindset rural providers need.”
The selection process the team had devised was unlike anything previously used in healthcare recruitment. Drawing on Smith’s Peace Corps experience with group assessment methods, they created an intensive weekend event at a motel in Renton, Washington, bringing together MEDEX candidates, preceptor physicians, and their spouses.
“The Peace Corps learned through hard experience that traditional interviews and credentials are poor predictors of success in challenging field positions,” Smith explained to his team as they prepared. “We need to observe these men not just in formal interviews, but in social settings, under stress, and interacting with each other.”
Smith also brought a sophisticated understanding of what he called “social investment behavior” to the selection process. His work leading the desegregation of the nation’s hospitals and working with the Peace Corps had taught him that successful social change required all participants to feel invested in the outcome. The selection weekend was designed not just to evaluate candidates but to begin creating those investments among everyone involved.
On a rainy Friday afternoon in May 1969, the candidates began arriving at the motel—men of varied backgrounds but similar bearing, their military experience evident in their posture and measured movements. Smith snuck an early look at the candidates as they gathered around the registration table, noting small details.
Who helped others with their bags? Which of them made eye contact with the staff? Who seemed at ease and who appeared guarded?
What made the selection process truly revolutionary for the time was Smith’s insistence on including the spouses of the candidates and preceptors. He had learned through the Peace Corps that family adjustment was often the determining factor in field placement success.
“We need to evaluate the entire family unit,” he reminded Vath as they watched the wives gathering in the motel lounge. “If the spouse is miserable in a rural setting, the placement will fail no matter how talented the MEDEX is.”
“My wife Joanne is circulating among them now,” Vath said. “She’s good at getting people to open up about their concerns.”
Throughout the weekend, candidates rotated through multiple interview panels while also participating in social events, group discussions, and problem-solving scenarios. The preceptor physicians and their wives observed and engaged, forming their own impressions.
One applicant, John Betz, who would be selected for the first class, later remembered the intensity of the process with a signature touch of wry humor: “We had two days of interviews, every 15 minutes. You got a schedule of different hotel rooms, and you would walk in, salute, sit down, sit up straight and say, ‘I like small towns, my wife likes small towns,’ and then answer their questions.”
As the team reviewed applications together, occasional moments of levity broke through the seriousness of their task.
“This Tom Coles fellow has listed ‘tuping‘ as one of his skills,” he said, showing the application around the table. “Any idea what that might be?”
Vath shrugged. “Some specialized military technique? A medical procedure I’m not familiar with?”
The team was intrigued. With no immediate way to look it up in those pre-internet days, they simply added it to the list of questions to ask Coles at his interview.
When they finally met Tom and asked about this mysterious skill, he looked as puzzled as they were. After a moment of confusion, realization dawned on his face.
“Oh! That was supposed to be ‘typing’,” he explained with embarrassment. “It’s just a typo.”
The team laughed. This was a welcome moment of levity amid the intense selection process. More than that, small interactions like these revealed personalities and character in ways that formal interviews and credential analysis never could.
By Saturday evening, Smith was exhausted but exhilarated. Over dinner, he watched genuine connections begin to form between the candidates and rural physicians. It was a promising sign. Later that evening, the MEDEX team gathered in Smith’s room to compare notes.
Vath spread assessment sheets across the bed, the results of brief psychological tests on the candidates he had conducted.
“So, we wanted to know why none of these highly skilled men pursued medical school; a fascinating pattern emerges. Our corpsmen all had verbal IQs above average, but their performance IQs were well above average as well, which suggests they are creative, or that they’re better at seeing and doing than at reading and thinking. These guys can go from the laboratory to the books. But they don’t go from the books to the laboratory.”
“An essential piece of the medical school model, of course” Smith mused, the implications dawning on him. “So, our curriculum needs to match this learning style. Less classroom time, more hands-on experience.”
“Exactly,” Vath continued, “The military trained them through pretty intense on-the-job methods. We should follow that model: A short classroom phase followed by an extended preceptorship. The traditional path just won’t work for them. It’s not a deficiency on their part. This is important to remember—it’s just a different kind of intelligence.”
On Sunday morning, Smith implemented the final, innovative element of the selection process: mutual ranking. The candidates were asked to list their top five physician preceptors in order of preference, while each preceptor was asked to rank his preferred candidates. The final selections would be determined not by the MEDEX team alone, but by finding the strongest mutual matches between applicants and physicians—partnerships formed by choice rather than assignment.
As the weekend concluded and the candidates departed, Smith stood in the motel parking lot, watching them drive away. From this group, the MEDEX team would soon choose fifteen men who would pioneer a new profession; who would and face skepticism, resistance, and the enormous pressure of being first along the way.
“By having both sides choose each other,” Smith would later recall, “we created a space for investment from the beginning. These assignments weren’t handed down from above; they were partnerships based on mutual selection.”
When the rankings were tabulated, the matches were remarkably aligned. Almost all the physicians’ first choices had also ranked them first.
“It’s as if they recognized something in each other,” Vath would observe. “A shared wavelength.”
As the weekend concluded and the candidates departed, Smith stood in the motel parking lot, watching them drive away. From this group, the MEDEX team would soon choose fifteen men who would pioneer a new profession; who would and face skepticism, resistance, and the enormous pressure of being first along the way.
“Sometimes not knowing the full magnitude of the challenge is the only way to begin,” Smith would later write when thinking back on this moment.
With the first class selected, the MEDEX team turned to developing the curriculum. Based on Dr. Vath’s psychological insights and the extensive experience the candidates already possessed, the design was very pragmatic: a three-month classroom phase followed by a twelve-month preceptorship with practicing physicians.
In the cramped MEDEX office, Smith joined Gerry Bassett at a table covered with draft curriculum documents and got to work. Bill Freeman periodically leaned over their shoulders, pointing out which skills the corpsmen already possessed, and which would need further development.
“Most of these men can already start IVs, suture wounds, set simple fractures, and recognize common illnesses,” Freeman observed. “There’s no point wasting time teaching them what they already know.”
Smith nodded. “This is what a competency-based approach is all about. If they can demonstrate proficiency in a skill, whether from battlefield experience or prior training, we acknowledge it and move on. Let’s focus the limited classroom time only on areas where they need development.”
The resulting curriculum would be radically different from traditional medical education. Rather than starting with theoretical foundations and gradually building up to clinical applications, MEDEX would focus on practical skills and clinical judgment from day one. The emphasis would be on primary care: diagnosing and treating common conditions, recognizing when to refer patients to their supervising physician, and managing chronic diseases.
