After spending more than 22 years as chair of the Department of Community and Family Medicine, J. Lloyd Michener, M.D., professor of community and family medicine, will soon step down to focus his attention on national and international projects designed to improve health outcomes and reduce health disparities, an extension of his work with The Practical Playbook.
In a recent interview, Michener reflected on his childhood, his medical training, and his time with the department and as chair.
Tell me about your childhood.
Michener: I’m the second child of two Quaker activists, both from Wichita, Kansas. They were quite active in Quakerism and looked at the role of individuals as being change agents within their communities and societies. Dad was fired, long before I was born, by the University of California where he was a teaching assistant, because he refused to sign the loyalty oath. So he lost a job and worked as a gas station attendant. He later got his doctorate in political science and ended up working for Social Security and rapidly rose up through the ranks to become a senior federal official, helped start the Office of Equal Opportunity. He was always in a bit of an awkward position because he continued his acts as a committed member of the community.
I grew up in Baltimore; we initially moved into a community that was historically Jewish. Homeowners were being told that African Americans were going to move into the community and they should sell their houses quickly while they still could. And then folks would buy the houses way under market value and then flip and sell them to black folks in the South, and basically drive rapid turnover as a way of making huge amounts of money on house speculation. That was part of how the cities actually transitioned to being largely black back in the ’50s and ’60s.
We moved into a community that was being flipped. So I was always going to schools and being in communities that had enormous tensions between historic ethnic communities, and mostly southern blacks. So I grew up mostly in what became largely black neighborhoods.
Living in complex, changing communities was part of my life experience. In fact I thought everybody lived in communities in which there was a lot of tension and there were great disparities. Millionaires were living literally on one side of the block, and next to us would be the gypsies. There was a very active community. I thought that was a normal community, you know. I went to public school being one of four white kids, and I thought that was normal. I was pretty comfortable being in very diverse neighborhoods.
Tell me about high school and college.
Michener: I went to high school at a public high school for science and math in Baltimore, and really enjoyed that, then went to Oberlin College and studied science, sociology, music and religion.
At Oberlin I was quite active in organizing myself. We were poor, so I ended up running a co-op system as a private business, where we would rent dorms from the college, the students would run them, including running all the food service and all the clean-up of the dorms, at a discount. Gwen [his now-wife] was the chief cook and I was the head of the association. It was very good training to be chair, by the way. As an example, those dorms were set up to be single sex with one bathroom on each floor. We quickly made them unisex, but my job would often be to explain to the outraged parents how this dorm worked. So I learned diplomacy early.
What led you to medical school?
Michener: I liked the sciences and I liked the humanities, and I thought I could do both. I went to medical school because I thought it would be intriguing and fun. I applied to a whole bunch, got in a whole bunch. I went to Harvard because nobody from Oberlin had ever gone to Harvard Medical School, so I thought I’d give it a try. So I applied, and darned if I didn’t get in … shocked everybody!
I went to Harvard, and didn’t have much money so I had to work during the summers to help make ends meet. I got a job working in the local community as a community organizer, as a research assistant first to a public health guy understanding the health needs of the communities around Harvard Medical School. And then the second year working as a health services researcher for the chair of surgery at the Brigham, who was one of Victor’s Dzau’s mentors, I’d add. I was studying why surgeons choose to hospitalize patients and what the reasons were, and what services patients get and what services patients should get, whether they differ.
I made it through, hated the basic sciences, but loved the clinical stuff and liked all my rotations. Harvard to this day does not have a family doc on faculty. I went into family medicine because I kind of thought I could do a bit of everything. I got intense pressure from the medical school not to do that, and was actually offered a position at my choice of the Harvard hospitals; I turned it down.
Why did you choose to come to Duke for residency?
Michener: At that point there were only four, maybe six, family medicine programs in the country. I interviewed at them all. I came to interview at Duke and didn’t know anybody in Durham so I asked a family friend if they knew anybody in the Durham area we could stay with, again as we didn’t have any money. They said, “Oh yeah, we have a family friend that used to babysit for us, I’ll give you his name.” So I wrote him a letter and he said, “Come stay with us, we’d be happy to have you.” His name was Art Christakis.
So I drove down, stayed with them, and it was at dinner that I discovered he was the dean. So I mentioned in my interview that I was staying with the Christakises, and they said, “You’re staying with the dean?!” I said, “Yeah, I didn’t know!”
I really liked Durham, liked the nature of the town, I felt very comfortable. I started residency the day the Duke Family Medicine Center on Crutchfield Street opened; we were the first group in there. We had no exam tables our first couple weeks, so we were doing pelvic exams on mattresses on the floor.
After residency, you completed a fellowship, then stayed at Duke to begin your academic career. Tell me about that time.
Michener: I finished the residency in 1981 and I did a fellowship funded by the Kellogg Foundation in change management. Then I became pre-doc director, so I worked for several years launching the clerkship in family medicine, and doing site visits all over the state to see how the students were doing. I sat in all the classes that the medical students took to learn and got engaged with the medical school curriculum committee, and quickly was asked to chair some review committees on how we’re doing, and ultimately served 20 years on the medical school curriculum committee.
