Interview with Dr. Roger Egeberg, former Assistant Secretary
for Health
Date: January 1993
Location: National Library of Medicine
of the National Institutes of Health
Bethesda, MD
Interviewer: Stephen Strickland
Dr. Roger Egeberg, former Assistant Secretary for Health
Conducted in January 1993 at the National Library of Medicine
Intro: Dr. Egeberg was involved in setting up the Regional
Medical Program in California. Later, in 1970, as Assistant Secretary
for Health of the Department of Health, Education, and Welfare, he
oversaw RMPs more generally. The purpose of this interview is to get
any latter-day judgments about Regional Medical Programs that may have
come to Dr. Egeberg over the last several years as he has reviewed
his long experience as a health policy maker and practitioner.
Strickland: I am especially wondering whether, since the
December 1991 meeting of former principals in Regional Medical
Programs, at which you were, as always, an outspoken participant, you
have had further thoughts about that ten-year endeavor. But first,
tell me how you got into health care administration?
Egeberg: I got into health care administration during World War
II when I was sent up to New Guinea to become Surgeon of the Command.
The Command was seven or eight thousand troops stationed there. Milne
Bay was building up to become our greatest forward base so few of
these troops were infantry. They ranged from stevedores, engineers,
quartermaster, signal, two field hospitals, and an air fighter
squadron. The responsibilities of the Surgeon of the Command covered
aid stations, hospitalization, evacuation, sanitation, malarial
control, VD control, and other duties. I knew nothing of the
specifics of this job, and there was nobody in my office such as a
knowledgeable sergeant to advise me, so I learned the importance and
the handling of my assignment the hard way. Its importance was
obvious to me and it excited me. After a year of dealing with these
problems and the evacuation of the sick and wounded from the Buna
front, I was relieved and soon after became General MacArthur's
physician and medical officer for the officers of GHQ. I had very much
enjoyed the beginning of the practice of medicine in Cleveland, Ohio,
before the war, but the field of public health to which I had been
exposed in Milne Bay continued to intrigue me. So from the war years
on my work became increasingly involved in such problems. This
continued through my years of running hospitals and medical schools
until later I was engulfed as Assistant Secretary for Health and
Scientific Affairs in HEW in Washington, where I continued
administrative public health duties until my retirement from the
Government in 1983. After practicing medicine for some years, I was
asked to be Medical Director of the Los Angeles County Hospital. When
I received that offer I was so proud and full of so many emotions that
I probably almost wept. Anyhow, I drove into the garage where I had a
place to park and ran up the stairs and into my office. But as I
entered it I was reminded of Elvis Berman, the former Medical Director
whom I had called upon about ten days earlier. I had called on him to
ask his advice, but also to make sure I wasn't easing him out of that
job. He was loved by all the attending men and I loved what I heard
about him and what he had done for the standards of that hospital. He
was a man who felt proud of his German-Jewish heritage just the way
many Scots feel proud of theirs, and when I went to ask his advice he
said the following (but he didn't ask me to sit down). He said
"Doctor, da biggest to do is da many crisis. I have an ulcer. When
da crisis come, I go home with my ulcer. When da crisis is over, my
ulcer better, I come back. You take my advice: you get an ulcer."
There are countless stories about him. For example, right near the
end of the residence quarters there was a big storage room just for
mattresses, so it just invited assignations and you could imagine that
not just on week-ends the nurses and the doctors were hooking up in
there. The newspapers had gotten wind of this and were about to air
it and Berman asked if he couldn't have just two days to straighten
out the situation. The newspapers respected the request. So he
called all the interns and residents into the gymnasium where the
folding-chairs were and he got up on the podium and he looked around
as if counting them. He said, "Boys, I know what you're doing. Don't
do it." And he went back to his office and they didn't do it after
that. Well, that was my introduction to the first day at the County
Hospital and some of the memories I had at that time.
Strickland: He sounds like a leader.
Egeberg: Well, the poor guy. For some reason or other the Board
of Supervisors which owned the County Hospital, so to speak, wanted to
get rid of him. But the whole attending staff loved him and the
reputation and good of the county hospital depended on the attending
staff, so one day when he was sick for a few days they moved his desk
out into the hall. But they didn't dare put anybody else in his
office. And when the attending men found out the whole story they
told the Board of Supervisors that they would not attend until Berman
was moved back into his office, which the Board did. He was a hell of
a good doctor. He brought the first EKG machine to this area and x-
ray and other equipment to the hospital. Anyhow, you want me to talk
on a broader scale than that.