“Medical schools try to teach students everything about everything,” Smith noted. “We’re taking the opposite approach. We’re teaching them to be experts at 75-80% of conditions they’ll see regularly in primary care, and equally expert at recognizing when they’ve reached the limits of their training. We’re emphasizing judgment as much as we are knowledge.”
“The three-month timeframe for the academic phase is deliberate,” Smith would explain. “These men already have advanced medical training and experience, often in the most demanding of settings. They’re certainly not starting at zero. And based on Ray’s findings about their learning styles, extending the theoretical classroom phase could actually diminish their effectiveness. We need to get them into their hands-on preceptorships as quickly as possible.”
Vath developed the behavioral medicine component, which stressed teaching the corpsmen how to recognize and address mental health issues in their patients. He created a curriculum that built on their combat experiences with psychological trauma.
“These men have seen intense suffering,” Vath explained. Most were experiencing some degree of combat fatigue or shell shock, which would later come to be recognized as post-traumatic stress disorder. “They understand psychological distress in ways most medical students never will.”
Years later, Smith would reflect on this intense period of work, and on the long days and nights of shared creativity and invention this team brought to the task at hand. […] And he would smile to himself, feeling again that moment of deep satisfaction that came over him when it became clear that all of this was falling into place, and that what they were building was more than a training program—it was something different.
Vath’s approach further emphasized practical communication skills. He taught the students to ask simple but powerful questions during patient histories. “Have you had some really difficult times in your life? Are you having trouble coping? Can you tell me about that?”
Smith was impressed by the elegant simplicity of this approach. “These aren’t the kinds of questions most physicians think to ask.”
“Most physicians don’t have time,” Vath replied. “But our Medex will. They’ll be prepared to build deeper connections with patients and address the emotional dimensions of illness that too often go unrecognized.”
Vath would also incorporate innovative teaching methods like role-playing to help students learn how to interview patients with psychological issues. Vath would himself play an alcoholic patient, demonstrating how alcoholics often cycle through the classic Karpman Drama Triangle roles of persecutor, victim, and rescuer during conversations.
“They’d ask me about my alcoholism, and I’d say I didn’t drink much, just the occasional beer,” Vath later recalled. “Because my role was to be an alcoholic, they’d press with indirect questions, and finally, I’d admit, ‘Okay, maybe I do drink too much—probably a fifth a day.’ Then they’d challenge me: ‘Don’t you understand what a bad effect that’s having on your family?’ That’s when I’d shift into the role of being a victim. ‘Oh yes, it’s terrible, I spend all the money that should buy shoes for the baby, and I’ll just go kill myself.’ And suddenly, they’d switch into rescuers, saying, ‘Oh, don’t do that.'”
This hands-on approach strongly matched the learning styles of these students. It provided them with practical tools for addressing psychological issues—an essential skill in rural areas where mental health specialists might be hours away.
Years later, Smith would reflect on this intense period of work, and on the long days and nights of shared creativity and invention this team brought to the task at hand. He had insisted on a collaborative approach, with everyone involved in decision-making, seeking input from multiple sources, and systematically anticipating problems before they arose. He would remember the coffee cups scattered across the conference table, the lights of Seattle glittering through the window. He would picture Bassett reviewing clinical rotation schedules, Vath drafting communication protocols for preceptors, Freeman listing emergency procedures that each Medex would be challenged to master.
And he would smile to himself, feeling again that moment of deep satisfaction that came over him when it became clear that all of this was falling into place, and that what they were building was more than a training program—it was something different.
When the classroom phase began in July of 1969, Dr. Smith stood before the fifteen selected students in a small lecture hall at the University of Washington School of Medicine. They sat attentively, notebooks open, their upright posture and quiet focus reflecting their military training.
“Gentlemen,” he began, “what we’re attempting has never been done before. We’re creating a new healthcare profession. Not doctors, not nurses, but something equally vital. You’ll be the pioneers, the ones who define what a MEDEX can be.”
He paused, looking at each face in turn.
“I’m guessing you know already that this won’t be easy. You’ll face skepticism from other healthcare professionals. You’ll encounter patients who question your qualifications. You’ll work within a system that isn’t designed for your role.”
Their expressions remained resolute, unintimidated by the challenges he described.
“This is because you will be part of something revolutionary. You’ll be a vital person extending quality healthcare to communities that desperately need it. The skills you developed serving your country in war will now serve your communities in healing.”
As the classroom phase progressed, Dr. Smith observed the students absorbing new knowledge and demonstrating their existing skills. Their learning style confirmed Vath’s assessment. They excelled at practical applications, at procedures and protocols, at clinical decision-making based on real-world scenarios.
By September 1969, they were ready. The classroom phase gave way to preceptorships, and the students began stepping into real clinical roles, proving themselves every day.
But Smith couldn’t ignore the looming shadow over their future. Without a legal framework to protect them, these men—trained, competent, and essential—could be forced out of practice before they’d even begun.
Autumn 1970
The grandfather clock in the hallway chimed 3 a.m. as Smith lay awake, staring at the shadows playing across his bedroom ceiling. His wife’s breathing had settled into the steady rhythm of deep sleep hours ago, but his mind refused such peace.
The first class of MEDEX students would soon complete their year-long preceptorships with rural physicians across Washington state. Pride in their progress mingled with a gnawing anxiety that kept sleep at bay.
What happens when they graduate?
Smith shifted onto his side, punching his pillow into submission. Outside the protective cover of the University of Washington, there was no legal path for these men to continue practicing medicine. Without legal recognition, these pioneers would have no future in the profession they were about to create. One lawsuit, one challenge from an entrenched interest, and everything they’d built could collapse overnight.
He closed his eyes, exhaling slowly. He had anticipated this problem. No new profession simply slotted into existing legal frameworks without resistance. He had built MEDEX knowing this fight was coming.
But time was ticking away.
The next morning, Smith sat alone in his office. The desk lamp cast a warm glow over the copy of Washington’s Medical Practice Act laid out before him, its pages marked with pencil notations and numerous paper clips. The gentle knock at his door pulled him from his concentration. Jack Lein, the University’s legislative liaison, stood in the doorway with a manila folder tucked under his arm.
“Morning, Richard,” Lein said, stepping into the office.
Smith rubbed his eyes. “Jack, thanks for stopping by. Still trying to understand what we’re up against legally.”
Lein, a veteran political operator who knew the complex corridors of state government better than almost anyone, placed his folder on the desk. “I may have found something.”
