{"id":9612,"date":"2016-10-31T11:22:42","date_gmt":"2016-10-31T18:22:42","guid":{"rendered":"http:\/\/depts.washington.edu\/medex\/?p=9612"},"modified":"2022-03-18T23:16:16","modified_gmt":"2022-03-18T23:16:16","slug":"medex-founder-dr-richard-smith-multiply-my-hands","status":"publish","type":"post","link":"https:\/\/familymedicine.uw.edu\/test\/medex-founder-dr-richard-smith-multiply-my-hands\/","title":{"rendered":"MEDEX Founder Dr. Richard Smith: Multiply My Hands"},"content":{"rendered":"\n

The following story is based on multiple interviews with, and recorded presentations by, Dr. Richard Smith, along with numerous interviews with colleagues, contemporaries and participants from the period of time being covered, as well as rigorous research into secondary news reports, professional publications, and archival resources.<\/span><\/em><\/p>\nR<\/span>ichard Smith, a young and deeply curious<\/span><\/strong> Howard University freshman, stood and observed a community health worker making her rounds. The year was 1951. The place, a community health clinic located in a Methodist missionary work camp in pre-Castro Cuba. Though Smith was no stranger to the economic struggles and ongoing racial discrimination that marked life for African-Americans in post-WWII United States, nothing could have prepared him for the degree of poverty and hardship that he witnessed there in the Cuban countryside.\n\nSmith watched a small child with no diaper crawl across the rough clinic floor, sick with diarrhea. As the child moved, a large tapeworm emerged. Focused and full of questions, he watched the young community health worker tend to this infant, and then to the many other sick people in the clinic that day. What was the extent of her medical training? Less than a year of training, probably two or three months. Were there doctors available? Yes, though their numbers were limited. He knew that a doctor dropped into this clinic one, maybe two days a week, when possible. Otherwise it was this young woman, this one health care provider, who would care for those filing into the clinic, day in, day out.\n\n[smartslider3 slider=78]\n\nWhat if there were others like her? Smith wondered. What if the answer to improved healthcare lay not simply in having more doctors, but in increasing the number of mid-level healthcare providers like this one? In multiplying her caring, skilled hands?\n\nMany years later, it was this volunteer trip to Cuba that would stand out in Richard Smith\u2019s mind not simply as a formative experience, but as the very moment that his long and illustrious career as a progressive healthcare visionary began. He returned from Cuba to Washington DC, and dropped his music major in favor of pre-med studies. His primary focus became parasitology. He entered the Howard University Medical School, and became renown for his expertise on mosquito and parasitic-born illness. His efforts came to the attention of the National Institute of Health, and Smith became the first medical student in the Public Health Service to become a Commissioned Officer. In 1957 Smith received his M.D. from Howard University.\n\nThe career of Dr. Richard Smith was underway, a career that would lead him down many paths and to many places, including Seattle, of course. But the memory of that small Cuban health clinic would never be left behind.\n\nA Vision for Training People<\/strong><\/span>\n\nBecoming a physician in the U.S. of the 1950s was a pathway to an affluent life. But Richard Smith\u2019s interests lay elsewhere, and he deliberately sought out placements working with underserved populations. For years, Smith believed his goals could best be accomplished by working through The Episcopal Church, the church in which he had been raised. But he soon came to realize that the model on which the Episcopal Church\u2019s missionary work was structured \u2013 doctors placed into communities to establish and oversee health clinics \u2013 was in many ways just the opposite of the vision he was developing based on the idea of \u201cmultiplying hands,\u201d or what he began to call the \u201cmultiplier effect.\u201d\n\n\u201cI did not want to be running a clinic,\u201d Smith says. \u201cI wanted to train people.\u201d\n

\u201cI did not want to be running a clinic,\u201d Smith says. \u201cI wanted to train people.\u201d<\/blockquote>\nIn 1961, Smith turned to John Burgess, then the first African-American archdeacon of the Episcopal Diocese of Massachusetts, and asked him to carry a proposal to the World Council of Churches (WCC) being held in New Delhi that year. \u201cWhat I was trying to say is that you can\u2019t do anything with one person,\u201d recounts Smith. \u201cThe multiplier effect had to be put into place. It was a full-scale public health approach\u2014not just a medical approach.\u201d\n\nArchdeacon Burgess was a supporter of Smith\u2019s approach. Ultimately, however, the WCC turned down the proposal.\n\nPeace Corps Experience<\/strong><\/span>\n\nA new direction came when the Public Health Service took charge of health care for Peace Corps volunteers. In 1961, Dr. Smith was invited to D.C. for a visit with Robert Sargent Shriver, the Kennedy administration\u2019s driving force behind the creation of the Peace Corps. An international incident involving the Peace Corps had arisen, and Shriver saw in Richard Smith someone who could manage the situation. \u201cWe need you in Nigeria,\u201d Shriver told him.\n\n
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The postcard that set off the Nigerian protests against the Peace Corps. Click to enlarge.<\/figcaption><\/figure>\n\nThe Nigerian situation was complex\u2014politically and medically. An American Peace Corps volunteer in training had written a postcard to a friend back home that noted the country\u2019s \u201csqualor and absolutely primitive living conditions.\u201d Before the postcard was mailed, however, it was discovered by a Nigerian student, who was offended by its contents and preceded to distribute copies of it all over campus. Crowds gathered. Riots ensued.\n\nInto this scenario stepped Dr. Smith as a Peace Corps physician in Nigeria. Smith\u2019s primary assignment was to assure the care and safety of Peace Corps volunteers. His rounds took him from community to community, which were sometimes 200 to 300 miles apart. His medical counsel became gospel to volunteers living in areas afflicted with unfamiliar diseases.\n\n
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Richard Smith in the Peace Corps, 1961<\/figcaption><\/figure>\n\nBut Smith also provided care to the Nigerian locals in several mission hospitals. It\u2019s in that capacity that he trained \u201cdressers\u201d\u2014 people who were charged with changing dressings.\n\n\u201cI volunteered my time to train these folks in the bush\u2014not in urban centers\u2014but in rural missionary hospitals,\u201d says Smith. \u201cIn each of those settings, I selected two people that seemed brighter than most. They just responded to me, and had enough English to operate. I trained them how to identify and treat two things\u2014malaria and fever. They had to know how to listen to chest sounds.\u201d These individuals were subsequently trained to treat diarrhea, dysentery, worms and malnutrition. Enough, that is, to cover 90% of Nigeria\u2019s most common medical needs.\n\nAfter a very short period of time, it became obvious to Smith that these former \u201cdressers\u201d were now taking care of most of the patients. With the memory of the WCC turning down his proposal still fresh in his mind, \u201cI knew I was on the right path,\u201d says Smith.\n\nAt the end of two years in Nigeria, Dr. Smith returned to the US in 1963, and was appointed to the position of Deputy Director of the Medical Program Division of the Peace Corps, with responsibilities for assisting in directing the health programs of more than 8,000 Peace Corps volunteers serving in forty-six countries.\n\nThe Beginning Ideas of MEDEX Emerge<\/strong><\/span>\n\n