Strickland: That is an excellent summary of your background in
managing health problems and health care institutions and leads us
right to the present consideration. As you know, for the last six
months I have been pouring through these articles and papers and
interviews with you and other people about Regional Medical Programs.
I am trying to ascertain basically what it all amounted to and more
especially if there is anything in the RMPsl in all their diversity,
that might be useful as our policy makers go to work trying to revise
the health care system. I am not sure that there is, but that is what
I am conjuring right now and trying to get a handle on. I read your
interview on the origins and what happened in California but I just
wondered if you had other thoughts, especially about the lessons from
RMP.
Egeberg: I don't know how much went into those interviews but if
it's duplicative you will have to forgive me. Under RMP we were given
an opportunity to spread the medical school influence more broadly and
where it was needed. I think the level of medical care that existed
in the university medical centers dropped on average in California
rather rapidly as you got out into the smaller towns and the
countryside. In those days there were still many doctors practicing
who graduated from those schools that the Flexner report had succeeded
in closing. Their level of teaching and their limited post graduate
training even influenced the care in cities as large as Bakersfield or
Fresno. When they asked us to get involved in this, I saw the
opportunity to broaden our influence on the practice of medicine,
possibly rather quickly, and jumped in. I believe our school, the
University of Southern California, was the first to become interested.
Before long, a number of medical schools in the State were creating
areas to come under their influence, so it was wise to establish an
organization for the coordination of the work in the whole state.
This became the California Committee of the Regional Medical Programs.
All of us saw the double opportunity of raising the level of health
care at a distance from the medical centers and of gaining insight
into the problems and the potential for improved medical care in the
State. It was proposed and seemed natural for us to invite one or two
selected physicians from a given hospital to come to our medical
centers -- for a day, or a week, or a month -- to receive postgraduate
training which they could then carry back to their hospitals and
disseminate, probably through clinics. Even before this started, I
felt that such programs would soon wither and die. I felt, and other
schools may also have felt, that the program should exist in the local
hospital. The education would have to take place in the local
hospital. If it can be initiated there, it could become a permanent
pattern. So, in USC's involvement, we started on that principle.
Strickland: But how do you do that?
Egeberg: Well we go about it this way: You tell them that you're
going be interested in them, that you're going to be able to give them
consultations, if they feel they need them, and are willing to help
them in any way that they would like. And some of them begin knocking
on your door saying "how are you going to help me" and you say, "why
don't you start a teaching clinic and anybody who has a problem
patient can bring the patient and the rest of you can discuss it. If
you need help, we will be glad to send a specialist -- or two or three
-- to run such a clinic for you on these cases. But the patients will
be your patients and we don't want to interfere." Well I figured they
would be their patients and they would start talking about them at
lunch and really feel they have something going. So they felt the
program was theirs rather than ours, at least that was my impression.
So, any advice I have to give to the future? Don't pass something
down all the time. If you can, through any means, work
collaboratively with doctors - in their territory. I think that that
is the important issue.
Strickland: Absolutely. What area of California are we talking
about here?
Egeberg: We wanted to get into Bakersfield because I knew a lot
of the doctors in Bakersfield and I thought they had one of the best
general hospitals outside of Los Angeles and San Francisco. UCLA
wanted to go out in an area closer than Bakersfield and decided they
wanted to help Fresno, and so we divided it up. There was so much to
divide up that we were free to give territory away so to speak and we
came to amicable agreements among the medical schools on where we
thought our respective influence should go.
Strickland: You were then at USC?
Egeberg: Yes.
Strickland: So that university was the starting institution in
the Los Angeles area?
Egeberg: Yes.
Strickland: But you had the cooperation of the medical societies
in various counties ... or did you?
Egeberg: I think we had their cooperation; if not, we certainly
worked for it.
Strickland: But you yourself knew so many practicing physicians,
that obviously helped.
Egeberg: Oh yes, in Bakersfield we were welcomed openly. There
were other hospitals north of us where we waited a while until they
invited us. We tried not to go anywhere unless we were invited. And
as the word spread, about a year later, they began to feel not so
threatened. of course it is amazing how quickly a graduate gets
scared of his own medical school. Overall it worked well for us, I
think Bakersfield was grateful for it as long as it lasted. I would
say that many of the relationships lasted once the medical schools
realized they had both a responsibility and an opportunity of
extending their influence.
Strickland: Was anybody working in the city of Los Angeles, the
urban part of L.A. county?
