INTERVIEW TOPIC LOG

0:43 Childhood, growing up in Chisholm Minnesota, multigenerational household, family economic struggles 3:52 Living in Washington D.C., exposure to diversity 5:08 Education, girls’ Catholic school 6:35 Diversity in Chisholm, living in an immigrant community 8:33 Father’s experience in a Slovenian immigrant family, father’s work with Congressman John Blatnik and activist influence 13:27 Applying to Northwestern for BS/MD, lack of advising, education experience as a woman 16:29 Emphasis on service in girls’ Catholic high school, activist exposure 17:33 Experience as a woman in medical school, coping with sexism 23:00 Encountering racism at Duke in residency, merging of Lincoln Hospital and Watts Hospital 25:40 Diverse peers at Duke, poor attitudes towards family medicine, diversity and family medicine activism as a medical student 32:44 Early involvement with community health in Chicago, eventual path back to Duke and residency teaching 36:38 Work with AIDS patients and care for low-income patients 49:16 Work in multidisciplinary teams, working with trusted members of the community 53:48 Educating residents about Durham history and diversity, activism of Lovest Alexander Jr. 57:32 Using recruitment of underrepresented minorities as performance metric for medical school, importance of data 1:00:56 GME program to increase diversity, learning to support students through the program, student advocacy, parental leave for students 1:05:43 Work in obstetrics 1:08:18 Students’ advocacy for parental leave, impact of board requirements 1:09:50 Learning to accept “baby steps” towards change 1:10:35 Issues with funding 1:11:45 Providing quality of education to residents, problems with residents having to complete Electronic Health Records work, measuring competency 1:14:35 Measuring Duke’s success through Durham community health outcomes 1:17:36 Diversity training, importance of diversity in teams 1:19:45 GME funding and student support, rewards of seeing student success 1:22:53 Increasing diversity in Duke health leadership 1:23:59 Value of pathway programs, examples of strong GME programs 1:26:34 Racial justice advocacy as a white woman, using leadership positionsfor advocacy 1:29:53 Work with addiction, benefits of family medicine for involvement in a variety of fields 1:34:23 Learning to persuade and negotiate to lead to changes 1:38:40 Benefit of diversity in health education in improving patient care

FULL TRANSCRIPT

Caroline Overton 0:16 My name is Caroline Overton. It is March 4th of 2024. We're recording in the Duke Medical School Library in Durham, North Carolina, and I'm interviewing Dr. [Kathryn] Andolsek. And thank you again so much for talking to us. So to start off, what was your- How would you characterize your upbringing in general? Where did you grew up? What was your family like? Kathryn Andolsek 0:43 So I had a wonderful upbringing. I'm just gonna sort of put it out there. I got to live two places every year, but the same places every year, from the time I was born to the time that I was in middle, almost high school. And so the one place I'd live half of the year was this little town of about 1,200 people near the Canadian border in Minnesota, called Chisholm, Minnesota- which actually, I later found out had some interesting connections with this part in North Carolina- but at any rate, Chisholm. And I lived in a multi-generational household of my grandmother, my aunt, uncle, cousins, and my parents. And my grandmother had emigrated from another country [Slovenia] with her husband- who was deceased by the time I was born, my grandfather- but they had come intending to stay a brief time and then go back to their country. They had left two children there. My grandfather came first, then sent for my grandmother [when he] got enough money to send for her. And they had two children once they reunited here in the States. So my dad [Ludwig Andolsek] and his sister were born here, but his siblings were born in another country. And my grandmother never got back to see her other children because World War One intervened, and life intervened, and they really did not have much money. So it was just a challenge. We'd write letters to them, but there wasn't WhatsApp, or the internet, or FaceTime, or whatever. So it was a choice to really relieve. It was not intended to be forever, but it became a forever decision to leave that life there. And for my grandmother, I'm sure life was never better. And I am sure, just reflecting back- kid and memories- that it was a very sad situation to have left kids. I can't imagine as a mom of four doing that, but she made that decision to try to get things to be better for her family, I'm absolutely convinced. And [she] left them with her sisters. It wasn't like she left them on the streets. But that was my little town in Minnesota. Everybody sort of knew everybody else and everybody else's businesses. It was a typical small little town. It didn't have particularly good medical access. It had a physician's office, but the hospital was about maybe 20 miles away. And in winter, which was nine months of the year, there were access issues to get there. And these people were largely poor, and most of the families worked in the mines, and the mines got closed a lot. And so people were unemployed, and there was a tremendous amount of disruption in this little town. And my family had every adult working outside the home. And so they got by, but I think it was because we had my dad, mom, aunt, and uncle all employed, and then my grandmother planted an acre a year of the food that largely fed us. And then there's always some adult, given the nature of the work that they did, around the house with my two cousins and me. And so that was half the year and then the other- And there was like a single school, so I went there. And then the other place my parents moved was inner city D.C., where my parents intentionally picked a community where we were the minority in the community, and so I was in an urban school. And so that was Washington D.C. And I would go back and forth to the same communities. So it would be the same apartment in Washington, D.C., same apartment complex, and it'd be the same house in Minnesota. So it didn't feel as disrupted as my friends who had military backgrounds, where they went from place to place to place to place. It was always the same connection. So anyway, that was basically my life growing up. And I loved it because in D.C., I would go to museums and concerts, and there was so much that was free, like the Smithsonian, and things I had never seen. And in Chisholm, I had this very close-knit community with an incredible amount of freedom, looking back. My job was to take the cash from my aunt's hairdresser business and pay the bills in cash to electricity, and rent, and plumbing, and whatever. I can't imagine being seven years old and carrying cash payments to these places, but again, in this little town, this is what you did. But nobody in my family was a doctor. Nobody at that point had gone to college. So it was probably my- And most of my friends in high school didn't either finish high school, or they got married right out of high school and had a bunch of kids. And so, I was in D.C., and by the time we moved, we moved to the 'burbs [suburbs] for high school, really because my parents wanted me to go to a girls' Catholic school. And there wasn't one in walking distance, and so they moved to a place where I could walk to a girls' Catholic school. So there, everybody got their college degree. Most people went on to graduate degrees. People were still having babies in their 40s. It was a very different group of people. And it wasn't the most affluent girls' Catholic school, which there were others, but it was one where I think education was- at least education for women- was prioritized. And it was a science teacher there that had me really- well, that and volunteer work- that had me fall in love with what I thought would be a career in medicine. CO 6:20 So you talked about how your parents wanted you to be in a community where there were more minority students, or where you said your family was a minority. Do you think their views on diversity ended up impacting your own? KA 