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Smith at the WHO Assembly in 1967<\/figcaption><\/figure>\n\nIn 1965, at the conclusion of his time with the Peace Corps, Richard Smith was asked by Dr. William H. Stewart\u2014the 10th<\/sup> Surgeon General of the U.S.\u2014to join his staff as the Director of the Office of Planning for International Health. Smith took the job, which included his becoming a US delegate, the youngest ever, to the World Health Organization (WHO) Assembly in Geneva.\n\nOnce there, Smith made it a point to identify the Assembly\u2019s key players, a habit that would continue to serve him over the years. Here they included Melvin Laird, then head of the House Appropriations Committee, Lyndon Johnson\u2019s personal physician Jim Cain, MD, and Gerald Dohrman, who later became President of the American Medical Association (AMA) from 1969-1970.\n\n
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Smith’s boss at this time was Dr. William H. Stewart\u2014the 10th Surgeon General of the U.S.<\/figcaption><\/figure>\n\nIn the meantime, Smith\u2019s boss Dr. Stewart visited Southeast Asia with Eugene Black, Special Adviser to the President on Southeast Asian Social and Economic Development. The message they returned with was \u201cWe need doctors.\u201d Propelled in large part by the intention of winning over the hearts and minds of the local populations of the region through improved access to healthcare, Bill Stewart returned to the US, walked into Smith\u2019s office, and said, \u201cYou know this crazy idea you have about physician extenders? I think we can put this together.\u201d\n\nThe term \u201cphysician extenders\u201d had become increasingly common in discussions of doctor shortages. Its meaning is mostly self-evident: personnel with less sophisticated but nevertheless skilled training could provide needed healthcare services where physicians weren\u2019t available. For Smith, the concept of physician extenders aligned with his earlier experiences in Cuba and Nigeria, and echoed his own developing ideas on the matter.\n\nStewart presented Smith\u2019s ideas to area officials. \u201cThey thought it was a good idea,\u201d recalls Smith, \u201cand wanted to know why we weren\u2019t doing it in the US.\u201d Their question caught Dr. Smith\u2019s attention. Up to that point, he had envisioned the use of community health workers mostly as a solution in international<\/em> settings. But now he began to wonder, why in fact weren\u2019t <\/em>we doing it in the US?\n\n
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Feldsher collage courtesy of PA History Society<\/figcaption><\/figure>\n\nDuring his tenure with the World Health Organization, Smith had also become familiar with something known as the \u201cFeldsher system\u201d that had emerged from the Soviet Union, with roots reaching as far back as the time of Peter the Great. Fundamentally, Feldshers were mid-level medical practitioners used by the military to provide healthcare to wounded soldiers and civilian populations across the Soviet Union.\n\nThe notion of applying the Feldsher idea to problems being faced by the United States\u2014problems tied primarily to considerable gaps in healthcare access, especially in rural areas\u2014was not lost on Richard Smith. “What I had to figure out was how to do it outside of the Soviet Union,” he said.\n\nThe seeds of what would become MEDEX were sown. But there was another significant career milestone for Smith before the concept could be fully realized in the US.\n\nDesegregating the Nation\u2019s Hospitals<\/strong><\/span>\n\nWhile working for the US Public Health Service in 1966, Dr. Smith was assigned as Director of Operations for the desegregation all hospitals in the United States. Desegregation was a required component of the implementation of the newly created Medicare program. In February of that year, the Surgeon General created the Office of Equal Health Opportunity (OEHO) as the agency specifically responsible for certifying that hospitals wishing to become Medicare providers were in compliance with Title VI of the Civil Rights Act.\n\n
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Smith at the far right while on the staff of the 10th Surgeon General of the U.S., Dr. William H. Stewart. Dr. Stewart, who assigned Smith as Director of Operations for desegregation of all US hospitals, is seated centermost.<\/figcaption><\/figure>\n\nThe nation\u2019s hospitals would have to be certified compliant by July 1966, in less than six months time. This meant that minority patients could no longer be denied access to any service provided by the hospital, or to any part of the hospital. Patient rooms, cafeterias, rest rooms, and even the blood supply had to be integrated. Qualified minority physicians, minority residents, nurses and medical technicians could no longer be denied opportunities. \u201cWe had less than one year to desegregate thousands of hospitals,\u201d says Smith. \u201cIt was the fastest thing I\u2019ve ever seen. We didn\u2019t have much time.\u201d\n\n
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Prior to the national desegregation of hospitals, whites and blacks had separate entrances, waiting rooms, care wards and blood supplies.<\/figcaption><\/figure>\n\nThe authors of Medicaire and Medicaid at 50: America\u2019s Entitlement Programs in the Age of Affordable Care<\/em>, take Smith\u2019s description a step further, calling it \u201cthe highest-stakes poker game in the history of federal domestic policy.\u201d\n\n\u201cOn March 4, 1966,\u201d they write, \u201cevery hospital in the country received a letter over the Surgeon General\u2019s signature describing the guidelines for compliance.\u201d The letter further required hospital administrators to sign and return assurance forms in a week\u2019s time, and detailed upcoming compliance visits. \u201cRepresentatives of the Department of Health, Education and Welfare will be visiting hospitals on a routine periodic basis to supplement this information and be able to offer further assistance in resolving any problems that may arise.\u201d\n\nAbout 1,000 volunteers were transferred to HEW in support of this effort, and Dr. Richard Smith was given jurisdiction over them. They did not, however, represent a random slice of HEW employees. \u201cMany were already involved with the civil rights movement and saw the temporary voluntary transfers as an opportunity to incorporate their activism into their day jobs. No one had to be drafted.\u201d\u2020 Training centers were established in Atlanta and Texas. Levels of volunteer training varied. Some attended hastily arranged two-day training sessions, while others learned the job on the fly.\n\nIn the midst of all this, Smith received a phone call from Vice President Hubert Humphrey, whom he had met previously at the White House Conference on Health in November of 1965.\n\n\u201cPresident Lyndon Johnson wants you to go to Marshall, Texas\u2014Ladybird\u2019s home town,\u201d Smith recalls Humphrey telling him. \u201cHe wants to send a message that he\u2019s deadly serious, and he wants the message to be loud and clear.\u201d So Richard Smith was sent to Texas as a walking message from the President that desegregation\u2019s time was now.\n\n