I was pre-doc director, then residency director, fellowship director, and then George Parkerson [then-chair] asked me to move to [Marshall I. Pickens Building] to collapse the residency program and the practice at Crutchfield into the building here on Erwin Road. But, we couldn’t easily fit. There were too many docs, too many residents. So we actually had 12-hour shifts, 5 days a week just to get all the patients seen. I was chief of community health, working with George Jackson, chief of occupational health; we had no Division of Family Medicine for awhile.
We ended up designing a bunch of programs with the community to try to reduce the need for patient care because we just didn’t have enough room to see everyone who wanted care. I never really shared that, but one of the reasons we got interested in reducing visits was simply we couldn’t accommodate everybody.
Somewhere around this time I started doing a lot of obstetrics. Duke didn’t think that was a good idea, so I went to UNC and did a mini fellowship in high-risk OB. I started doing inpatient care at Duke Hospital; Don Bradley, Kathy Andolsek and myself were the first admitting family docs at Duke Hospital, and then we did our OB out at Durham Regional. We did probably 500 deliveries between the three of us, every third night call for years. Part of why I know a lot of folks in Durham is I delivered a lot of babies, and I did a lot of home visits.
Tell me about your work with outside foundations that contributed to department projects.
Michener: I had a visit one day by a guy named Siegfried Heiden. Sigfried was interested that I was concerned about prevention and public health and wanted to introduce me to his work with foundations, so he arranged a visit by a guy who was the executive director of the Fullerton Foundation. I met with the man and we talked about some neat ideas. He said, “I’ll follow up with you.”
I pinged the dean’s office saying, “Hey, I just heard from the Fullerton Foundation,” and they said, “You talked to the Fullerton Foundation?” I said, “Yeah, I’ve got his card here, it says the Fullerton Foundation.” There was this long gasp and they said, “You don’t have authority to talk to the Fullerton Foundation.” I said, "Well, they contacted me. I don’t know who they are.”
And then a week later, the dean’s office called back to say, “You have completely disrupted everything. We have a multimillion dollar ‘ask’ to the Fullerton Foundation. You had no business talking to them.” I said, “With all due respect, sir, I didn’t ask for it, they asked to talk to me. If you want I’ll tell them I can’t talk to them.” They said, “No, no, no, you can’t do that.” Ultimately, I ended up working with the foundation for 25 years of continuous funding on prevention.
I also worked with Kate B. Reynolds Charitable Trust early on, and the Macy Foundation, working with Eva Salber on community programs, and then ended up doing a lot of work just with the Durham communities and the foundations, around training physicians and PAs — a lot of the early basic grants on team training 25 years ago.
How were you selected as chair?
Michener: George Parkerson, of course, had become chair after Harvey Estes, and then the agreement was that he would serve in a transition role. We launched a search for a new chair; I was on the search committee. We had somebody we were really excited about — Klea Bertakis from UC-Davis. And about a month before she was going to come, she called Ralph Snyderman, our chancellor, to say she wasn’t coming because the faculty position for her husband, who was an English professor, was a professor “in” English rather than a professor “of” English. And that makes a big difference, apparently. He wouldn’t come, so she wasn’t going to come.
Ralph called me in on a Friday and said, “Lloyd, Klea isn’t coming. I want you to be interim chair. I need to announce that because Klea’s going to announce she’s not coming.” I said, “Ralph, I need the weekend, that’s a biggie.” I talked to Gwen and she said, “That’s nuts, but you can do it if you want.”
I didn’t want to be chair; I was medical director and chief at that point. I said, “Ralph I’ll do it on the condition that it’s not interim. You can get rid of me after a year if you want, but don’t use ‘interim’ because we have work to do.”
We didn’t have a contract; we shook on the deal, and that’s how I became chair. So it was a handshake and no negotiation, we just started.
What projects were going on in the department at that time?
Michener: Rebuilding the residency, looking at the efficiency of the practice, and integrating us in with the medical center. Back when we were off campus we were out of sight, out of mind. So I was quite engaged with growing the family medicine inpatient service, and we were growing the residency. It was a time of rapid change. Duke was trying to figure out what to do with family medicine.
Looking back on your time with the department, what would you say have been some of the moments you’re most proud of?
Michener: How we handled crises and issues. One of them, which is now pretty well forgotten, is Duke had the biggest outbreak of menengitis the U.S. has seen. It started with a case on campus with a student — Student Health was very much part of the department at that time. By the time we had a second case the next morning I figured we might have an epidemic and we convened a meeting that day to start contingency planning if we had a third case.
We involved Duke ED, we involved the health department, and we had a third case later that day. So we planned for and implemented a mass campaign for management of meningococcemia on Duke campus with the CDC, the health department and the university. Marshall I. Pickens Building became the hub of that. Howard Eisenson was the point person because he was head of Student Health. We had all three news networks camped out with their big TV trailers in the Pickens parking lot for a week.