Egeberg: USC was allied with the county; we had the County
Hospital, Harbor Hospital, and three hospitals scattered over the
county, all part of our teaching system. But aside from that, in some
of the smaller suburbs there were hospitals that would call on me and
say they would like to have some association and we welcomed that.
The Orange County General Hospital felt a little bit snobbish about it
but when they saw how we were working they were perfectly happy to
have us come down and hold clinics there when they had a special case.
In fact, I think it was for the Regional Medical Programs that I went
down to the Naval Hospital in San Diego and asked them whether they
would like to be associated with us.
Strickland: How many medical schools in Southern California were
there at that time?
Egeberg: There were UCLA, USC and the College of Medical
Evangelists which later became Loma Linda University and The College
of Osteopathic Medicine.
Strickland: Nothing in San Diego?
Egeberg: Not yet. There was that very good naval hospital which
we worked with. It was not ticklish, and it was fun to tie in with a
Federal Government institution and have them like it.
Strickland: I am especially curious about that. Because my
impression from reading a whole lot, but also visiting six or eight
people who were involved in Regional Medical Programs, is that it
seemed that it was more difficult to get them organized in large
metropolitan areas than in small states like Connecticut or North
Carolina.
Egeberg: Well, I don't know about New York, but in California we
all felt happy about it. The schools were scattered at the time, with
Davis, UC San Francisco, Stanford, UCLA, USC, College of Medical
Evangelists, and we brought in people representing communities,
organizations and otherwise such as medical associations, unions,
elected officials and the Board of CCRMP. Today, 25 years after the
beginning of Regional Medical Programs of the 60's, practices are in
some ways similar, but in many ways different aren't they?
Egeberg: Yes, definitely.
Strickland: But wouldn't you say that the biggest factor for
people today is the fiscal one, the financial one? There are still
counties that don't have doctors, we know that; there is still that
sort of scarcity for people in certain geographic areas but mainly it
seems to me that what policy makers are going to have to deal with are
the financial questions.
Egeberg: Oh yes, they are going to have to deal with the
financial question and with the governmental interference.
Strickland: Is there anything we can extrapolate from RMP in how
to improve the current health care system?
Egeberg: Well, in the Regional Medical Programs, we were able to
raise the level of health care in the outlying communities. As I look
at some of those communities now, the care is just about as good as it
is in a big city. I am thinking of California, except rurally where
you maybe had a ten bed hospital which presented a special situation.
Rurally, I think they probably still need help, and one big problem is
transportation for the rural poor. I remember meetings on this 15
years ago but I don't know how far this has advanced.
Strickland: Let's say we are talking about Montana, I don't
remember where the Veterans' Administration hospital is.
Egeberg: There was one put up in Miles City, Montana, because
the Senator from Montana wanted it. There were two doctors in town,
one was an alcoholic and the other one elderly. And there were no
patients, but they put in a hell of a good two hundred bed hospital
with the Senator's assistance.
Strickland: Senator Murray. How long ago was it?
Egeberg: This was shortly after the war.
Strickland: Let me interrupt your train of thought to ask you
this: If in fact we are looking at the need for medical services in
regions where there are simply no doctors and no facilities and one of
your objectives is to put medical care within reach of most people,
what would you think about the use of existing public health service
hospitals and Veterans' Administration hospitals? And what are we
going to do with the V.A. hospitals?
Egeberg: I think that the V.A. hospitals could become a very
important part of what we do with medical care because we would want
something a little bit similar to what they have and they have a good
organization. When the money goes down, the care goes down, but it's
a good organization especially given its connections with the medical
schools. I bet you that 80% of their patients are in hospitals that
are connected with medical schools. So you have something good there
that you shouldn't slight.
Strickland: I did a large study of the V.A. when I was working
with Phil Lee in San Francisco, in 1969-70 or so, and we couldn't find
anyone outside of the teaching facilities affiliated with the V.A. who
really wanted anything to do with the V.A. hospitals. The general
position in the medical community was that they saw the V.A. as a
fossil and I am not sure how you would overcome that attitudinal
barrier.
Egeberg: While working for the Veterans' Administration, I
applied for admission to the Los Angeles County Medical Association.
I had to interview a member of the medical hierarchy in Los Angeles.
He was genial and welcomed me warmly to the city. Finally, he said,
"Where are you going to practice?" and when I told him that I was
already working in the VA Hospital, his friendliness left. "Oh," he
said. "that ogre" and finished the interview.
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