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President Lyndon Baines Johnson signed the Medicare bill into law on July 30, 1965. Desegregation of all hospitals was a required component of the Medicare implementation.<\/figcaption><\/figure>\n\nA Dangerous Time<\/strong><\/span>\n\n\u201cWhen I went to Marshall, I thought I was going to be killed,\u201d Smith recalls. And in fact it was a dangerous time. In the news was the story of a white female internist who had been reporting on the situation within the hospital during this time, and was assassinated in her Mobile, Alabama home.\n\nEveryone knew why Smith was there in Marshall. The Texas Rangers would not venture into the hospital. He met with the hospital\u2019s Board of Directors, who told him that they were not going to desegregate. \u201cYou\u2019ve just kissed $100 million bucks goodbye,\u201d was Smith\u2019s response. On Monday, Smith got a call from the Chairman of the hospital\u2019s Board of Trustees, who reported to him that they had hired a new administrator.\n\nSmith then received word that Lyndon Johnson was traveling to Baton Rouge the following Tuesday, and the request that the hospital there be desegregated by the time of the President\u2019s arrival. So he turned his attention to Baton Rouge. An administrator there told him, \u201cWe can\u2019t desegregate our hospital. Last year we tried to desegregate our community swimming pool, and they blew it up.\u201d Still, Smith pressed the issue.\n\n\u201cWho do you report to?\u201d the administrator asked.\n\n\u201cThe Surgeon General,\u201d Smith replied.\n\n\u201cAnd who does he report to?\u201d asked the administrator.\n\n\u201cThe President of the United States,\u201d said Smith.\n\nTwenty minutes later, the Baton Rouge hospital administrator called back and asked, \u201cOkay, what do we have to do to desegregate?\u201d\n
[smartslider3 slider=84]<\/div>\nDuring the desegregation assignment, the Surgeon General\u2019s office uncovered subterfuge at HEW\u2014the US Department of Health, Education and Welfare. There was tampering with the mainframe computers at HEW to get certain hospitals off the targeted list. \u201cThe government had to put one of their staff in there each night to stop this,\u201d says Smith.\n\nTo break the resistance, Surgeon General Bill Stewart prosecuted five hospitals. \u201cWe won these first five cases, and everything else collapsed after that,\u201d reports Smith. It was also necessary to close a number of black hospitals because they were segregated.\n\nOn reflection, Richard Smith views this desegregation experience as the source of enlightenment and encouragement that allowed him to moved forward with the burgeoning MEDEX concept. As Smith summarizes it, \u201cHere was an idea that took into consideration those for and those against, and how to change attitudes in order to move a social effort forward.\u201d\n\nThe MEDEX Vision Clarified<\/strong><\/span>\n\nAt the conclusion of the yearlong desegregation effort in 1966, Smith\u2019s job with the OEHO changed to more of a caretaker role\u2014something that didn\u2019t particularly engage him. He was instead becoming increasingly interested in putting his visions concerning expanded healthcare into action.\n\n
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Dr. Richard A. Smith<\/figcaption><\/figure>\n\n\u201cMy vision was clarified,\u201d says Smith. \u201cI kept going back to the way that change was affected during my early days in Cuba and Nigeria. They represented something for me. They represented possibilities. What I had been learning was the world in which these possibilities could occur. I was amazed at how clear it was, at what had to happen. And I was also afraid it was a dream I couldn\u2019t pull off.\u201d\n\nSmith knew he wanted to pursue this dream on the West Coast, but to do so from within the auspices of US Public Health. Bill Stewart gave his blessing, but with one catch: Smith could remain in the Public Health Service, but he would be put on leave without pay.\n\nStewart was getting a lot of flack from Congress concerning the Public Health Service\u2019s role in desegregating thousands of US hospitals, and in particular Smith\u2019s role in this as Director of Operations. \u201cHe found out that there was tremendous opposition to desegregating the hospitals, but he supported me thoroughly through all this,\u201d says Smith. \u201cWhen we had finished, he felt pressure from a lot of people on me. He said, \u2018It\u2019s better if you go.\u2019\u201d\n\nA Path For Medically Trained Military Personnel<\/strong><\/span>\n\n
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Dr. John R. Hogness, then the Dean of the UW Medical School<\/figcaption><\/figure>\n\nAlready familiar with the leadership at University of Washington in Seattle, Smith wanted to leverage that to develop a pathway for the vast numbers of medically trained military personnel to reenter civilian life with a qualified career as mid-level health practitioners. At that time the concept was discussed as “physician extenders,” perhaps to soften the blow to the established medical profession. Smith approached Dr. John Hogness, Dean the UW Medical School. “John Hogness thought it was a crazy idea,” Smith recalled, “but one that sounded intriguing to him.”\n\nUnbeknownst to Smith, a similar initiative had started two years earlier at Duke University in Durham, North Carolina. Dr. Eugene Stead, the Chair of the Duke Department of Medicine, launched the first physician assistant program to fill the gap between nurses and physicians. In 1967, Duke graduated its first three PAs from the fledgling program. \u201cIf I had known what Dr. Stead was doing, I would have gone down to see him,\u201d says Smith. Instead, Smith was getting input from the Surgeon General, AMA President Gerald D. Dorman, Ted Kennedy\u2019s medical advisor Dr. Lawrence C. Horowitz, and a host of Peace Corps docs that Smith had worked with over the years.\n\nDeputy Director<\/strong><\/span>\n\nDr. Gerry Bassett and Richard Smith had crossed paths when they were both commissioned officers with the US Public Health Service. Upon meeting again in 1969, Bassett was teaching and working in research at the UW School of Medicine in what would later become the Department of Public Health\u2014Preventive Medicine. He was also working part time as the Director of Environmental Health and Safety for the university.\n\n
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Dr. Gerry Bassett became the Deputy Director of MEDEX Northwest<\/figcaption><\/figure>\n\n\u201cDick showed up at the University of Washington,\u201d says Bassett. \u201cHe had this idea way back when, as he can tell you. He began to talk with me about what he had in mind.\u201d\n\nBasset had three years with the Navy as a Lieutenant JG (Junior Grade) on aircraft carriers in Korea. Grasping the value of Smith\u2019s concept wasn\u2019t a big leap. He understood the target audience for this program.\n\n\u201cThese are former military corpsmen, highly skilled and trained,\u201d says Bassett. \u201cWe\u2019re not talking entry level. We\u2019re looking to get people who already have training and experience to continue that in the civilian area. Really, there wasn\u2019t much for them except to go into academic programs for another one or two years or more. Mostly, these trained corpsmen had already been through a lot of that stuff. So we figured, why not capitalize that, and find out what they\u2019ve learned, what they can do, and put it to immediate use\u2014filling in the holes of what they don\u2019t know, what they hadn\u2019t done. That was the basis of it.\u201d\n\nGerry Bassett came aboard as the Deputy Director. \u201cI hired him to be in charge of the curriculum,\u201d says Smith. \u201cIt\u2019s got to be a competency-based curriculum,\u201d meaning that the students would have to be able to demonstrate their knowledge, both previously acquired as corpsmen and newly acquired through the program.\n