He opened the folder and pointed to a section he’d underlined in red pen in the Medical Practice Act. “Right here—an exemption for ‘trainees in programs at the University of Washington School of Medicine.'”
Smith leaned forward, reading the provision carefully. He looked up, mind racing with possibilities. “So, if our MEDEX students are officially designated as ‘trainees’…”.
“They’d be legally covered during their education period,” Lein finished. “It’s a start. Not a permanent solution, but it gives us time to work on legislation.”
Smith nodded, his expression serious. “I’ll speak with Hogness this afternoon.”
Later that day, Smith strode purposefully into Dean Hogness’s office with the marked-up copy of the Medical Practice Act tucked under his arm.
“John, we’ve found our legal pathway,” he said without preamble. “The Medical Practice Act has an exemption for trainees at the medical school.”
Dean Hogness leaned back in his chair, considering. “So, you want to classify your MEDEX students as trainees?”
“Exactly. If you write letters officially designating them as ‘trainees’ at the School of Medicine, they’ll be legally protected during their education period. That gives us time to secure permanent legislation.”
Hogness nodded slowly. He had recruited Smith precisely because of his innovative thinking and willingness to challenge convention. “It’s within the spirit of the law. They are trainees, after all. I’ll draft letters beginning with ‘Dear Trainee’ to emphasize their status. That phrase will be your legal shield.”
Smith smiled, a feeling of relief washing over him.
But this immediate legal coverage was just the first step in Smith’s comprehensive strategy. The “trainee” designation would protect students during their education, but for MEDEX to become a sustainable profession, they needed permanent legislative recognition.
Smith knew the real battle wasn’t in his university office. It was in Olympia, in the hearing rooms and legislative chambers of Washington’s state capital where the future of MEDEX would ultimately be decided.
He needed Washington State Medical Association leaders and key legislators to support the program. But that kind of support didn’t come from speeches or position papers; it had to be earned through demonstrated value.
Over the past year, Smith had deliberately placed students with physicians who had influence in both the WSMA and the state legislature: Dr. William Henry in Twisp;. Drs. Richard Bunch and Ken Pershall in Othello. Each strategic placement represented not just a training opportunity, but a potential advocate when the legislative battle began.
“These doctors have seen firsthand what our students can do,” Smith reminded his team during a strategy session in the MEDEX offices. “They’ve experienced the transformation in their practices, the relief from crushing workloads. They’ll be our best advocates because they’re speaking from personal experience, not theory.”
The plan was working. Rural doctors were making calls to legislators they’d known for years, sometimes decades. Their messages carried weight that no university professor’s testimony could match. Momentum was building.
Then came the roadblock.
Smith looked up from a stack of student evaluations as Vath walked into his office, closing the door quietly behind him. The psychiatrist’s usual composed demeanor had given way to tension evident in the tight line of his mouth.
“We have a problem,” Vath said, dropping into the chair across from Smith’s desk.
Smith set down his pen. “Go on.”
“Senator Day won’t support the bill,” Vath said flatly. “He’s refusing to move it forward in committee.”
Smith leaned back, the chair creaking under his weight. Senator William S. Day, a chiropractor from Spokane and chair of the Senate Health and Welfare Committee, controlled whether a recently introduced bill that recognized the fledgling PA profession would advance or die in committee. Without his support, the legislation was effectively dead.
“What’s his issue?” Smith asked, though part of him already knew the answer.
Vath shook his head. “It’s not about us. It’s about chiropractors. Senator Day is demanding the WSMA push for insurance coverage for chiropractic care. If they don’t, he blocks our bill.”
Smith exhaled sharply. Politics. Always politics.
This had nothing to do with healthcare quality or rural access. It was about leverage and professional turf wars. These were the same battles that had shaped American medicine for generations.
“So, what do we do?” Smith asked, looking across his desk at Vath, whose psychiatric training had proven invaluable in navigating resistance to change so far.
Vath spread his hands. “Without Day, we’re dead in the water.”
Smith called the team together. The weight of the first MEDEX class, and countless patients who would benefit from their care, pressed down on his shoulders.
It was time for another collaborative problem-solving session.
During the meeting that ensued, someone mentioned two veterans’ organizations with significant political skills: the VFW and the American Legion.
“What if we reach out to them?” Smith said, a surge of energy returning to his voice.
Vath’s expression shifted from doubt to consideration. These organizations had enormous influence, especially in rural communities where MEDEX students were already working.
Smith paced the small conference room, his mind racing. “We’ve been thinking like academics, approaching this as a medical education issue. That’s why we’re hitting walls.”
He stopped suddenly. “But what is MEDEX really about? It’s about veterans. It’s about taking men with battlefield medical skills and giving them a path forward. It’s about recognizing their value.”
“The veterans’ organizations understand political pressure better than we ever will,” Smith continued, energy returning to his voice. “They know how to mobilize supporters; how to frame an issue so legislators can’t ignore it.”
As hearings were held, the veterans’ organizations brought busloads of citizens to testify. They shared personal stories of comrades whose lives had been saved by field medics in Korea and Vietnam. They spoke of the irony that these same medics couldn’t legally provide basic healthcare in their hometowns. They emphasized their own struggles to access medical care in rural communities.
He turned to face the team. “We approach them not with politics, but with honesty. Tell them, ‘We’re trying to create opportunities for returning Vietnam medics. We’re new to this process. Can you help us?’ Then let them do what they do best.”
Within days, the plan took shape. They contacted both the VFW and the American Legion, explaining the MEDEX mission and the legislative challenge they faced, but deliberately not mentioning Senator Day’s conditions.
The response was immediate and overwhelming.
As hearings were held, the veterans’ organizations brought busloads of citizens to testify. They shared personal stories of comrades whose lives had been saved by field medics in Korea and Vietnam. They spoke of the irony that these same medics couldn’t legally provide basic healthcare in their hometowns. They emphasized their own struggles to access medical care in rural communities.
As the MEDEX team had hoped, the legislators couldn’t ignore these people. These weren’t university professors or healthcare theorists, but voters, constituents, and respected community members.
The next day, Vath received a call. “It’s Senator Day,” he mouthed to Smith as he picked up the phone.
Smith watched as the psychiatrist’s expression shifted from concern to surprise during the conversation.
After he hung up, Vath looked at Smith with a smile. “Bill Day’s had second thoughts. He says he feels the program should stand on its own merits, and he’s adding his name to the list of sponsors.”
Smith exhaled a breath he felt he’d been holding for months.
We might actually pull this off.
On April 15, 1971, Smith stood in Governor Dan Evans’ curtain-draped office, his pulse quickening as Senate Bill No. 182 was signed into law.