We ended up, I think, with 14 or 16 kids who got meningococcemia. When you get meningococcemia you’re starting to feel puky, and a few hours later you’re nonresponsive. It’s an incredibly bad disease. We moved really fast; we flew in the world’s supply of meningococcal vaccine. We chartered a jet and flew it in; I had my administrative assistant pick the vaccine up with her pick-up truck. I said, “Do not get in an accident!” We took over the student union and set up mass vaccinations, immunizing, I think, 80 to 90 percent of the campus in three days.
But what I’m most proud of, because we moved so fast, we had about 16 kids be in the intensive care unit and none of them died or even had any complications. Every one of them survived and did fine. It’s because it was an integrated health care-public health-university activity. We just crashed through barriers.
The other one is the more famous one of getting really frustrated with family medicine and how we’re training residents on inpatient care but not on working with communities. After several years unsuccessfully trying to persuade the national residency review committee, I basically decided we wouldn’t take any more residents so we could refocus on population health training. Parts of this I mishandled.
The thing I’m proud of, it was the right decision. It was poorly communicated, I learned a lot from that, but fundamentally that decision to stick to what we knew worked made all the difference. I don’t think any of the things that have happened to the department since would have happened if we hadn’t made that hard call. God, it was hard; I had 20,000 nasty letters and emails from that. But it was right.
What have been your priorities as chair?
Michener: The marching orders I got when I became chair were to help Duke learn the value of family medicine and the department, and I feel like we have done that. The institution now understands why a largely tertiary care medical center needs a group that cares about the family and the community, so I think that succeeded.
What I added to that mix, and George Parkerson said it best, was that we put the community back in the department. Cause we were the Department of Community and Family Medicine in name but not in action. And now the value of the community and what it brings to the table is reasonably well woven into the department.
How has the department contributed to the health of communities in Durham?
Michener: Duke and Durham have a complex relationship. What we have done, not uniquely but perhaps more than anyone else, is gone out and met community groups and members where they are. And that has been done quietly and without fanfare. Part it goes back to doing a lot of OB and home visits, and realizing that we need to be a partner in some of the solutions and not forcing it. And so over time we became partners with over 100 different community groups, as a department, then the CTSA came and we built an infrastructure around that.
We’re some of the founders of the N.C. Medicaid program, so I think what we‘ve done is design, implement and evaluate programs that have brought health care to people who didn’t have it before, in ways that they hadn’t experienced it. That is including everything from providing services to folks with Medicaid, to finding groups that traditionally had to come to us — for example seniors and the Just for Us program, the Latino community, the LGBT community.
We’ve learned to say, “How do we partner with different groups in Durham?” as opposed to saying, “We’re here, come to us.” We’ve asked, “What can we do to serve you better?” and along the way we can show significant improvements in health outcomes in those other groups that historically nobody ever looked at.
Additionally, what’s the role of academic health centers in a country in which there isn’t enough money and health outcomes are not improving at the rate we wish? And to what extent should we be doing high-end research and training — those are critically important — but to what extent should we also be engaged with our communities and finding solutions that work for them? I think what we’ve done with the department and with Duke and Durham is demonstrating a different sort of academic health center that’s engaged with its community, does the high-end stuff but also has its roots in and gets its strengths from its partnerships with communities.
Of all the things we’ve done, I think demonstrating that that’s doable and a place like Durham and Duke can do it, is probably the most important. It still has a long way to go. Duke and Durham have a different relationship now than they did before, and I think that we’ve had some role in that.
Experiences from your childhood and throughout your career seem to indicate you’re a bit of a “disrupter.” Do you see yourself as that type of person?
Michener: Oh, absolutely. I take after my parents. Part of leadership is not in what you say, it’s in the choices you make and the risks you take to show that the world could be different than it is. It involves the thoughtful willingness to use yourself as an agent of change. And to me it’s something you do all the time.
The other thing I’m realizing my job is — I’m a bridge person. I’m comfortable being in two or three groups that usually don’t talk to either other and trying to bridge them.
Looking ahead now, what are your plans?
Michener: There’s a really cool thing happening between health care groups, academic included, communities and minority groups. It’s about how do you understand health outcomes and disparities, and design interventions that can work to improve health outcomes and reduce disparities. It involves use of data and what you measure. There’s now a national discussion about changing the data, selecting partnered interventions, and changing how the states and health systems view those questions. And that’s what I’m really looking at focusing on, it’s Playbook but it’s Playbook at-large, and internationally. We probably have a discussion with a different country once a week now. This is really fun stuff. So I’m really looking forward to spending more time on this.
And it’s been an honor and really been a joy being chair, but I am definitely feeling pulled and called to focus on this state, national and international work.
Anything else you would like to reflect on or share?
Michener: No one person can do any of this. What has made this work has been the people, the department, folks who can see the value in this larger work. Every bit of this has been done by a team, and I think the part I’ve most enjoyed has been the team. It’s been all the folks who make it happen, because by yourself you can do very little.