Then there came the question of what to call the program. Smith said to Basset, \u201cWell, don\u2019t you know, this is kind of an extension of medicine\u201d. Together, they kicked it around and, according to Bassett, Smith came up with the following wordplay. \u201cHere, how about this: extension of medicine, medical extension\u2026 MEDEX!\u201d<\/blockquote>\nThen there came the question of what to call the program. Smith said to Basset, \u201cWell, don\u2019t you know, this is kind of an extension of medicine\u201d. Together, they kicked it around and, according to Bassett, Smith came up with the following wordplay. \u201cHere, how about this: extension of medicine, medical extension\u2026 MEDEX!\u201d\n\nTogether, Smith and Bassett put together the idea of a core staff and began looking around for sources of funding.\n\nHiring Staff<\/strong><\/span>\n\nBy June 3rd<\/sup>, 1969, a small faculty and staff were hired for the federal demonstration project known as MEDEX Northwest. Offices were located just off-campus in the University District Building at the corner of NE 45th Street and 11th Avenue NE.\n\nThe very first staff hire was Carolyn Robbins and, a bit later, Lorna Carrier. \u201cLorna and Carolyn were key staff members,\u201d recalls Bassett. \u201cWe wouldn\u2019t have gone anywhere without them.\u201d\n\n
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Lorna Carrier in 1969<\/figcaption><\/figure>\n\nThere was a third administrative support person who didn\u2019t last long. \u201cI had a secretary, and she was overwhelmed,\u201d recounts Smith. \u201cThen this 21-year-old girl came into my office named Lorna. She came in, organized our office, and the 43-year-old woman who was overwhelmed, left.\u201d\n\nLorna recalls the accelerated stride during the initial years at MEDEX. \u201cIt was very exciting,\u201d she says. \u201cSome people who came to work for MEDEX left after the first day because they couldn\u2019t take the pace. We didn\u2019t have coffee breaks. We just rolled and really enjoyed it. It wasn\u2019t stressful, like we had to do it. We wanted<\/em> to be doing it. I think our enthusiasm would spread.\u201d\n\n\u201cThings were moving pretty fast at the time,\u201d adds Gerry Bassett.\n\nKey among the early MEDEX staff was Bill Freeman, who came to Smith\u2019s attention while at the Surgeon General\u2019s office. \u201cMy colleagues in the Peace Corps called me and said, \u2018There\u2019s a Green Beret corpsman here in our office. We think you should talk to him.\u2019\u201d\n\nAt first meeting, Smith describes Freeman as \u201cthis runt of a guy filled with knowledge and experience. His father had been a pathologist, and Bill had been in the Peace Corps in Columbia. He told me what he did on the battlefield\u2014suturing and transfusing people. Bill was<\/em> MEDEX. He told me, \u2018If you ever get this thing funded, I\u2019d like to work for you.\u2019\u201d\n\nAt the start of the project there was no funding, so Freeman agreed to come onto the MEDEX project for room and board. He moved in with Smith and his family. \u201cI was still a growing boy at age 26-27, and I nearly ate him out of house and home. Dick couldn\u2019t believe how much I ate.\u201d\n\nFreeman served in the Peace Corps from \u201862 to \u201864 in the city of Cartagena, Columbia doing community development work. Later, he joined the US Army Special Forces to go to Vietnam and work among the indigenous Hill Tribes. \u201cThis was a time of cold war Kennedy-style liberalism,\u201d says Freeman. \u201cHis two pet organizations were the Peace Corps and Special Forces.\u201d\n\nIn Vietnam, Freeman trained as a medic. The technical title was a Special Forces Aid Man\u2014an independent duty medic. \u201cI had a years training to function like a physician where there was none in a very resource-limited environment,\u201d he says.\n\nAt MEDEX Freeman was given the title Associate Director. He supplied the knowledge about what candidates could do, and therefore, what did not have to be taught. He also knew what was missing for these candidates to function in a similar situation but with a physician either out in the rural areas or the inner city. \u201cI participated in screening of possible applicants,\u201d says Freeman. \u201cBut my main job was to help develop a curriculum that relied on what they already knew, and taught them what they didn\u2019t know but was necessary for their setting.\u201d\n
[smartslider3 slider=79]<\/div>\nAnother essential addition to the staff was Carnick (Mark) Markarian (1925-2014) who served as Deputy Administrator. A sailor in WWII and Captain in the US Public Health Service, Markarian had trained pharmacist\u2019s mates and was experienced in administration and finance in Washington, DC. \u201cHe was an everyman in the grants and applications area,\u201d explains Bassett.\n\nDr. Raymond Vath completed the core staff. \u201cWe thought it would be reasonable to have a psychiatrist onboard to better understand how are potential candidates were put together,\u201d says Bassett.\n\nThe program recruited a couple of educators\u2014Gary Dunn and Bill Wilson. \u201cEdD educators, we\u2019re not talking PhD educators,\u201d explains Bassett. \u201cWe picked up these educators as we went along to get some input on how people learn, what teaching methods could be used. We didn\u2019t want to jump into a high-powered academic masters PhD, that kind of thing.\u201d\n\n\u201cThere were others that came in and out too, but those were key,\u201d says Bassett. \u201cWe had a marvelous group. It took a different mix of people\u2014people that could sit around, get ideas, and not worry about their egos being stepped on. Here are people who could concentrate on getting a job done without getting egos and personalities in the way. That\u2019s not easy. I\u2019m not sure we called ourselves that at the time, but we were doers. We were thinkers. We went from the thinking to the doing. Our staff meetings were free, open and rollicking.\u201d\n\nApparently the group was not in the habit of taking formal meeting notes. \u201cNever for a minute did it occur to us that people would be looking back at us,\u201d says Lorna. \u201cWe didn\u2019t document.\u201d\n\nAs a footnote, the tight intensity of this group of thinkers and doers had effects beyond the creation of a new medical profession: two enduring marriages came out of the birth of MEDEX. Bill Freeman and Carolyn Robbins eventually wed, as did Dick Smith and Lorna Carrier in 1976.\n\nEngaging the Support of Rural Communities<\/strong><\/span>\n\nFor funding, Smith applied for $700,000 from the RMP, Regional Medical Program. But there was resistance, or rather, a lack of understanding.\n\nSmith talked to the Washington State Medical Association, and they didn\u2019t know what to make of his MEDEX proposal. From his experiences with desegregation of the nation\u2019s hospitals, Smith knew that he had to sell his idea as the solution at the points of greatest fracture. He requested a list of the most overworked doctors in the state. These were all located in rural areas\u2014small towns in Eastern Washington like Tonasket, Odessa and Othello. Smith contacted these physicians, and arranged town hall meeting in their communities. \u201cI set my targets on the docs who needed help the most. This became the MO,\u201d he says. \u201cWe\u2019d go into a town where the doc was planning on leaving. The doc would stand up and say, \u2018I hadn\u2019t told you yet, but I was planning on calling a moving van.\u2019\u201d\n\nThe doctors delivered the message, and Smith would explain the scenario. The towns wanted to know what they could do.\n
\u201cI was flying by the seat of my pants,\u201d Smith says. \u201cWhen I stood up to lead these town meetings, it was really amazing. Most of them had never seen a black man.\u201d<\/blockquote>\n\u201cI was flying by the seat of my pants,\u201d Smith says. \u201cWhen I stood up to lead these town meetings, it was really amazing. Most of them had never seen a black man.\u201d\n\nSmith knew that he had to identify the people who were for and against the concept of outside help in the form of trained Medex, as they were called at the time.\n