He couldn’t stop grinning.
A year ago, this moment seemed all but impossible. The program had existed in a legal gray area, reliant on a temporary university loophole. Their fight through political resistance, entrenched interests, and last-minute legislative standoffs had tested every ounce of patience and strategy he possessed.
Now, standing alongside the governor, the legislators, and the physicians who had lobbied alongside him, Smith felt the weight lift from his shoulders.
With the stroke of a pen, PAs became legally recognized in Washington State. For the first time, the state’s law defined the new profession.
A “Physician’s Assistant” was now recognized as someone enrolled in or who had completed a board-approved training program to “practice medicine to a limited extent.” Under the law, PAs would only work under the supervision and control of a licensed physician—but crucially, the bill clarified: Supervision and control shall not be construed to necessarily require the personal presence of the supervising physician at the place where services are rendered.
This was the breakthrough.
It meant PAs could work independently in rural communities, reaching the very people MEDEX had been created to serve.
The legislation placed regulatory authority under the State Board of Medical Examiners, which would determine qualifications, training standards, and scope of practice rules. No physician could employ or supervise a PA without board approval, ensuring a structured path forward.
As the governor’s pen moved across the page, Smith understood the significance of what they had accomplished. He cast a glance around the room—Governor Evans, the legislators, the veterans who had championed the cause, the rural doctors who had put their reputation on the line.
The fight had been long. The political maneuvering exhausting. The risk immeasurable.
But in that moment, all he felt was joy. MEDEX had started as an idea, little more than a flicker of possibility in a Cuban clinic. That flicker had survived Nigeria, had taken root in the Peace Corps, had been shaped in makeshift training rooms and motel conference halls where men who had once saved lives in combat now trained to do the same in small-town clinics and other underserved areas. Now, it was written into law.
He clapped a hand on the back of Hal Zimmerman of Camas, a representative of the 17th District, who had helped push the bill through the House, his excitement spilling over. There were handshakes, cheers, and slaps on the back. A camera flash captured the moment. Smith’s wide, jubilant grin showed a victory made real.
He thought of the men who had put their faith in him. The fifteen pioneers who had left behind one identity to forge another. Men who had risked everything to join a program with an uncertain future, who had trusted that their battlefield medical skills would be valued in civilian life. For them, this legislation was a doorway to the future. It was a chance to build careers, serve patients, and change lives. It was even a chance to alter the medical landscape, reshape rural healthcare, empower future PA generations, and redefine what was possible in American medicine.
The fight was worth it.
Smith slowly exhaled, steadily collecting himself. There was more work yet to be done. More battles to fight. But in that moment, he allowed himself to feel the rarest of things: a moment of pure, unfiltered triumph.
The legislative victory of April 1971 had secured the future of the profession, but another essential milestone had occurred months earlier when the inaugural class members had completed their training and graduation day was upon them. That day had been its own kind of triumph; one built on faith that the legal foundation would eventually follow.
September 13, 1970 dawned with clear skies over Seattle, the unusually pleasant 65-degree weather seeming to smile on the occasion. Inside the University of Washington Health Sciences Building, the atmosphere was charged with a sense of historic occasion.
What began on July 7, 1969, with fifteen former military corpsmen entering an experimental three-month training program, was culminating at this moment. These men had spent the past year in preceptorships, receiving on-the-job training under the supervision of practicing physicians across Washington State. Now, they were about to graduate.
Now, they stood on the threshold of a new profession.
Dr. Smith straightened his tie as he surveyed the modest auditorium. The simple printed program in his hand belied the complexity of what they had accomplished: “The University of Washington School of Medicine and the Washington State Medical Education and Research Foundation welcome you to the graduation exercises of the first class of the MEDEX Program.”
“We’ve actually done it,” Vath murmured beside him, scanning the room where university officials mingled with rural physicians, state medical authorities, and the families of the graduates.
Smith nodded. “And more importantly, they’ve done it.” He watched the fifteen men in their blue coats, symbols of their distinct professional identity, checking each other’s appearance with the same precision they’d once applied to military inspections.
UW School of Medicine Dean Robert L. Van Citters approached the podium to welcome the attendees. His authoritative voice carried through the room as he described the journey that had brought them to this day—the three months of intensive training in didactic and practical medical care under university faculty supervision, followed by twelve months of preceptorships with general practitioners throughout Washington.
As the speakers followed in succession, Smith felt quiet pride. Each represented a different element of the “receptive framework” he had so carefully constructed.
Dr. Roland D. Pinkham, President of the Board of Directors of the Washington State Medical Education and Research Foundation, spoke of the Foundation’s involvement and how the program represented a new approach to healthcare delivery.
Dr. J. Thomas Grayston, Dean of the UW School of Public Health and Community Medicine, addressed the public health implications, emphasizing how MEDEX would extend healthcare access to underserved populations.
When Dr. Richard Greenleaf, President-elect of the Washington State Medical Association, took the podium, Smith felt a particular satisfaction. Early support from the WSMA had been crucial in legitimizing MEDEX in the eyes of practicing physicians. Greenleaf acknowledged the initial skepticism many had felt, then spoke candidly about how the model had proven its value.
Dr. John R. Hogness, Executive Vice President of the University and former Dean of the Medical School, had been one of Smith’s earliest allies. “When Dr. Smith first presented this concept,” Hogness began, “I called it a ‘crazy idea,’ but today I’m proud to say it was one of the most important ‘crazy ideas’ this university has ever embraced.”
The moment arrived for the graduates to receive their certificates. Dean Van Citters and Richard F. Gorman, Executive Secretary of the Washington State Medical Association, stood together at the podium—a visual representation of the academic-professional partnership that had made MEDEX possible.
One by one, the graduates crossed the stage: John Edward Betz and Paul Thomas Snyder, both headed to Othello; Eddie Joe Bivens to White Salmon; Michael James Carraher to Seattle; L. Carl Chillquist to Twisp; Thomas Grant Coles to Seattle; Ronald Dale Graves to Davenport; Orin Alfred Kent to Lynden; Louis LeBert to Harrington; James Rondia Mathis to Saint John; Dean Alexander Meade to Seattle; Mark Alan Patterson to Tonasket; Steven Duvall Turnipseed to Seattle; Robert James Woodruff to Cheney.
Smith watched Turnipseed with particular pride. As the only African American in the first class, Smith knew well that he had overcome additional barriers to appear on this stage. His placement at Group Health Cooperative in Seattle represented the program’s reach into urban healthcare settings alongside its rural focus.