6:35 Oh, absolutely. I think they were just very different people from their time. My mother [Regina Burnett Andolsek] was from a town of 400 people in South Dakota, and my dad was from a community of 1,200 people in Northern Minnesota. But I think the diversity that they saw was in this little town. There were multiple Catholic churches. We were Roman Catholic, but I grew up saying it was Roman Catholic because there were several other types of Catholic, and people were from multiple countries. And so the people my grandmother's era only spoke their language, and listened to their radio, and had their own newspapers, and whatever. And so even within this small community, there were differences. But everybody kind of enjoyed those differences in some way. They would celebrate. I always remember food, and dancing, and music. But whether it was Greek day, or it was Italy weekend, or it was Slovenian weekend, or Polish. And so again, there were these separate communities that were clearly separate, so in that sense, there was diversity, but- And there were some indigenous. Not many, but there were a few indigenous because we weren't immediately close to a reservation. Although we were certainly on tribal land. But I think that- and I don't know really exactly what got them into the differences and appreciating diversity, but they both had World War Two experience. My dad was drafted, and my mother volunteered. So probably in the setting of being in the military, they certainly got moved around geographically. And that's where they met, and why they met. But they also probably just encountered different kinds of people, or more overtly different people, not just kind of background- largely Western Europe types of background, but also people of different color. And certainly other people had different languages, so linguistically, they were used to that. But I think it was more the different kinds of people. And I think my Dad's [through his] experience- feeling like he was from an immigrant family, didn't speak English until he went to school- was even seeing back then the visibility of people who seemed to have some upward mobility in this country versus a group who never really achieved some of those same benefits. And why was that? I don't think he would have had any idea of the words we use now for that, like "structural racism," but I think he would have understood some of the things that were happening. And my dad got very involved in politics along the way. His best friend [John Anton Blatnik], also from this little town, ran for Congress and served in Congress for 20 something years, and that's how my dad came to D.C., as his administrative assistant, and for a while legislative assistant. So they were very much into the era of trying to get civil rights, and the War on Poverty, and “make the world a better place,” and clean air, clean water, and that really early environmental stuff that I really remember in this country. And so, I think there was this- some spirit of activism that either was there and got nurtured somehow, or they found it someplace. But anyway, it wound up being that that was the kind of household I grew up in. So, Martin Luther King's speech definitely, [inaudible], the Poor People's March or- all of that were things that I remember from being little. CO 6:42 Can I ask you, what country was your grandmother from? KA 10:08 So I used to say this fairly without a thought, and no one ever heard of it, so it was easy. But it's actually the same country as Melania Trump is from, so it comes with a different level of flavor at the moment. But it was Slovenia. It was the Austro-Hungarian Empire at the time, but it was Slovenia, which has its own distinct language. And Yugoslavia is this made up country that was created after World War One, and it has multiple religions, and multiple languages, and multiple alphabets. These people had no reason to be in the same country really. There was a communist dictator, Josip Broz Tito, who kind of cemented these people together for a while. And because they were communists, my dad actually got hauled up by the McCarthy Commission when they were investigating the communistic threat in the country in the '50s. And so he had go appear before the committee because they thought he was a communist because his family was from a communist country. So, it was- to the best of my knowledge, we weren't communists. But again my father- I'll tell you one thing, one issue I've come to later. People talk about [how] experiences of diversity are who your parents might have objected to you dating or marrying. And my friends in D.C. were largely Black. Men I dated were Black. But my dad sat me down one day, and he said, "I don't care who you date or marry," he said. "They can be any color. They can be of any religion." He said, "You know, everybody thought your mother and I had a mixed marriage because she was from an Irish family, and I was from a Slovenian family." And that was considered different and radically different. So he said, "Whatever." But he says, "You just really can't marry a Republican." [Laughter] So, even in our family, there were biases, but they just weren't around other issues. So I think that just made an impression on me. Also maybe because I was the only girl of my parents, and the only child. My dad used to take me with them to the Hill on weekends when we were in D.C., and he would always say, "You can be anything you want. You can be the first [woman] president. You can be whatever." Again, we're going to the '50s. That was sort of like early imprinting, that anything was possible before I knew that, well, maybe it really wasn't me [laughter]. Or it would be very tough to do. And he would say, "You can be the best. You can do anything you want. But if you do it, you have to be the best at it." And then there was a lot of focus on trying to be as good as you can be. And his whole notion of government was [that] the metric by which government is successful is how well it supports the least of the people in it. If you are supporting the people who are the most privileged, who cares? They're going to do well anyway. But how well do we take care of the least? And so he was really a big champion of what he perceived as being the people that did not have the same advantage. So yeah, I think that rubbed off. CO 13:12 That makes sense. [Break to adjust microphones 13:13-13:19] So, you mentioned it a little bit, but I was wondering more about how you decided to become a doctor, or how you first saw yourself-? KA 13:27 Well, I lucked into this. So I'd done a lot of volunteer work at a nursing home and a hospital, and I loved high school biology. And so I just thought, "Well, maybe this is a career in medicine." I mean, I didn't really know. And at that point, I picked my colleges out of a book. There were physical books describing them. There wasn't an online way to search for colleges or whatever. And I was going to be applying out of high school in the D.C. area, so I was sort of looking around, and I didn't really care where I went particularly. I knew I had to sort of minimize expenses, or at least be careful about expenses. And so I looked at a lot of schools and a lot of options, and- this is a segue this probably is nothing to do what you're talking about- but I got into a school [Northwestern University] that I really, honestly, had no business going into. At the time I was applying, there were a lot of schools that didn't take women for undergrad. Many were about to do that, but within the next year or two because of all the Title IX kind of stuff. But they didn't take it my year. So I had experiences with colleges telling me, "Oh, we'll put you in nursing school for a couple years, and by then we'll be accepting women undergrads, and we'll just move you over to undergraduate campus," or that kind of thing. But I thought I really want to minimize the time spent. And there were a couple programs I found- I didn't find all of them. There were probably a few more I didn't know about, but I found a couple of them- that offered a combined undergraduate and M.D. degree, and so I applied to two of those. I got into one [Northwestern University] and got waitlisted at the other. Really