[smartslider3 slider=83]<\/div>\n\u201cWhat we were after is a systems change,\u201d Smith says. \u201cThis whole idea is what became known as the receptive framework. What I wanted to do was to create an irresistible force such that, if you went against it, you\u2019d have to face the whole town. If you get people to invest in town hall meetings, and demonstrate how each of them benefits from what you\u2019re trying to pull off, you make them accountable. They will make it work.\u201d\n\nSmith had brought psychiatrist Dr. Ray Vath onto the MEDEX staff to help manage change.\n\nSpeaking of Dick Smith, Dr. Vath said, \u201cHere’s a guy who’s organized and understood the issues that need to be dealt with. He was very careful about information, who got what, where, when, and how. When you’re trying to get change, a lot of people are going to oppose us. He told me, \u2018That’s why you’re here, because we need psychiatrists here to overcome resistance to change.\u2019 That’s what psychiatrists do\u201d.\n\nVath recalls one pocket of potential resistance in Spokane, WA that they had to overcome.\n\n\u201cDick and I were presenting to the Spokane Medical Society,\u201d says Vath. \u201cAfter Dick’s presentation, a doctor got up and said, \u2018I think this is a communist plot and we need to squelch this immediately. It’s out to destroy the practice of medicine.\u2019\u201d\n\nDick turned to Ray Vath and asked, “What do we do?\u201d\n\nVath said to Dick, “Let me try.”\n\n
\"Dr.<\/a>
Dr. Raymond Vath<\/figcaption><\/figure>\n\nDr. Vath stood up. “You know, I have concerns too. I’m not sure if this is a good idea either. It’s too early to tell. But when it comes to loyal Americans, I just got out the military after ten years active duty and four years in the reserve. I don’t think my loyalty is going to be in question.\u201d\n\nVath continued to preempt the concerns of the doubter. \u201cLet me tell you, we need people like you to watch our program. And if you see us doing something dangerous to anybody, I want you to call me personally. Here\u2019s my card with my name and number. Because I can destroy this from the inside quicker than you can destroy it from the outside.” That man became a MEDEX supporter and the next president of the Spokane Medical Society. There was no resistance.\n\nIn every town there were a lot of questions, but there wasn\u2019t a single detractor. During the late 1960s, the doctor was the most powerful person in a small town. \u201cDoctors understand transformation and how to change the mindset of people,\u201d says Smith.\n\nEventually Dick Gorman, the Executive Director of the Washington State Medical Association, assigned one of his staff, Roth Kinney (1920-2006), to work directly with the MEDEX team. \u201cGorman knew these docs were in trouble,\u201d says Smith. \u201cThey were overwhelmed. He told me, \u2018You can sell them anything.\u2019\u201d\n\nAt the same time, Smith and his team were recruiting these same small town physicians to become preceptors\u2014to assume an active role in the MEDEX Northwest students\u2019 clinical education outside of the classroom. And part of the deal was that the preceptor\/physician would hire the student once they graduated. \u201cEvery Medex had a job before they were recruited,\u201d says Smith.\n\nThe Quest for Funding<\/strong><\/span>\n\nDespite this, funding remained out of reach. The Regional Medical Program (RMP) met to discuss Smith\u2019s $700,000 proposal request. Smith wasn\u2019t present for the RMP meeting where the MEDEX funding was discussed. Word got back to Smith on the controversy. One individual in the group said he \u201cdidn\u2019t want any black bastard getting his hands on this much federal funding\u201d. Two staff members resigned on the spot in protest.\n\nLater, these two staffers contacted Smith, and he went to lunch with them. \u201cThey were in tears because they saw the value of this program, and they were enthusiastic about it. I told them, \u2018We\u2019re going to get our money. Don\u2019t worry.\u2019\u201d\n\nThat night Smith called Surgeon General William Stewart, Joe English and Dr. Stan Shirer from HRSA (Health Resources and Services Administration). \u201cIt took exactly 30 minutes with Stan and Joe for me to get three quarters of a million dollars from HRSA. What sold them was the fact that we had done our early preparation.\u201d\n\nRecruitment Begins<\/strong><\/span>\n\nIn mid-1969 the MEDEX Northwest program was underway, and recruitment could begin.\n\nVisits were made to a number of Army, Navy, Air Force and Coast Guard installations to inform groups of corpsmen about the proposed project, and to elicit applications.\n\n\u201cWe tended to gravitate towards the Special Forces corpsmen because they had the best training and the most independent medical work, often behind enemy lines in the mountains of Vietnam,\u201d says Ray Vath.\n
[smartslider3 slider=81]<\/div>\nSmith traveled to a number of military training institutions, including Fort Bragg where they train Special Forces corpsman and the Naval Hospital in Bethesda. \u201cThe Special Forces corpsman and Navy Seals have this tremendous medical training, like 1800 hours of training,\u201d says Smith. \u201cAir Force corpsman and Navy corpsman also had tremendous training. That was going to be wasted in the civilian sector if something like this didn\u2019t happen.\u201d Word got out.\n\n80 applicants were screened, and 26 candidates were interviewed for the demonstration project. From that, fifteen students were selected to be part of MEDEX Northwest Class 1.\n\nOne of Smith\u2019s objectives was the underserved populations of the US, so he thought it was necessary to recruit from minority groups.\n\n\u201cIn that first group I wanted to find, at least, an Hispanic and a black,\u201d he says. This proved rather difficult because Medex was an untried profession. \u201cMost of the people I talked to were not interested in getting a job that wasn\u2019t going to be guaranteed.\u201d\n\nSteven Turnipseed, MEDEX Class 1<\/strong><\/span>\n\nSmith found his sole African American candidate working as a MTA at Leavenworth Federal Prison where he was treating life-term inmates. In the late 60s, an MTA or Medical Technical Assistant operated much like a physician assistant within the Federal Bureau of Prisons Health Department. Turnipseed was back in the States from 10 years in the US Army, his last duty assignment with the 1st<\/sup> Special Forces Group in counter-intelligence and psychological warfare in Northeast Thailand along the Cambodian and Laotian borders. Early in his military career, Turnipseed received advance training as a surgical tech, a radiological tech and, later, as a medic to accompany the Special Forces team.\n\n
\"turnipseed-ear-exam\"<\/a>
Steven Turnipseed of MEDEX Class 1<\/figcaption><\/figure>\n\n\u201cSomeone called me on a Sunday night,\u201d recalls Turnipseed. \u201cHe said, \u2018Hi, this is Dick Smith. \u201cI\u2019m really interested in you coming out and looking at this new program we have called MEDEX.\u2019 He tried to explain to me a little bit about the dynamics of what he was trying to do, where he was going.\u201d\n\nTurnipseed listened, took it all in and went back to his colleagues at the prison. \u201cThey all looked at me and said, \u2018Are you crazy? That will never fly. Once you get outside the prison where you have the protection of the Federal jurisdiction, there\u2019s nothing to cover you. No person\u2014no doctor, no nurse, no patient, would accept a Medex. You just can\u2019t do that. People don\u2019t want that.\u2019\u201d\n\n
\"Steve<\/a>