The regional and geographic distribution of placements reflected Smith’s strategic vision—not just addressing rural shortages but demonstrating the model’s viability in diverse communities. Most of the graduates were headed to small towns across eastern Washington where the need was most acute, but several would remain in Seattle along with Turnipseed.
As the ceremony concluded, the program’s final words resonated through the room: “Today we are witnessing the beginning of a new program to extend the capacity of physicians to provide care to those in their communities.”
Here it was, the multiplication of hands he had dreamed of for so many years.
After the ceremony, sunlight streamed through the windows as Smith moved through the reception, accepting congratulations but consistently redirecting praise toward the graduates and their preceptors.
He paused beside John Betz, who stood with his supervising physician from Othello.
“Ready to make it official?” Smith asked.
Betz nodded. “Dr. Pershall has already set up an exam room with my name on it.”
“And the patients?”
“They’ve been asking when the ‘doc’s assistant’ is starting full-time,” Dr. Pershall interjected with a smile. “Some have been holding off on appointments until John’s official first day.”
Similar conversations echoed throughout the reception. What had begun as an experiment was already becoming an integrated part of healthcare delivery. Communities had begun to embrace these new providers, seeing not “second-class medicine” but an extension of their trusted physicians’ care.
Later, as the event wound down, Smith found himself standing with Vath, Bassett, and Freeman near the open windows where a gentle breeze carried the promise of early autumn.
“This is just the beginning,” Smith said quietly.
“One class, in one state,” Freeman agreed.
“But what a start,” Bassett added. “From concept to certified professionals in less than two years.”
Vath raised his glass. “To MEDEX Class One! The pioneers!”
As Smith raised his own glass, he was already thinking beyond this moment. Washington was just the first step. The model needed to spread—to other states, other regions, eventually nationwide. And beyond that, perhaps globally.
But for today, this was enough.
While the graduation celebrated a professional milestone and the legislation secured an institutional future, Richard Smith knew that the true essence of MEDEX transcended both. Behind the policies, protocols, and legal frameworks beat the heart of something more fundamental: a profound human connection that these former combat medics brought to healthcare. Their battlefield experiences had forged in them something medical school alone could never teach. This something was a hard-won wisdom about life, death, and the fragile space between.
Amidst the policy battles and program development, Smith never lost sight of the human dimension of their work. The MEDEX program wasn’t just about healthcare systems or professional identities; it was about people—both the providers and those they served.
This reality was brought home powerfully about three months into the program, when Vath and his wife suffered the loss of a baby during childbirth. As they navigated their grief, Vath was deeply moved by the response from the MEDEX students.
“Ray told me something remarkable,” Smith said to Freeman one evening as they reviewed administrative files in the office after hours. “He said the corpsmen provided more comfort in his grief than anyone else. More than his pastor, more than his colleagues.”
“Why do you think that was?” Freeman asked, looking up from the papers.
Ray thinks it’s because they’ve seen death up close. Not sanitized hospital death, but violent, sudden death. They’ve held dying men in their arms. That creates a different kind of empathy.”
Years later, Dr. Vath would reflect further on this. “I learned so much about grief and comfort from those guys, and that’s what I wanted to see in the MEDEX that evolved. It’s continued to this day, as PAs still are the most compassionate part of medicine.”
Smith saw this human dimension play out in other ways as well. When the MEDEX students entered their preceptorships, many rural communities embraced them with unexpected warmth. Patients who might have been expected to question their qualifications instead welcomed them as returning heroes, as extensions of the trusted local physician.
The human dimension of the MEDEX program—the relationships, the personal growth, the emotional support couldn’t be quantified in reports or measured in healthcare outcomes. Yet Dr. Smith increasingly recognized it as central to the program’s success and sustainability.
In one small town, the local newspaper ran a front-page story about their Medex, featuring a photo of him in his combat medic uniform alongside one in his new clinical role. The headline read: “From Battlefield to Main Street: Vietnam Veteran Brings Medical Skills Home.”
This is part of their healing too—transforming wartime trauma into civilian service, finding purpose in their skills outside the context of destruction, Smith thought.
Smith was particularly moved by the story of one Medex who discovered that a patient had been in the same firefight in Vietnam where the Medex had treated wounded soldiers. The patient had never received proper follow-up care for his injuries, carrying shrapnel and suffering chronic pain for years. The Medex was able not only to arrange appropriate treatment but to provide a kind of emotional closure for both of them—a circle completed via the longest route possible, from battlefield to his hometown clinic.
These human connections extended to the team itself. The MEDEX staff worked long hours together, celebrated milestones, weathered setbacks, and gradually formed bonds that transcend professional collaboration. It was not uncommon for staff meetings to include personal updates, shared meals, and genuine concern for each other’s wellbeing.
Two romantic relationships even formed within the original staff: Bill Freeman and Carolyn Robbins eventually wed, as did Dr. Smith and Lorna Carrier in 1976.
The human dimension of the MEDEX program—the relationships, the personal growth, the emotional support couldn’t be quantified in reports or measured in healthcare outcomes. Yet Dr. Smith increasingly recognized it as central to the program’s success and sustainability.
As the program grew, Smith recognized the need for strategic media outreach to build awareness and support across the country.
Some of this media attention came knocking on his door in the form of national television and news magazine outlets. NBC News correspondent Don Oliver called him saying, “We’ve heard about this program called MEDEX. We’re coming up to do a story.”
“Are you asking me or telling me?” Smith later recalled responding. “First, I didn’t trust them and, second, I thought it was too early. We were still trying to gain acceptance.”
But by the time the Class 1 students were placed with their preceptor physicians, the media could not be held back. In 1970, lengthy stories about MEDEX appeared on the NBC and CBS Evening News broadcasts.
Feature magazine stories in Parade, Time and Life Magazine followed. The news angle Smith and the MEDEX team pitched, and that the reporters picked up on in return was this: here is a solution to the crisis in healthcare facing our rural communities. The coverage was exceptionally positive and receptive.
By 1971, Smith had fully embraced the power of media to tell the MEDEX story and decided to take the narrative reins by producing a documentary film about MEDEX: “MEDEX: The Program and the Person.” The film captured the early success stories and explained the concept to the broader public and medical community.
It opened with a stark assessment of the healthcare crisis:
“There is a health crisis here, but it may not be visible…one out of 50 Americans have no access whatsoever to a doctor, none at all. For others, the distance to the nearest doctor is very great or difficult. For still others, because physicians have such heavy caseloads and for other reasons, getting medical attention is often a discouraging process.”