no advising. I never talked to a doctor about their life. Or I never- there was no guidance counselor in high school that was really telling me about- there weren't people that have gone into medicine really at my high school. People had gone into humanities, or law school, or social work, or whatever, but it wasn't- And these were all women, and I graduated in 1970, so it wasn't a hotbed of science in particular. But there were advantages of being a girls' school. I was on athletic teams, which I didn't realize was unique at the time, at that point when one in 30 women played high school athletics. But I did because they needed that many people to field the team. I wasn't that athletically great, but it's like, "Okay, we need a certain number to play on this team. So you're at least gonna run and move." And I was on the debate team. I was on the newspaper. And we were small. We only had 70 people in the graduating class. So by nature, being small and all women, you were gonna get these jobs, which I'm sure would have gone to- or more likely would have gone to- male students if I'd been in a large public high school. Or I might have been reserved enough. I wouldn't have raised my hand or done things. I think you just had to step up and do it. So I think that was- and my school's motto was- it was a Catholic school- but the motto was the word "service" in Latin. And it was on our jacket as a little patch. I think you just by osmosis kind of infused the sense that we really should be doing something for other people and did a lot of volunteer work and what we call now “service-learning.” But that was just all part of what they did. That was kind of part of the curriculum. It wasn't even co-curricular. It was embedded in the curriculum. And a lot of these nuns actually wound up leaving the convent because this was a time of change in the Catholic Church, too. And so these women were bright, well-educated, had a real passion for service, but they were objecting somewhat to the hierarchical nature of the church and the sense that it was really getting in their way of a mission to the underserved. So I kind of lucked out, I think. [Laughter] CO 17:21 So what was it like being a woman in the 1970s in medical school? KA 17:33 So I think anything you do is normative for you, right? I didn't have a compare and contrast. I didn't know a lot of other people. It looked to me like things were changing. We knew there weren't a lot of women, but things were changing. I knew one of the members of the faculty- I remember the first woman who ever lectured us was a physician. And I can tell you what she wore to this day because we hadn't had women lecture us in med school. It was so incredibly amazing to have this woman there who was pretty. She was- gorgeous dress. She had a husband. She had kids. She had a normal life. But it was like, "Wow, you could be that," because there just wasn't anybody like that we'd seen before. But there was another woman that I knew that was from actually Slovenia originally and had come here and emigrated. But she had gotten paid- and she was very forward about saying this- but she was paid half of what her husband was paid to be on faculty because they knew that she had a husband, so she didn't need that money. So again, it was kind of an interesting time. The kind of urban legend for the med school was- and maybe it wasn't true- but they said that each year for the med school, they took four women or four people of color because you did four people to a cadaver. And they thought it was unseemly for men and women to dissect a cadaver together, or for Blacks and whites to dissect a cadaver. Now, again, I don't know that was true, and that had stopped before our class. But that was the origin story of getting women and minorities in our school. So at any rate, by and large, I felt like, you know, the guys were guys. And I felt like, in retrospect, we tolerated a lot of what you'd call now "microaggressions." But it was kind of just putting your head down and trying to ignore that and to keep it in perspective. It wasn't getting- it was unpleasant- but it wasn't getting in the way of what we learned. With clinical stuff, I felt usually pretty gratified that the things I thought might be impediments- like male patients telling me about sexual issues- that often a lot of men told me it was easier to talk to me as a woman than it would have been to have that conversation with a man. So I felt like it rarely seemed to impede. People would sometimes laugh or be nervous. And often they would say, "The nurse was here," or whatever. They wouldn't quite get- But again, there weren't a lot of women that they would have expected to be physicians at that time. So, again, I don't think I had much of an ego about that. It was more stuff that you laugh about. And, frankly, certainly when I was a medical student, to be mistaken for a nurse wasn't bad because the nurses were competent. I was probably pretty inept as a medical student. So it's like, okay, how am I going to be offended that somebody thinks that I have this level of competence? It just seemed to be disrespectful to my nursing colleagues to feel like it was demeaning to me to be considered a nurse. It was more that- again, playing the odds- you see a woman in a little white coat, they're not going to be a medical student. So it made sense from what the patients were- but at any rate. So I think it was different. But I didn't feel- it was all about trying to get us as good as you could get and experienced as you could get. So I didn't feel- Yeah, there were funny instances about it, but there were not- I think the worst was when I came here [Duke University] for residency, and they had made the women wear these little white skirts, and I hated the little white skirts. And what I wanted was pants, and they wouldn't give us pants. And I want pockets, because you stuffed all your [inaudible], and there were no pockets in the white skirts they gave you. And so one of the guys in my class was a very slender guy, and he was from Louisiana. It was just, really, the best of Southern charm. And he said, "I'll get you pants." So he went down and sweet talked to the people who gave out the uniforms that he needed two extra pairs of pants. And the women of course gave it to him because he was so sweet, and so he gave me those pants. And so I wore pants. But they wouldn't give me a pair of pants. So you just worked your way around it. But it wasn't like I've heard of a lot of the abusive stories of my friends of color. But again, a lot of people would certainly mistake who I was. KA [Omitted 22:14-22:44] CO 22:44 Yeah, that all makes sense. So when you first arrived at Duke, what were the diversity efforts like at the time, or were there any? Or the general attitudes people had towards more marginalized students? KA 23:00 I did my residency at Duke, so I came here in '76. So I think my big “aha” with this started when I was looking for apartments, and some person was helping me look for apartments. And the person who was helping me look for apartments said- because there's a really cute apartment that I wanted- and they said, "Oh, you can't live here because there's Black people living here." And that was a shock to me because that wouldn't have crossed my mind. And in the end, I actually wound up getting an apartment there. But it was just the whole idea was very different. Now it isn't like I hadn't lived in places like that before. But this was so much later and just was so overt that that was kind of a surprise to me. The other part that was just really clear was I moved in '72, and '68 Watts Hospital- the old white hospital- and Lincoln Hospital- the old Black hospital- had combined. And obviously there had been some growing pains in that, and not the least of which was probably power differentials. Because all of a sudden, you went from two head nurses to one head nurse, or two CEOs to one CEO, and who won in that. But it was clear that there were just some patients and staff that definitely felt differently about patients of color, that you went to Watts to avoid some of the Black patients or Black peers. And so, again, that was still around in '76. When I came here, even though it [the merging