Steve Turnipseed’s MEDEX admissions photo from 1969<\/figcaption><\/figure>\n\nAfter three or four days of deliberation, Turnipseed made up his mind to apply to the MEDEX program. His coworkers at Leavenworth said, \u201cWell, okay Steve. We expect you back in about three months. You\u2019ve got a GS18, and that\u2019s pretty high. You just can\u2019t get out of this.\u201d\n\nIn Seattle, Turnipseed met Dr. Richard Smith in person. \u201cDick is a unique individual in himself because he was so passionate, and he was so knowledgeable. When he talked, things happened. People believed in him, and they followed him. He became my mentor. I followed him, and this is how we got to where we are today.\u201d\n\nSmith describes Turnipseed as \u201cone of the most wonderful human beings I know. He had incredible skills, both people skills and medical skills.\u201d Steve spoke fluent German and Spanish, despite the fact he didn\u2019t have a high school education. Later, Steven Turnipseed got his GED and received his bachelor\u2019s and a master\u2019s degree in Public Health.\n\nDuring the preceptorship phase of his MEDEX education, Steve was placed in an urban Seattle hospital setting\u2014Group Health Central on Capitol Hill. He worked there for a number of years, ran an outpatient clinic and developed a highly successful addiction treatment services program.\n\nIn 2006, Group Health created the Steven Turnipseed PA-C Award, an annual honor recognizing outstanding service among one of the 136+ individual PAs currently working at Group Health.\n\nJohn Betz, MEDEX Class 1<\/strong><\/span>\n\nThe US Navy had supplied John Betz with his initial medical training. \u201cAfter three years of college, I joined the Naval Reserve, and went to Great Lakes, Illinois, for boot camp,\u201d he says. Betz was accepted into the Hospital Corps School, and then sent to a receiving station in Philadelphia to work with patients. \u201cI had the good luck to end up at Bethesda Naval Hospital, which is a wonderful place to work.\u201d\n\n
\"John<\/a>
John Betz of MEDEX Class 1<\/figcaption><\/figure>\n\nAt Bethesda, Betz started out on the pediatric ward and, after a year and a half, made senior corpsman on the pediatric ward. Betz worked there until the end of his six-year enlistment. He stayed at the Naval Hospital, but switched to the allergy clinic as a civilian allergy tech. \u201cI made allergy serums, skin tested people, and did that sort of thing,\u201d he says.\n\nOne day Betz was introduced to Dr. Richard Smith, and the trajectory of his life changed forever. A woman who had set up John\u2019s tuition payments to the University of Maryland was showing Smith around the Bethesda hospital. He was searching out candidates for his MEDEX program. Betz was mistakenly identified as someone studying to be a doctor. Dick said \u201cWell, bring him over here, let\u2019s talk to him.\u201d\n\nSmith spelled out his vision of the MEDEX program, and the role of physician extenders. \u201cHe said they were really looking for retiring chiefs with 20 to 25 years experience, but here\u2019s an application. Fill it out, send it in, and we\u2019ll see what happens.\u201d\n\n
\"John<\/a>
John Betz’s 1969 MEDEX admissions photo<\/figcaption><\/figure>\n\nBetz received a positive response to his application, and was invited to Seattle for an interview before the selection committee. In Seattle, John roomed for the weekend with Tom Coles, a fellow candidate, Army Medic and Green Beret who served in Vietnam. Tom told tales of above the knee amputations and C-sections in the jungle without a tent. John thought, \u201cI\u2019m never going to get in this program. I took care of babies with ear infections, pneumonia and the like.\u201d\n\nDick Smith deployed a rigorous approach to group interviews from his years in the Peace Corps. The candidates stayed together in small groups as they moved between different interview panels. \u201cWe had two days of interviews, every 15 minutes,\u201d says Betz. \u201cYou got a schedule of different hotel rooms, and you would walk in, salute, sit down, sit up straight and say, \u2018I like small towns, my wife likes small towns,\u2019 and then answer their questions.\u201d By design, the selection committee was stacked with small town practicing physicians who had a vested interest in the outcome.\n\nIt\u2019s useful to note that Smith paid the greatest attention to the screening of wives. Because he wanted the MEDEX candidates to go into underserved areas, the spouses would help determine placement. \u201cIf a spouse grew up in a rural area or grew up in an urban area, we felt that they would be comfortable going back to that,\u201d says Smith.\n\n\u201cThey sent us all home, then got together and had a meeting,\u201d Betz says. The committee decided whom they were going to accept, and sent us a letter shortly after that. I got accepted to the first class.\u201d\n\nYears later, Betz himself became part of the MEDEX selection committee process. In 2015 John Betz retied after 44 years as a physician assistant in the rural Eastern Washington community of Othello. In that same year he became the first PA to receive the UW School of Medicine Alumni Service Award.\n\nStrategies For Educational Change<\/strong><\/span>\n\nBy design, the 1969 MEDEX curriculum model was developed as a short course. The high-level medical skills acquired in battle or even Stateside during the Vietnam War era did not translate into qualified employment out of service. Returning medics or corpsmen might find a job changing bedpans but, by and large, anything more would mean a return to school. And yet these returning veterans often had more hands-on medical experience\u2014including life and death\u2014than any medical student in an academic setting.\n
[smartslider3 slider=82]<\/div>\nWith all fifteen students sharing extensive medical background through the US military, the MEDEX didactic phase was trimmed to three months. After a brief classroom phase, the emphasis was on getting the students into the field for 12 months, working in family medicine under the preceptorship of the already primed and receptive small town physicians.\n\nOne of Dr. Ray Vath\u2019s duties was to assess the psychological states of the fifteen MEDEX students.\n\n\u201cOut of the IQ tests we found our corpsmen all had above average verbal IQs, but their performance IQs were well above average,\u201d says Vath. \u201cIn my field, that\u2019s considered creative. The psychologist we talked to said these people are better at seeing and doing rather than reading and thinking. On-the-job-training was developed by the military. These guys can go from the laboratory to the books. But they don\u2019t go from the book to the laboratory, which is the classic medical school model.\u201d\n\nPart of what Vath did was to help the returning servicemen in reintegration, especially around issues like PTSD. Vath prepared the MEDEX students on how to make a new dynamic in a field that was going to be resistant. \u201cHe helped us understand what our role was, and how to develop it,\u201d says Steve Turnipseed.\n\nIn turn, Vath discovered an unexpected aspect of character from these fifteen corpsmen during a time of personal crisis.\n\nIn the first year of MEDEX, Ray Vath and his wife lost a baby in childbirth. \u201cIt was the most painful thing we’ve ever been through,\u201d says Vath. Among all those who offered their sympathies\u2014ministers, friends, family, colleagues and patients\u2014the most effective were the corpsmen.\n\n\u201cThose guys, they had an empathetic understanding of the pain I was in,\u201d he says. \u201cI thought about it afterwards and realized, these guys had others die in their arms. That\u2019s what the military does. They kill people. Somehow, their presence was so comforting. I learned so much about grief and comfort from these guys. 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.\n\nMovers and Shakers<\/strong><\/span>\n\nThere was a little downstream problem. Outside of the cover of the University, it was illegal for these new Medex to practice medicine. Smith had to rally some broad systemic and legal changes before these fifteen students could practice medicine.\n\n
\"Dr.<\/a>