The film showed MEDEX-trained practitioners at work in various settings—rural, suburban, and urban—demonstrating the flexibility and effectiveness of the model. It captured testimonials from physicians whose practices had been transformed by their MEDEX partners.
“The MEDEX program has done several things for us,” explained Dr. Kenneth Pershall, one of the original preceptors. “We had a very busy practice, and our practice is busier today than it was previously. It enables either Dr. Bunch or I to be home in the evenings, where previously we were not.”
In White Salmon, Washington, Dr. Wayne Hickel, who had been in practice for 27 years and had been planning to leave, shared how the presence of a Medex had renewed his commitment to the community: “There is no question in my mind that participation in this program has been of considerable benefit to me personally—more free time, more time with my family, recreation.”
The film also highlighted one of Smith’s key innovations: the blue coats worn by MEDEX practitioners. “The distinct identity is furthered by the blue coats that Medex wear so that they are not confused either in the medical school setting or out in practice with physicians who usually wear white,” the narrator, Smith, explained. “In addition, the word ‘medex’ like ‘doctor’ is a form of address as well as a title.”
By the time the film was produced, Smith could proudly report that “at present there are more than 200 MEDEX working in 27 states. Four more medical schools are planning MEDEX programs, and it’s anticipated that soon there will be at least 10 medical schools training MEDEX for 30 to 40 states.”
The film ended with a powerful vision statement: “What you have seen has been an approach by the medical profession to provide the leadership and direction in bringing about change that we feel is inevitable in our healthcare system. The MEDEX method of training and deploying appropriate health manpower can be adapted according to needs and resources into many geographic and socioeconomic settings.”
The film became a key tool in Smith’s outreach to medical schools, state medical associations, and rural healthcare communities considering the MEDEX model. Overall, Smith’s media strategy proved highly effective, helping to build nationwide acceptance of the MEDEX concept and inspiring similar programs across the country.
Richard Smith knew that power in Washington, D.C. didn’t always work the way people assumed. It wasn’t always about grand announcements or official endorsements—it was about knowing who to call, when to listen, and how to keep an idea alive long enough for the right people to take interest. By the time he began shaping MEDEX, he had spent years in government and understood how influence moved behind the scenes.
By the late 1960s, Smith had built a network of policymakers, health officials, and behind-the-scenes strategists who were beginning to see the potential of his vision. Some had been skeptical at first, but Smith had a way of making them understand.
The World Health Assembly in Geneva had been a turning point. What had started as an intense diplomatic immersion had become a proving ground—a place where relationships turned into alliances, where quiet conversations over coffee set the stage for real change. Gerald Dorman, a trustee of the American Medical Association who would later become its president, had been one of those figures. While the AMA had long resisted the idea of non-physician providers, Dorman wasn’t dismissive. Over dinner at a restaurant on Lake Geneva, he had given Smith a quiet but powerful offer:
“Because of my position, I can’t give you direct help with the development of the non-physician provider movement. However, I can keep you posted on who’s going to be driving the trucks that are going to be trying to run you over.”
Smith didn’t need public support—he needed time, and he needed to see the roadblocks coming before they hit. Dorman gave him both.
Back in the U.S., Smith was also developing connections with key government figures who could provide critical support. Dr. William Stewart, the Surgeon General, had encouraged Smith’s vision after visiting Southeast Asia and seeing the desperate need for healthcare workers.
Congressman Neil Smith of Iowa, who headed Health Appropriations, engaged in long conversations about healthcare funding, seeing the potential for physician assistants to expand access to care in rural America. Melvin Laird, then head of House Appropriations before becoming Secretary of Defense, initially thought Smith was “crazy” but quickly recognized that the concept “had to happen.” Even Jim Cain, President Johnson’s personal physician, became an important ally, offering a direct line to White House support when needed.
Malcolm Merrill, president of the American Public Health Association, recognized the urgency of the problem before most others did. “You’re onto something,” Merrill murmured during a debate on rural healthcare delivery. “Keep at it. We’ll need this sooner than anyone realizes.”
These weren’t public endorsements. No one stood in front of cameras shaking hands. But Smith understood that the real work of developing MEDEX would happen behind closed doors, in quiet phone calls, in committee meetings where names were dropped in the right moments.
Not all of Smith’s allies were in Washington D.C. Some were physicians who had been experimenting with new ways to structure medical practice long before MEDEX. One of the most important was Dr. Amos Johnson, President of the American Academy of General Practice (now the American Academy of Family Physicians) and a small-town doctor in Garland, North Carolina. Johnson had spent years training his assistant, Henry Lee “Buddy” Treadwell, to handle much of his patient care. This was exactly what Smith was proposing, except on a national scale.
Johnson saw the fight coming before Smith did. The medical establishment wasn’t going to let this happen without resistance. So, for two years, on the first Wednesday of every month, Smith’s phone would ring.
“Hey doc, how’s it goin’?” Johnson would say in his deep Southern drawl. “Who’s trying to shoot you down?”
Johnson helped Smith navigate the politics of organized medicine. He made sure that MEDEX wasn’t positioned as a threat, but as an answer to an already broken system. More importantly, he offered Smith a way to take the fight to the medical associations directly.
One day, Johnson made a simple but powerful offer: he would arrange a private meeting between Smith and the executive directors of every state medical association in the country.
Smith hesitated.
Am I in over my head?
He picked up the phone and called Gerald Dorman, the AMA insider who had been feeding him intelligence.
“No,” Dorman told him. “The time is right.”
Smith flew to New York, where the meeting was set to take place. Inside, he stood before the state medical association directors and made his case. He expected pushback. Instead, the questions came fast, practical, and specific.
Could these providers handle hospital rounds? What about liability? Would they be supervised?
Smith answered what he could. and when he couldn’t, the directors answered for him. They were already thinking through how this could work.
It was a turning point. The AMA had not officially endorsed MEDEX, but they had begun to accept that it wasn’t going away.
The men who helped MEDEX weren’t all public champions of the program. Some, like Johnson and Howard, were open about their support. Others, like Dorman, worked quietly to ensure that the program had the time, funding, and legitimacy it needed to survive.
Smith and Dr. Robert Howard, who had taken over Duke’s physician assistant program after Dr. Eugene Stead, began communicating regularly around 1970. They recognized that although their programs had different approaches, they were working toward the same goal of expanding healthcare access. Howard helped align MEDEX with broader physician assistant efforts, ensuring that both programs gained legitimacy as national initiatives. While Stead had pioneered the PA model at Duke, it was Howard who actively engaged with Smith, sharing insights and discussing strategy as MEDEX took shape.