of Lincoln and Watts] had happened in '68, that was close enough on people's minds that that was sort of a current thing. And then at Duke, the thing that I can still remember making my skin crawl was that the clinics in the same specialty for the more privileged patients- which tended often to be white, although not maybe 100% white, but certainly the more privileged patients- [had] nicer furniture, coffee, and quieter, bigger spaces, and they were the private clinics. And in the public clinics- where presumably the residents would be learning- were the ones that were dingy or in the basement, smaller, more cramped, were patients scheduled in, not the amenities. So it just felt different. You'd be in the same building, but you'd be on two different floors of the building, and it felt like such an artificial distinction to me. And in terms of diversity, we had diverse- I had diverse peers in my residency. I had a Native American Indian co-student, and I had a Black student a year ahead of me who was a resident. And I don't remember them feeling- we were family medicine. I think we were getting marginalized because we were family medicine. I don't know whether we felt more marginalized because women or gender. I don't remember that. I do remember the American Indian student- whose daughter is here, actually, which I just found out about within the last couple of months- he was much older because he'd been a PA for many years, and then came back to medical school. So he just may have been able to handle it because he just had so much presence being older and having done a lot of patient care that probably people couldn't get away with some of it. But I don't think that- just my recollection is that this wasn't top of mind, or at least not discussed. Now, again, maybe he didn't feel comfortable discussing it with any of us in the residency, but we spent a lot of time on-call and long nights. However, I don't think that ever really came up. If there were visible efforts to get anything to happen at the student level, I certainly didn't see them in the residency level. Except to say that the demographics of the residency group did not match the demographics of Durham. That was pretty obvious. CO 27:20 How did you first get involved in active diversity efforts? KA 27:24 Well, I think I was involved in medical school, and I was involved in residency. But I think from the perspective of diversity efforts being often gender, and race, and ethnicity, we would all get together to talk about ways to improve our lived experiences, but it was always all of us. So I guess I was- and really, that probably happened through the '90s, where I really felt like the diversity stuff I was doing was because there were few women and few Blacks, so we were all together. And it wasn't until later where it was like, "Oh, gosh, I guess we're now- there are more women in medicine, but how come there's not more Blacks in medicine?" and realizing that the gains were not equivalent across all the different areas of diversity. So I think that was- But early on, I think those were active colleagues trying to kind of make things better in terms of admission, or onboarding, or curriculum, or- but again, not- What I wish I recognized earlier was that the strategies were not being as useful as they might be to everybody. CO 28:43 Early on, when it was mostly young doctors or residents getting together talking about this, what would you all end up doing trying to improve diversity efforts? KA 29:00 [Omitted 29:00-29:48] KA 29:48 And you know, some of it was trying to get the visibility to be on selection committees for the chairs or the deans or whatever. And we used to laugh as the same three of us used to get appointed all the time. We thought, "Can they not think of other women and other Black people?" We show up for the first meeting of a selection committee and it's like, "Oh, here we are again." But it was clear to us how silly that was because there were so many other people that they could also give the nod to, whether we're being asked because they think we're complicit or easy or whatever, or they just don't know. And they're just kind of going to the usual suspects. But I do think there was the tension between do you try to do- and probably we should have done something in the middle- but do you try to be with an affinity group alone? Or do you try to magnify your presence, given that you've got a finite amount of time? Do you try to get your presence in larger organizational structure? CO 30:49 That makes sense. And then you alluded to it a little bit, but specifically within family medicine, what was the activism scene like, or your experience with it? KA 31:07 I think we're very counterculture at the time. People called us the "sandals and granola group." But we didn't have a public-private distinction or clinic. So all patients were our patients. And they might happen to be my patient, just because they started seeing me, and we believed in longitudinal care, or they might happen to be an attending's patient. But they were seeing the patient who was Medicaid or no-pay. We saw people for no-pay. We absorbed some of the clinics that had been at Watts Hospital for people without financial resources. We did a lot of outreach to the community. So I feel like we did a lot of that. But we were still considered bizarre to the medical center who didn't really see us- I don't think- as really legitimate as physicians. We weren't specialists and internal medicine or surgery or peds or whatever. And I think again, we were pretty new as a discipline. It only started as a specialty in '72. This was '76ish, late ‘70s. So I think they didn't understand what we did. This idea of generalism was not really compatible with this very large, academic subspecialty area. And it's still kind of rare. There's not many private med schools that have departments of family medicine, even now. One has to believe in a specialty of generalism to be able to get to the point that you would even respect the people who did that. CO 32:36 That makes sense. And how did you first get involved or interested in graduate medical education? KA 32:44 There's a little part in the middle. I'm just gonna tell you. So to fund my medical school, I got a scholarship from the National Service Corps that was going to pay for medical school and give me a stipend to live on. And I thought I had more money than I would ever need in exchange for service to the underserved, and that's what I was gonna do anyway. So it was a win-win to do what I was gonna do anyway. And they paid for school and gave me money to live in, and I lived in a dorm anyway, so I saved lots of money. And it was like, "Wow, I'll never need more money than this." So that was great. And then when I was going to do my service, at the end of residency, I looked at a very rural practice in North Carolina- which I might have done, I would have been comfortable doing- And I looked back in Chicago, where I'd gone to med school, and I looked back there, and I had been involved in a free clinic in med school. And my job was to organize our clinic sessions and recruit faculty to come supervise the med students. And I got involved in running some grants for the clinic, and so that was all part of the flavor of med school. But anyway, I was gonna go back there potentially as their- one of their doctors. So in the end, I decided not to do this rural practice thing just because I felt like I would have been too isolated and too caught with too many patients between two clinics in a hospital without an NP or PA or another doctor, and I just wasn't sure how I could pull this off. So I went back to Chicago. They didn't have my site approved, but they put me in a similar site [Uptown People’s Health Center]. So I was in this inner city clinic for what I thought was gonna be the rest of my life. And after the core experience was close to ending, there was some political stuff going on with the clinic. And anyway, it looked like I wasn't gonna be able to continue there past my core obligations. So the program director back here called me up and wanted me to do a curriculum project and I said, "Okay, I'll do that for a year but then I'm going to be looking at community