Dr. Gerald Dorman, President of the AMA<\/figcaption><\/figure>\n\nSmith put out a call to meet with the executive directors of all the US state medical associations. At the same time, doubt came to mind. \u201cI wondered if I was in over my head,\u201d says Smith. \u201cAm I overstepping my bounds with the AMA?\u201d\n\nSmith called his old friend Gerald Dorman, then the AMA president. \u201cNo, the time is right,\u201d Dorman said.\n\nIn 1969 the AMA held its annual meeting in New York, where Smith addressed the directors of all the state medical associations. Explaining the MEDEX model, he told them \u201cThis is the future. We have got to be a part of it, or get run over by all the problems that occur.\u201d\n\nThe crowd bombarded Smith with questions. \u201cI couldn\u2019t answer all of them,\u201d he says. \u201cBut they started coming up with the answers themselves.\u201d\n\nThe Path to Regional Legislation<\/strong><\/span>\n\nOn April 15, 1971, Washington governor Dan Evans signed enabling legislation that would allow trained physician assistants to practice medicine to a \u201climited extent.\u201d\n\nFor a fee of $50, any physician licensed in the state could apply to the State Board of Medical Examiners for permission to use the services of a specific PA. Chapter 30 of Senate Bill No. 182 specified \u201ceach physician\u2019s (sic) assistant shall practice medicine under the supervision and control of a physician licensed in this state, but supervision and control shall not be construed to necessarily require the personal presence of the supervising physician at a place where services are rendered.\u201d\n\nBut there was a period when both the Medex and their preceptor\/employer\/physicians functioned for a time without legislation. \u201cThis was a gutsy move by all concerned\u2014MEDEX, the MDs and Dick Smith,\u201d says Bill Freeman, MD, MPH, CIP, and current Program Director at the Northwest Indian College, Lummi Nation.\n\nThe work to win this legislation was significant. Smith\u2019s efforts to create a \u201creceptive framework\u201d paid off. He had laid his foundation of support in the small rural Eastern Washington communities where the need was greatest. According to Bill Freeman, Dick had deliberately solicited MDs who were influential leaders in the Washington State Medical Association as well as with the Washington State Legislature\u2014people like Dr. Bill Henry of Twisp, Kenneth Pershall and Richard Bunch of Othello.\n\n
\"Washington<\/a>
Washington State Governor Dan Evans signed into law the MEDEX enabling legislation on April 15, 1971. Smith is pictured to the left of the seated Governor.<\/figcaption><\/figure>\n\n\u201cDick was very smooth and knowledgeable about getting some of the preceptors who were politically powerful in the WMSA and\/or state politics in general,\u201d say Freeman. \u201cThese were powerful people. They had first-class experience with MEDEX in their preceptorship. So when they spoke about the need to have MEDEX to the State Legislature\u2014when they were lobbying for this legislation\u2014these were important people who could help influence folks.\u201d\n\nBut for the first MEDEX class there was a gap of 7 months between the end of their 12-month preceptorship in September of 1970 and the enabling legislation of April 1971. How did the newly trained Medex legally work within their assigned communities?\n\nJack Lein, the UW legislative liaison, pointed out that the Medical Practice Act allowed for UW medical students to practice a limited form of medicine under supervision while they were trainees.\n\nSmith remembers Lein\u2019s solution to bridge the gap. \u201cThe law said that a trainee at the School of Medicine at the University of Washington is exempt from the Medical Practice Act. The next day I saw Dean Hogness and said, \u2018John, I want a letter from you to every MEDEX student. I want you to begin it by saying, \u2018Dear Trainee<\/em>.\u2019 He did that, and as soon as they got this letter, they became legal\u2013 for 9 months. Until they were no longer trainees, until the program ended. So I had 9 months in order to get the legislation passed. That was the window we had to work with.\u201d\n\nThere was another ingenious stroke at work. The final legislation retroactively covered the Medex\u2019 work at the end of their preceptorship. \u201cIt was a retroactive coverage,\u201d says Freeman. \u201cIf that had not been included the plan was simply to extend the preceptorship until the point of the enabling legislation. The medical school was ready as a fallback position.\u201d\n\nSteve Turnipseed, PA-C, recalls the uncertainties of the new profession at the time. \u201cAll during this process there was no enabling legislation or concept about what a PA could do or what a PA was. We went through the whole training program\u2014the preceptorship, the concept, everything. But lo and behold, we had to delay graduation because we didn\u2019t have enabling legislation. This is when Dick, Roth Kinney, others and the Legislature got together and implemented the enabling legislation. But we were already in practice and doing what we did very well.\u201d\n\nDuring this period of uncertainty, Smith\u2019s advance work with the rural doctors paid off. \u201cThe development of what we called the receptive framework for this began by working with these physicians that were in trouble,\u201d says Smith. He would learn which physicians had ties to representatives in the State Legislature, and invest in these physicians\u2014with student clinical placements\u2014so that they would talk to their legislators.\n\nHow This Played Out With Nursing<\/strong><\/span>\n\nWhen the HRSA funding for MEDEX came through, Smith received a call from Hildegard Peplau, the President of the American Nurses Association. Peplau was well-known for her Theory of Interpersonal Relations, which helped to revolutionize the scholarly work of nurses. Nurses all over the world valued her achievements and she became known as the \u201cMother of Psychiatric Nursing\u201d<\/em> and the \u201cNurse of the Century.\u201d<\/em>\n\n
\"peplau\"<\/a>
Hildegard Peplau, the President of the American Nurses Association<\/figcaption><\/figure>\n\nPeplau requested a meeting with Smith about the MEDEX program, and flew to Seattle.\n\n\u201cShe told me she thought this is not something we should do,\u201d recalls Smith. \u201cI said, \u2018I\u2019m sorry, but this is what I want to devote my life to.\u2019\u201d\n\nSmith reports that Peplau got up, walked into another room where she had already called a press conference, and \u201cbegan lambasting me about what we were doing\u201d.\n\nIn the meantime, Smith had gained the backing of the Washington State Nursing Association. \u201cI was very open with them, including them in how were going to get the legislation, and that that we were going to train nurses if they wanted.\u201d\n\nBill Freeman recalls Smith\u2019s efforts to overcome any potential opposition from nurses within the state. \u201cMEDEX met more than once with the leadership of the State Nursing Association, typically accompanied by the WSMA as well. Very purposefully Dick included Nurse Practitioners in the final enabling legislation.\u201d\n\nEfforts on the National Front<\/strong><\/span>\n\nSmith had also set his sights on national expansion. He had an idea of a \u201cCouncil of MEDEX Programs\u201d\u2014a program in each time zone. The idea was to build the program\u2019s reputation and coverage by engaging influential medical academic supporters in key communities across the US.\n\nHe gained the interest of Bella Strauss, a physician at Dartmouth College in Hanover, New Hampshire. Also in his sights was Dr. Bob Eelkema at the University of North Dakota, followed by Dr. Cleve Hudson from South Carolina and contacts in Utah.\n\nSmith reached out to include his alma mater, Howard University. At first, he couldn\u2019t talk them into it. \u201cEssentially, I said I\u2019m sitting on all this money,\u201d he recounts. \u201cThe President of Howard was a friend of mine. He picked up the phone and called the Medical School Dean. We moved ahead.\u201d\n\nNext was outreach to the community in South Central LA. \u201cThe town meeting there was the most difficult we had,\u201d says Smith. \u201cThose black mommas kicked my ass! \u2018What do you mean trying to sell us on second-class medicine? You ought to be ashamed of yourself.\u2019\u201d\n\nSteve Turnipseed (Class 1) had accompanied Smith, and talked for 20 minutes about what he had accomplished as a Medex at Group Health Cooperative in Seattle. After hearing Steve, those at the LA town meeting said, \u201cWe want MEDEX!\u201d\n\n