“With the right people in the right places, MEDEX had more than just momentum,” Smith later reflected. “It had protection, advocacy, and legitimacy. Without this network, it would never have gotten off the ground.”
The first MEDEX class hadn’t even begun training before the groundwork had been laid down. The allies that Smith cultivated—sometimes formally, sometimes in passing conversations—became just as critical as the policies and funding that followed.
It’s important to recognize that MEDEX wasn’t an accident. It wasn’t just a bold idea. It was a carefully built machine, powered by the right people in the right places, all working toward the same goal, whether they admitted it publicly or not.
By 1971, the MEDEX model had proven its worth in Washington State, but Richard Smith knew that its long-term impact would be limited if it remained confined to one region. Expanding the program nationally would demonstrate its adaptability and cement its place in the broader healthcare system.
At a staff meeting in the spring of 1971, Smith leaned against his desk, arms crossed, listening as his team discussed the latest physician feedback and student placements. The reports were promising, but he was not satisfied.
“If we stay in Washington, we’ll be dismissed as a regional experiment,” he said, his voice measured but firm. “We need national credibility. That means proving MEDEX works in every kind of setting—big cities, rural farming communities, the Deep South, and the Midwest. We need a program in each time zone.”
He unfolded a map of the United States across the conference table, pointing to regions across the country. “We should think beyond geographic diversity. This is about showing that the model works everywhere, under different state laws, with different healthcare challenges.”
Smith’s vision crystallized into what he called the “Council of MEDEX Programs”—a national network that would demonstrate the model’s versatility while maintaining consistent training standards. He was strategic in his approach, focusing not just on locations but on the right institutional partners and regional leaders who could champion MEDEX in their communities.
Through his network of connections from the Public Health Service and the World Health Organization, Smith identified key allies at institutions across the country. Each was selected not just for their location, but for their commitment and influence.
Dr. Bella Strauss at Dartmouth College became the first expansion target, bringing MEDEX to New England. The rugged, independent character of New Hampshire provided the perfect testing ground for a program that emphasized self-reliance and practical skill.
Next came Dr. Bob Eelkema at the University of North Dakota, whose remote rural communities faced some of the most severe physician shortages in the nation. Winter blizzards could isolate towns for days or weeks, making healthcare access literally a matter of life and death. If MEDEX could succeed there, it could succeed anywhere.
In the South, Dr. Cleve Hudson in South Carolina embraced the model enthusiastically. Southern states had some of the worst physician-to-population ratios in the country, particularly in African American communities. Hudson saw MEDEX as a way to address long-standing healthcare inequities.
Smith was particularly determined to establish a program at his alma mater, Howard University in Washington, D.C. When initial overtures met resistance, Smith leveraged his personal connection with the university president, James E. Cheek. As Smith later recalled, “I couldn’t talk them into doing this. I said essentially, ‘I’m sitting on all of this money.’ Cheek was a friend and he picked up the phone and called the Medical School Dean and we moved ahead.” This connection to the historically Black institution was especially meaningful to Smith, as it furthered his commitment to expanding healthcare access to underserved communities.
By 1972, with programs established in each time zone, Smith had created what he described as an “overground movement,” which was a fully legitimate, widely recognized model for extending healthcare that was gaining acceptance across the country.
The University of Utah program expanded MEDEX’s reach into the Mountain West, while a joint program between UCLA and Charles R. Drew Postgraduate Medical School brought the model to South-Central Los Angeles, addressing urban healthcare needs that were just as critical as rural ones.
A town meeting held in South-Central Los Angeles revealed the complexity of expanding into urban minority communities. When Smith presented the MEDEX concept, he faced immediate skepticism.
“What do you mean trying to sell us on second-class medicine?” one community member challenged. “You ought to be ashamed of yourself.”
Smith had anticipated this resistance. He had brought Steven Turnipseed, the African American MEDEX graduate from his first class, who spoke for twenty minutes about his work at Group Health Cooperative in Seattle. Turnipseed’s eloquent testimony transformed the mood of the meeting.
“We want MEDEX!” declared those gathered.
These strategic expansions weren’t just about geographical coverage. Each new program strengthened the legitimacy of the MEDEX approach and created a network of advocates who could defend it against criticism and regulatory challenges.
As news of these successful implementations spread, MEDEX gained increasing visibility and credibility in healthcare and policy circles. By 1972, with programs established in each time zone, Smith had created what he described as an “overground movement,” which was a fully legitimate, widely recognized model for extending healthcare that was gaining acceptance across the country.
The Council of MEDEX Programs met regularly by conference call, sharing strategies, solving common problems, and coordinating their approach to state legislation and medical practice regulations. This unified front was crucial when facing challenges from regulatory bodies or competing professional interests.
For instance, when Smith learned that the Senate Finance Committee was preparing to discuss Medicare reimbursement for physician assistants—an issue he believed was premature and potentially damaging if rejected—he quickly organized a conference call among all MEDEX programs. Their coordinated response successfully removed the item from the committee’s agenda, preventing what could have been a premature rejection that might have set the profession back by decades.
Through this national expansion, MEDEX transformed from a single university program into a movement that was reshaping American healthcare delivery. More importantly, it demonstrated that the innovative approach Smith had developed in Washington State could be successfully replicated and adapted to meet the needs of diverse communities across the United States.
The rapid expansion of MEDEX demanded an increasingly grueling schedule from Dr. Smith. By early 1972, his life had become a blur of constant motion—flying between Seattle and the growing network of programs across the country, meeting with state medical associations, addressing physician groups, testifying before state legislators, and mentoring new program directors.
A typical week might include meetings in Seattle, presentations at Dartmouth, discussions with medical societies in North Dakota, meetings with government agencies in Washington D.C., and administrative work back in Seattle – all with minimal rest between engagements. The pace was relentless, fueled by dedication to his vision and the growing evidence that MEDEX was transforming healthcare access nationwide.
By 1972, this constant travel and stress were taking a visible toll on Smith’s health. He began experiencing chest pains with alarming frequency—a symptom he recognized all too well. “Men in my family apparently have a genetic predisposition to early deaths due to cardiovascular disease,” he would later write. “My father died suddenly at age 32, probably from a heart attack. At 35, I began experiencing high blood pressure and increasing episodes of chest pain.”
This health crisis coincided with a period of immense personal challenges. Smith’s brother Julius had died of a stroke at 45 earlier that year. His 72-year-old mother Mabel had passed away from colon cancer complicated by heart problems. His marriage was ending. According to the Holmes Stress Chart, which predicts the impact of life events, Smith was “off the high end,” facing multiple major life changes simultaneously.