health centers." I wanted to work at Lincoln, both before I left residency and later, but they weren't taking family docs. Dr. [Evelyn] Schmidt was very opposed to family docs, and I was not an internist or pediatricians, so she didn't want me. She liked me, but she didn't want a family physician. Got that. So, anyway, there was no role really immediately in Durham. So I came here [for] what was supposed to be for a year, and I met a guy, and I- four kids later- have not left Durham. So I went away for a few years, came back in '81 on faculty, and I've been here ever since. And so, as part of that, I got very involved in residency teaching and education. And I actually wanted to be involved in the medical school admissions processes. And the then-Dean of Admissions told me that my med school wasn't an IV, so he didn't want me involved in admissions because that would be a bad message to give the student applicants. So it's like, "Okay." But I got very involved in residency teaching, loved it, and there was a woman- two people that were faculty development people that teach our faculty how to teach. And so I got to work with them and tried to get a little bit of teaching skills. And anyway, a few years later, I became the residency director [of the Duke-Watts Family Medicine Residency Program] and loved it, thought that that was just a wonderful gig. And Duke tried to close our department [Department of Community and Family Medicine] as an experiment that failed. And they were very upset about some other things, but we had had this glowing external review [by Llewin and Associates, Inc. from Washington, D.C.]. And so in the end- largely because all the family docs in North Carolina said they would never send another patient to Duke, and they would send them eight miles away to Chapel Hill, I think- the university changed their opinion and kept our department. But we lost our chair [Harvey Estes Jr.] over that. We lost the Division Chief. We lost a lot of people who resigned in protest. And so it was a fairly tumultuous little period. But the other thing that happened during all of this was I was enough in a leadership role in the residency practice, and the residency in Chicago, I'd begun to see patients that in retrospect had HIV/AIDS. And here, there was early HIV/AIDS. Duke had a lot of wonderful trials. [I] can't say enough positive aboutJohn Bartlett. He was incredible. But it was also clear that there was a lot of fear in the community about people who would take the patients for primary care. And so we took a lot of the early HIV positive patients or patients who were in the at risk groups who later were found to have HIV/AIDS because there's just a lot of places they couldn't get care. And so the nice thing was being able to work with A.I.D. people to get them into trials sometimes. Because that was their only shot at getting access to medication you wouldn't even have access to otherwise. Yes, they might have the placebo, but they also might be randomized, the other trial. But it was also the opportunity to just care for a really unique group of patients who were marginalized in various ways. And this was people who had clotting inherited diseases that were in a particular clotting clinic at UNC, who then later- because the factor XIII that they gave them was pooled blood and extractive pull blood- so a lot of them got HIV from the treatment for this clotting disorder. And then the individuals who were gay or bisexual, or people who had exchanged sex for money, or people who were IV drug users- there was just a lot of other populations who were at risk, but we provided care for them and we didn't care- well, we did care- but we provided care for them regardless of financial resources. So if they could qualify for some kind of federal reimbursement or state reimbursement, fine, but otherwise, we made some allowances that you could be on a payment plan and pay for a dollar or whatever. And, at one point, they estimated we cared for a fifth of the people in Durham. Now Durham was a lot smaller then, but that was still our little residency practice. And we had evening hours until 9pm every night, and we had Saturday and Sunday hours- this was before urgent cares. But we were really able to do a lot of homecare, nursing home care. I took care of patients at 11 nursing homes locally. I did a lot of home-based care. I was Medical Director briefly for hospice back when that sort of started here. It wasn't a residential hospice, but it was hospice in people's homes. [I] worked with a lot of the visiting nurses, so that was great. But I was getting to get more involved in residency education and thought, "Oh, this is really cool. I will do that." But in '98, I stopped that chapter of my life- I've been here too long, so I've had many, many different lives- But in '98, my department chair decided to be- and that's a story. One part I won't tell you about- But one decided to start a new division, and we were the Department of- I don't know what the name was, and it's changed about five or six times- but it had "community health" in the title [now Division of Community Health]. But we didn't have a community health division, and we had efforts in the community, but we didn't have a label division to it. But he decided to create a division. And Sue Epstein Yaggy [Dr. Susan D. Yaggy] was division chief, and Michelle Lyn was in that division. There are some other folks that got pulled in. But I went there as the first physician. So what that was a chance to do is some things I'd done in Chicago in the community health center in Chicago, but bring them to Durham. And so this is when we started in alliance with Lincoln County Health Center, the [Durham] Health Department, the Housing Authority, with Duke, with North Carolina Blue Cross Blue Shield, and with all the major stakeholders in the area, and we did some projects based on community needs assessments. So some of the most fun things were we discovered that- I had in mind diabetes and asthma and whatever- but we discovered that kids in public school had daily tooth pain, and a huge proportion of them had no dental care and had no access to dental care, and only a couple of dentists took Medicaid and only a couple of Medicaid patients a year. So the community wanted dental care for kids. I don't know anything about dental care for kids. I'm a family doctor. But I learned about dental care for kids, and what we did was created- with everybody else- a dental van, that's like a cardiac cath van, and went from school to school to school to school and got permission from the schools, and got- the Health Department kicked in a halftime dentist. And then they got permission from parents to let the kids get their care, dental care, there. And so we got kids dental care. So that was a very early initiative, and Duke parked our dental van where they park their cardiac care vans. And so again, everybody contributed a little bit. We had a group of great undergrads who worked with us to find a very large after school program that took kids from schools that were high free and reduced lunch. These kids, some of them had lunch at 11 in the morning- these were little kids. They weren't high school, like grade school- had 11am lunches. And then this daycare where they went to, some of them didn't get picked up until seven in the evening, and we knew some of them didn't eat when they went home. So we got a nutritionist from the Health Department to do some assessment of nutritional status, and shockingly, these kids didn't have food. Probably today, we'd say they were in “food deserts” or whatever. But nonetheless, they weren't getting fed. So these undergrads helped us find restaurants that were tossing out food, but had food available. And we figured out what it would take to get a food storage that would pass inspection at the daycare center from the Health Department helping with what they do and inspections. And getting trucks that people would donate that were- the use of the trucks, not overall trucks- but that would do food transport anyway for just where the food goes to grocery stores and dairy or meat products or whatever that have to be refrigerated. So we'd get those trucks to pick up the food from the