\"Smith's<\/a>
Smith’s plan for a “Council of MEDEX Programs” was to have representation across each time zone in the US.<\/figcaption><\/figure>\n\nSmith had pulled together a Council of MEDEX Programs\u2014a tightly knit group of people across the nation who were interested in growing the program. They met mostly by phone.\n\nDr. Gerry Basset became instrumental in the expansion of MEDEX outside the Pacific Northwest. \u201cAbout the time of the pending legislation, I left UW and went to North Dakota to become the Director of the University of North Dakota program, MEDEX Central,\u201d he says. Dr. Bob Eelkema had approached Smith and Basset, expressing an interested in starting a program at the UND School of Medicine\u2014Public Health. \u201cWe put together a staff with similar backgrounds,\u201d says Bassett.\n\nDuring that time Smith received a call informing him that the Senate Finance Committee had on its agenda a discussion to talk about reimbursement for PAs. He arranged a conference call among the MEDEX Council to get the topic off the agenda. \u201cI thought it was too early,\u201d he says. \u201cIf the Committee were to bring it up they\u2019d kill it. It would have been dead for decades if that happened.\u201d\n\nManaging Imagery<\/strong><\/span>\n\nSmith was keenly aware of all the careful steps required to manage social change. \u201cMy avocation is the field of communications,\u201d he has said. \u201cI know nothing about it, but I\u2019m interested in it.\u201d\n\nIn the case of MEDEX, he was introducing the first new medical profession in 100 years. And he knew enough to realize there were key steps to be taken all along the way with image in mind.\n\nAll of the MEDEX candidates fit a particular profile that one could conventionally describe as masculine and handsome. Additionally, the country was still in the middle of the Vietnam War, and there had been a lot of media coverage on the contributions of Army medics and Navy corpsmen.\n\n
\"Steve<\/a>
Steve Turnipseed at Group Health wearing his blue coat.<\/figcaption><\/figure>\n\nSpeaking to Ray Vath, Smith pitched a way to visually distinguish the Medex from the physician. The idea was to have them wear blue coats instead of the usual white medical coats. \u201cI\u2019ll tell them to wear polka dots if that\u2019s what you want,\u201d responded Vath.\n\nPerhaps most important was the naming convention. An early MEDEX document explains the original intent for the terminology. \u201cWhen the term appears in capital letters, reference is to the training program. The term in lower case letters (Medex) refers to the trainee or the graduate of MEDEX.\u201d\n\nThose who graduated from the MEDEX program could apply the credential Mx after their name. For Smith, this was an effective distinguishing mark to MD for the physician.\n\nBut this term was not to gain wide acceptance outside of Washington State.\n\n
\"Life<\/a>
Life Magazine story from July 12, 1970<\/figcaption><\/figure>\n\nDouglas Fenderson, a HRSA official, returned to DC with a glowing report of the MEDEX program, forecasting that the new profession was going to grow. He asked Smith to send him a couple of Medex\u2019s to move things forward. \u201cThat\u2019s impossible,\u201d Smith told him. \u201cThese guys have docs who have agreed to hire them. We can\u2019t renege on our promise.\u201d\n\nSmith suggested that Fenderson contact Dr. Bob Howard, the former director of the Duke University PA Program. There he found two Duke graduates that were subsequently hired by HRSA. Duke\u2019s early naming convention was physician associate, which later became physician assistant. The abbreviation PA stuck and trumped MX. \u201cI decided I wasn\u2019t going to pursue the imagery issue,\u201d says Smith.\n\n
\"Time<\/a>
Time Magazine story from March 29, 1971<\/figcaption><\/figure>\n\nIn the interests of a different sort of imagery, Smith moved the MEDEX offices out of the UW School of Medicine and into the same building as the Washington State Medical Association. \u201cThat way we had the same address as the WSMA,\u201d says Smith.\n\nBefore long, major media were knocking on Dr. Smith\u2019s door. NBC News correspondent Don Oliver called saying, \u201cWe\u2019ve heard about this program called MEDEX. We\u2019re coming up to do a story.\u201d\n\n\u201cAre you asking me or telling me?\u201d replied Smith. \u201cFirst, I didn\u2019t trust them and, second, it was too early. We were still trying to gain acceptance.\u201d\n\nBy 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. Soon, feature stories in Parade<\/em>, Time<\/em> and Life Magazine<\/em> followed. The news angle was this: here is a solution to the crisis in healthcare facing our rural communities. All the coverage was exceptionally positive and receptive.\n\nhttps:\/\/youtu.be\/ZXWLDrfqld0\n\n \n\nhttps:\/\/youtu.be\/6lmCCTLMeP0\n\n \n\nPioneer vs. Settler<\/strong><\/span>\n\nDr. Richard Smith devoted 4 years of his life to the development and launch of MEDEX Northwest, from 1968 to 1972. In that brief time he brought forth a new medical profession to address a worsening healthcare crisis\u2014a shortage of practitioners, particularly in rural environments. He also tapped into an underused resource, that of our medically trained returning military veterans.\n\n\u201cIt wasn\u2019t simply a matter of training some people and sending them out into new jobs,\u201d he says. \u201cTransformation is a systems metaphor for change. It\u2019s more process oriented and dynamic.\u201d\n\nThrough MEDEX and the emerging PA profession, Smith and his colleagues got into all types of communities\u2014affluent, poor and middle-class. \u201cThat\u2019s when I knew we had a success on our hands,\u201d he says.\n\nAnd it was at that point that Smith knew he had to leave. \u201cBecause I\u2019m not a settler,\u201d he says.\n\nActually, this was a quality shared by all of the leadership of MEDEX at the time. Speaking of Smith, Deputy Director Gerry Bassett, Bill Freeman and himself, Ray Vath says, \u201cAll of us were innovators. We love the challenge of creating, but not one of us likes to manage.\u201d\n\nThat\u2019s the difference between a pioneer and a settler. Smith knew himself well enough to recognize that his talents were best applied to systems development.\n\n
\"David<\/a>
David Lawrence succeeded Smith as the Director of MEDEX from 1973 to 1977. He went on to become the Chairman and Chief Executive Officer of Kaiser Foundation Health Plan.<\/figcaption><\/figure>\n\nDavid Lawrence was a Robert Wood Johnson Scholar at the University of Washington, and he was recruited to replace Smith as the Director of MEDEX from 1973 to 1977.\n\nAnd yet there was much more innovation to come from Dr. Richard A. Smith. Ever a man of vision, he wanted to take the concept of the MEDEX program global. In many ways this would bring him full circle, back to his time with the Methodist missionary in 1951 Cuba. The dream was to train mid-level healthcare workers in countries where there may not even be a medical school or a national health ministry. MEDEX International would become the focus of his work for the next 10 years, from 1973 to 1983.\n\n \n\n \n\nNext<\/strong>: Dr. Richard Smith, Part 2\u2014MEDEX International<\/em><\/span>\n\n\u2020 \u201cMedicare and Medicaid at 50: America\u2019s Entitlement Programs in the Age of Affordable Care\u201d<\/em> (2015) by Cohen, Colby, Wailoo and Zelizer\n\n