The breaking point came one Saturday morning in 1972. Smith was seated with his family at their breakfast table, which overlooked the placid waters of Lake Washington. Suddenly, he felt a crushing pain in his chest radiating down his left arm. He lost consciousness briefly, falling from his chair to the floor. The medical evaluation that followed was sobering: two cardiologists and a psychiatrist diagnosed Smith with stress-related angina and delivered a stark warning: he would need to dramatically change his life if he wanted “to stick around for a few more years.”
This health crisis forced Smith to reflect not only on his personal wellbeing but also on his role within the MEDEX program. During one of his many flights between program sites, as he stared out the airplane window at the patchwork landscape below, a reassuring realization came to him.
My role is changing. I’m no longer the one driving every decision, solving every problem. The system is beginning to sustain itself.
The program no longer needed his daily involvement. It had developed its own momentum, its own advocates and leaders.
This recognition was reinforced by an evaluation Ray Vath had written early in the program’s development. “All of us were innovators,” Vath noted. “We love the challenge of creating, but not one of us likes to manage. That’s the difference between a pioneer and a settler.”
By 1972, about four years into the program, Smith recognized it was time for a transition. “I’m a pioneer, not a settler,” he explained to Dean Hogness during a meeting in the dean’s office. “My strengths lie in creating systems, developing frameworks, and launching initiatives. Others are better suited to manage and grow established programs.”
“What are you thinking?” Hogness asked, disappointed but not surprised. “Who will replace you?”
“David Lawrence,” Smith replied without hesitation. “He’s a Robert Wood Johnson Scholar here, he understands the vision, and he has the management skills to take MEDEX to the next level.”
At the same time, Smith was contemplating new frontiers—international opportunities to extend the MEDEX model globally. As if on cue, a timely invitation arrived. Tony Kunimura, a state legislator from Kauai, invited him to launch a MEDEX program in Hawaii.
This opportunity resonated with Smith’s lifelong ambition – one that had begun forming during his transformative experience in Cuba as a 17-year-old in 1951, crystallized during his Peace Corps service in Nigeria in the early 1960s, and gained strategic clarity during his time at the World Health Assembly in 1967. His vision had always been to establish a model that could multiply healthcare capacity globally, addressing workforce shortages in underserved communities worldwide. Even his earliest proposal to the Episcopal Church, which had been rejected years earlier, outlined this international focus. Hawaii now offered the perfect gateway to finally realize this global dimension of his vision.
The catalyst that truly set Smith’s international vision in motion had come a bit earlier, in August of 1971, when Dr. Gnas Kansou, the health officer of Truk in the Eastern Carolines of Micronesia, arrived in Seattle seeking help to strengthen medical care in his Western Pacific island communities. Dr. Kansou was referred to MEDEX Northwest by the University of Hawaii, where he was finishing a post-graduate degree in public health.
I can’t imagine a clearer sign, Smith thought. I couldn’t have asked for a better opening.
With MEDEX Northwest now established at the University of Washington and programs successfully implemented across nine other universities nationally, Smith saw this as the perfect opportunity to take his vision to the international stage. With arrangements made to transfer his assignment with the Public Health Service, and the Seattle team in solid hands under Lawrence’s leadership, Smith relocated to Hawaii in 1972.
Hawaii would prove to be the ideal strategic launchpad for Smith’s global vision for several key reasons. Its location—2,000 miles from the mainland yet positioned as America’s gateway to Asia and the Pacific—made it an excellent base for international health work. Its proximity to developing nations in the Pacific, coupled with the connections Smith had forged at the World Health Assembly, positioned him perfectly to expand MEDEX beyond American borders.
The Hawaiian Islands also offered Smith a healing environment that his physicians had insisted he needed. “Honolulu is the runningest city in America,” Smith later noted, describing how he embraced the active, outdoor lifestyle by taking up jogging and making dietary changes that would help manage his heart condition.
Perhaps most crucially, Hawaii held significant political clout in Washington, D.C. Senator Daniel Inouye, chairman of the Senate Foreign Appropriations Committee, would secure a total of $31 million over the 21-year span of MEDEX’s international expansion.
“Senator Inouye was the chair of foreign appropriations. His assistant was Chief Richard Collins,” Smith later explained. “The reason I came here was because I knew we could get money into the University of Hawaii.”
Smith also recognized that Hawaii’s multicultural atmosphere would resonate better with foreign visitors than mainland locations. “I knew that I could get Ministers of Health to come to Hawaii and give me large amounts of time based on the possibility of a trip to Hawaii,” he said with characteristic candor.
Once settled in Hawaii, however, Smith quickly encountered an unexpected obstacle. He realized almost immediately that launching a MEDEX program in Hawaii would face significant resistance from the established medical community.
“Within three months, I realized that that would be political suicide,” Smith later recalled. “There was no way we could ever start a MEDEX program in Hawaii. The doctors were too threatened financially.”
This setback, though challenging, did not deter him. Instead, it propelled him to shift his focus to Micronesia, where he had already laid groundwork with Dr. Kansou in August 1971. “I took him around the State of Washington and showed him what our Medex were doing and he was turned on,” Smith remembered. “So when I arrived [in Hawaii], Ngas and I had already begun the groundwork for MEDEX in Micronesia.”
The transition to Hawaii marked an inflection point in both Smith’s health and the MEDEX program. With David Lawrence appointed as the new Director of MEDEX Northwest, Smith could direct his energies toward the international expansion of the program while following a regimen that would preserve his health.
For Smith, this personal health crisis reinforced the importance of balance. It was a lesson that would inform his approach to healthcare work for decades to come. As he recovered his health, he also found ways to nurture his creative side, developing what he playfully called his “chocolate mousse hunting adventures,” pursuing the perfect chocolate mousse dessert in restaurants around the world.
The transition ultimately proved successful both professionally and personally. Smith’s health improved significantly, and his new team, the internationally focused MEDEX Group, would go on to establish programs in Micronesia, Lesotho, Thailand, Guyana, Botswana, Pakistan, and numerous other countries.
From his base in Hawaii, Smith was able to magnify the impact of his original vision far beyond what he might have achieved had he remained in Seattle. As MEDEX had evolved from a regional experiment to a national movement, it was now poised to become an international model with far-reaching impact. Through Smith’s unwavering commitment to his vision—even when it required personal sacrifice and transformation—the program that began in Washington State would eventually help train healthcare providers serving millions of patients around the world.