restaurants that would give us the day's food from last night, and then deliver them to the daycare so these kids could have a snack or healthy snack when they got back there from their school day. So we were trying to, again, connect some of these dots in ways that are really easy. There were another couple programs that we did where we did a home visitation program to low-income older adults, who, by definition, were low-income, because they were in low-income housing, but a huge number of them had never gotten Medicaid. So they all had Medicare, they all qualified for Medicaid, but they hadn't done the paperwork for it. So we got a part time social worker from the Health Department- or Departments of Services- and we got a little postage stamp closet from the Housing Authority. And we had the social worker go door to door and enroll these people in Medicaid. So with Medicaid, they got prescription drug benefits, because just on Medicare alone, they didn't- at that point nobody had that other part of Medicare that will pay for prescriptions now- But then they qualified often for help on heating, or food stamps, or other services they were eligible for, but they'd just never gone down and enrolled in those services. And then we got churches to agree to pick weekends, and Saturdays or Sundays of these weekends, to provide food. Because they were getting like, some Meals on Wheels delivered during the week, but they weren't on weekends, and so we got a food source. And then The Y [YMCA] had extra capacity at some of their exercise and pool sessions. So we had a church van to pick up people who wanted to go to do exercise classes at The Y. So everybody was giving a little bit so that you didn't really have to create a whole lot of new money to fund these things. But again, you just sort of had to connect the dots. And we did a little bit with the Latino community at that point. Because it was clear there was a Latino community, and you'd say, "Okay, what are we going to do?" And people go, "Oh, no, there's no Latino community." Well, yes, there is. If you walk around town, there clearly is. And there was a great nurse at the nursing school who did a lot of outreach and needs assessment in Latino community, particularly around the violence when there were just the men here first- which kind of reminded me of my grandfather when he would have been here first- But when they were just guys, and they were all paid in cash, and everybody knew when they were going to be paid. And so there were a lot of robberies from these people, and they wouldn't report to police because they were afraid of being deported. So it was kind of a revolving cycle of these people getting robbed. So anyway, you couldn't have a bank account unless you had a social security number, so this is when El Centro started a credit union so that you could open a bank without needing a credit union. And that allowed for some greater security and decreased violence against these men. But after the men had been here for a while, the women and then kids started to come, and for a while they were following a migrant stream. But eventually they kind of stopped. And we're here, and you could see it by walking around and seeing all these little Spanish shops and food places. And so anyway, it just was very clear [we] should be getting ahead of that curve. But I don't think we ever really got ahead and probably made a whole lot of mistakes other places have done. But anyway, it was this community engaged work that I did for a while. So then I thought, "Okay, the only thing that's ever gonna get me out of this is residency education again." And the head of all Duke GME [Graduate Medical Education] reached out to me because he knew I was really interested in education, and he hired me to be the Associate Head of GME. So I left my community health thing, in terms of my role in the division, but I still did some clinical work in the division. And I still do some clinical work with them. But I left my real job. But it was just so clear. There were assets different people had. Like, one year, at Lincoln, Dr. Schmidt couldn't find doctors and I went to her and I said, "Okay, so faculty really want to help. So if we put together each a half day of every week, and said, ‘we'll send you a doc, a family doc’- which I know you don't want- but we'll send you a family doc, could you put us to use in a way that would help with being a band-aid for your lack of a workforce?" And so she created a way that we would be, collectively, the kind of urgent care doc. And that would keep her docs, who were internists and pediatricians, seeing their own longitudinal patients more without having to pull them to be an urgent care doc. So that was a win-win. And so I did get to work at Lincoln eventually, for a couple years, and loved it there. So it was all trying to see who's got what that could help and throw this in. And at a time when I don't think there was a lot of other Duke initiatives really doing this. You talked about the people that have to worry about grants. Probably the best thing was- I think it was Michelle Lyn, who's now the division chief [of the Department of Family and Community Medicine], who had an MBA and was brilliant with coming up with how to fund these great ideas- but she really helped convince the then CEO that we had geo-mapped where patients who went to the emergency room at Duke or Duke Regional came from who were there for a couple of key conditions, like asthma, hypertension, and diabetes, but who didn't really need to be in the emergency room. And, shockingly, they were in a few zip codes, and they were in zip codes that were mainly minority and poor. And so they gave us that money- she convinced them to give us half that amount of money that they had paid in care [that] they didn't get any money for to upfront do some services, with the thought being that they would then spend less money. They wouldn't make new money, but they would end up spending less money. And it worked. And we just did some case management of patients with community health workers, which is something I've done a lot of in Chicago. And we got peers to sort of become community health workers for their neighborhood, and help, again, reach out to people to make sure if they got a prescription for insulin, they were able to go fill it. Or if they needed their eye appointment, they had somebody to get them there, or whatever it was that they needed, rather than just saying, "Well, people just missed their appointment," or "People just didn't get their medicine," but to try to do those things that now we've got things like patient navigators and other types of members of the healthcare team. But it was sort of the first attempt to care management prospectively with a group of people that we knew were going to have more challenges to get to the resources they needed. CO 48:47 That makes a lot of sense, and thank you so much for backing up into the community engagement and then the community health programs. And I was wondering- You talk a lot about initiatives that are extremely interdisciplinary and involve physicians, but also involve social workers and a variety of different types of doctors. What has it been like working on teams that are like that, that are very interdisciplinary or involve a lot of different types of medicine? KO 49:16 I don't think I have an experienced where I haven't done it, so I don't have the other way around it. My best course in college [Northwestern University] was a geography course where they did a square mile area in Chicago, and they divided us into teams, and we had to work on improving something within that square mile area. And shockingly, mine was health. So it was there that I learned about physician assistants for the first time and figured out that this care was going to be delivered by PAs because it was too small to be done by a physician, but PAs that were then linked into the broader healthcare system if somebody needed to be hospitalized or needed a specialist or whatever. So, here, my department [Department of Community and Family Medicine] had the PA program because I didn't really fit anyplace else. And for a while, we had the PT program. And we always had nurse practitioners and PA clinicians who are our partners in the practice. So I don't think I ever practice practice when I didn't have these individuals around. So I don't think I know what it would be like to do it. But it was also very clear that, again, everybody can contribute the piece that they did, and we needed everybody. It wasn't a sense of being territorial because we just needed all hands on deck, and we needed lots of different kinds of hands to do the work. In the same way, we needed these peer navigators in the community because you talk about who has trust in the community, it's somebody who probably lives there, and they're going to listen to that person more than they're going to listen to me. So a lot of it was trying to do some engagement. So I used to go talk to some of the pastors to talk about things like flu vaccination. And we tried to do some health education out of barbershops because that's where people went. So if you inform people, if you give people- Talk to them. What are they seeing? What do they feel comfortable with? What are the areas that they feel like they'd like to have more information to give to their clients? You can actually extend what you do with the people we recognize maybe as being the formally trained health professionals, but also just the people that people are going to be talking to. And when I was in inner city Chicago, the group that I loved was these healers, and in the Spanish speaking community, curanderos. I started working with them. Because when I'd see somebody that I knew had PTSD probably, or some depression, or whatever, I'd often refer them to them because they had all the cultural context I did not have with these patients. On the other hand, if somebody had something they thought was appendicitis, they'd send it to me. So we had a very easy referral network there. And I wouldn't say they have formal training, but they had a lot of informal training, and more importantly, the trust they were going to get at stuff I would never get at because either my language wasn't good enough, or I just didn't have the context of what that was in the background. So yes, I think you have to have everybody. CO 52:00 That makes a lot of sense. And you talked too about- KA 52:03 Oh, I'll tell you the other reason. So when we did some of these things that were with home visitation- either in neighborhoods that were where some of the housing projects were in Durham, or in this Just for Us program, which still exists, which was for the older adults- At that point, if I went and did all the home visits, it ran through the Duke Physician Payment Retrieval System, or whatever. And we would wind up getting $13 a patient visit. And this was a long time ago, so $13 was worth more than it was now, but it was still $13. If we hired the nurse practitioner out of Lincoln, and they did the same visit, instead of me, they would get $95. And it's because the [Lincoln] Community Health Center had some favorable reimbursement for these low income patients, and because Duke extracted so much money from what was billed and then delivered. So again, she could afford to take the time she needed to see patients getting $95 an hour, versus I would have to churn through a million people to get the $13 out. So some of this just made sense with the quirky reimbursement that we have to try to figure out the team so that you can optimize the amount of money you're getting to providing the service the patients really needed. And I lost the fun of seeing those patients, but the patients were getting their needs met. And in the few times the nurse practitioner wanted to talk about somebody, then I got to see them. So that was fun, but I had to look at the bigger picture and not just how I would be preferring to spend my time. CO 53:28 That makes sense. And you mentioned, with the residency teaching program, really loving the opportunity to get to do the teaching. How did your activism or diversity efforts you think filter through getting to do the teaching? KA 53:48 I think for one thing, for my own program [Duke Family Medicine Residency Program], I think there were some really clear ways that I felt like I could do that. And not just me alone, other people too. It [has] never been really anything I've done. It's been always a team. But I think for residency, one of the things I wanted people to know is what they were getting in Durham. So really just some- as part of orientation, which they were required to do- just something to give them some introduction to the community, and why Durham was so unique, and what had gone on with this community. Really speaking with some of the indigenous groups that had been in the community, but also- and again, it was hard to find some of this information pre-internet- but finding out some of what makes this place- Who has been in this place before, and why are we here now? And what some of the issues have been in the community. I think there's somebody- if you haven't talked to him, you really need to talk to him- Lovest Alexander [Jr.]. Lovest and I always would say we spent a night together, which sounds much more scandalous than it was. But we convinced the university to open a special needs shelter back when we had one of these events where we lost power in the community for a bunch of days, and there was this horrible ice storm. And so, the university gave us a building. And then we had a special needs shelter because the shelters in town wouldn't take people at all that were sick. So we had cots, and we had people bringing us in these patients that had everything from mental retardation, to psychiatric disorders, to on insulin, and needing asthma nebulizers and inhalers, all kinds of mixed groups of people. And the University Food Service brought us food. But they needed medical supervision, so Lovest and I were there. And I learned so much about Lovest, including, as a person from here and going to Central [North Carolina Central University], they would march up to the Howard Johnson's Restaurant where it was on 15-501. I don't live very far from it now, although it's gone. And they'd get arrested because they weren't supposed to get an ice cream cone at Howard Johnson's as Black students. And so then the police, he said, would laugh and say, "You know we've got to arrest you," and whatever. And they get arrested and booked and then let go. And then the next Saturday, they'd go off and do it again. But just the differences in the lived experiences here. And I knew from home visits, that there are people here that didn't have running water or electricity. And so even here in Durham, it's not like everybody has done well in Durham. And even in the African American community, there were African Americans who were very middle class and affluent and politically connected, and people who weren't. I don't know where I was yesterday, someplace. But I said, "One thing"- I think because when I was younger- "is I really have some sense that I can tell who's being left out." Who's not at the table that should be at the table. And I think that was something kind of early on. So I wanted the residents to get a condensed version of what is this community they're coming into, the best that I can be informed, by film or books or the kind of work you're doing, whatever was there. And there is some, or there was some, but there's so much more richer information now. But I didn't see a lot structurally happening. But my own residency, I used to take people on bus tours. So we would go around the town and see different areas and stop at places like Lincoln Community Health Center. And why is this significant to the community? And even in my current program, I try to get involved in like, who was Pauli Murray? And why is Pauli Murray so exemplary to some of what we're doing? And people like Pauli that we don't even know yet, or we don't have their names yet, but they were working behind the scenes to get this work done. So I tried to do that. The thing that I did that was probably somewhat controversial was the chancellor [of health affairs] [Dr. Ralph Snyderman], for totally unclear reasons to me, decided that they were going to measure the chairs’ performance and different dimensions and give them like a report card. So he asked me to come up with a couple of metrics for the chairs' performance and [inaudible] me, residency education. And he didn't really care what I did. He just wanted something to go on record. So one of my three metrics was the recruitment of underrepresented minority residents. So I looked at the- the chairs would tell me, "Well, there's just no applicants. You just can't find Black radiology applicants. They just don't exist." It's just an example. I'm not just trying to pick on radiology. But all the fields would say this. "They just aren't there to be recruited." So I would find databases that would tell me how many residents in the country were from different race and ethnic groups, even back then. And so simply look at the proportion of them, and did the Duke residency programs have that same proportion of residency grads, of residents, in that specialty, that area? And so if they had the typical number you would expect, they would get a little green. Because I tried to model this after what the hospital was doing for their quality improvement metrics. And if they had a little less than that, they'd get a yellow. And if they got way below that, they'd get a red. And then if they exceeded that, they'd get a blue. So we have four color combinations. And I wasn't there to pass judgment, but just say, if you don't have the same proportion as there are nationally, have you ever been curious enough why not? And what might you want to do about that? So again, that was around 2002, 2003. So I don't think that was the time when that type of thing was as thought about or talked about. And again, I'm grateful to my boss [Dr. Ralph Snyderman] for letting me do this. This was not a hugely popular move. But I was really surprised, having been a residency director, that people weren't curious. They just expected people to find them. Then it's like, well, do you ever go to recruiting fairs to some of these affinity groups for medical students who are of color? Or Latino Medical Student Association? SMMA [Sinkler Miller Medical Association]? Do you ever try to get residents maybe from another program? And we had residents here who were very happy to work with programs that didn't have diversity, to reach out to their applicant pool, or to the people they invited to interview, so people didn't feel like they would be as alone or isolated, even if there wasn't anybody else who looked like them in their program. So, again, it was this conversation starter was what I intended it to be, not some way to beat up on the chairs. But I guess- in med school, I proposed them starting an MPH in my med school [Northwestern University]. And I got the MPH, although I wasn't the first person to finish it there. But it's like- I love data. And to me, data are not judgments. Data are conversation starters. You should be curious about why it says this. And maybe they are wrong, and you get better data. But you also may learn something by not being afraid to look at your own data, and seeing if you couldn't influence it in some way. CO 1:00:37 That makes a lot of sense. And, within GME overall, what were- I guess you've talked about this a little bit- but what were some of the efforts you made to help use GME as a way to increase diversity within medical education, or who's becoming doctors? KA 1:00:56 Yeah, well, I think trying to find out what would work, what would help, what would be good strategies. And I think trying to listen to those constituent groups. And it was race, it was ethnicity, but it was also other things. Women. And we had no parental leave- not that they're the only people that have babies- but we had no parental leave. We had very [pause] inadequate resources for people who might be struggling in some way. And so I guess, again, being in family medicine, I knew some of the people that could help sometimes do assessments and find out that there were some people who had learning differences and had never known that because they were so smart, they'd managed to get all the way there, and that was when they stumbled. Or people who, just like other patients, had depression, or had a substance use issue or whatever. And again, the advantage was finding that early so you get people the help that they needed and get them back on track. Or what we now recognize as burnout or whatever. So, again, I think it was trying to develop a pathway where we could listen, and then try to work with groups to do that. I know there was a wonderful group of Black residents who were very helpful, incredibly helpful, and very generous with their time. And I didn't always understand some of what they wanted me to do. Again, they were helpful in educating me about things. But some of it was even the mentorship for them. And so I actually try, in small ways, to try to find, not just mentorship, but sponsorship. Can I find ways to get these people connected with other things that can be ways to enhance their career? Or network them with somebody that they don't know who could be helpful to their career. And just seeing where that more thought or activity can be helpful. I felt the same way with issues of mental health. A lot of my energy early on was trying to do activities to help people's wellness. And then a lot of people, the residents, would push back and say, "Why are we responsible for our wellness? If the system weren't so challenging, we wouldn't be so- need that attention to ourselves." So, you can't yoga yourself out of something that's a hostile environment. So, how can we improve the environment? I don't think I did a good job with that. But I think that they helped me understand that there was more. Things were not simplistic. It was not all individual effort on their part that needed to be expended. And there were just more structural things that we needed to look at and figure out ways with them to make these better. CO 1:03:49 What was it like going from being a student that was asked to come be on a lot of those committees to being the administrator? That was- KA 1:03:55 Well, humbling. You realize how much power you don't have. Yes, these are great ideas, and I'd love to do them, but I don't have fairy dust or a magic wand yet. So it's like, okay, some of these things take time. Some of it is residents are brilliant and energetic, and to some extent, they want to see change. And I love that. I'm really sort of a change junkie. I love to change. But sometimes it felt like I'd change one thing one way, and then the next year's group would want it the way it was. And so we'd change it back. And then we change it- So some of it is just okay, how much of the change is about [how] they want to make an imprint on something? Versus how much is this going to be really a sustaining thing that's going to be good across the board? So I remember parental leave was an example. Initially, people really didn't want parental leave, but that was at a time when the boards were all viewing parental- and I saw this early on- the boards all took parental leave very differently. And if somebody was going to take leave time and then be stuck having to make up a lot of time at the end, they probably didn't want to do that as much as somebody else, who maybe their board didn't make the makeup all that time. So, they were not homogeneous in what they wanted, I guess is the point. And who were you listening to? And whether that was really informed by a community or a smaller group of people. But I think I'm still learning that with the students I have now. CO 1:05:26 How has your work as a clinician in women's health or with pregnant people impacted how you worked with pregnancy or parental leave within the GME program? KA 1:05:43 My work with patients? Well, I guess I feel- I don't even know what to say about that. I did a lot of OB when I was younger. Probably the first 20 years of my practice, I did a lot of obstetrics. And I was lucky for that because there were no women at the time that did- well, first 15 years- there were no women in Durham who delivered babies, really, except for me and one other family medicine faculty member. And because OB was a new specialty- OB was all men when I started being in residency. So there's been the gradual feminization of obstetrics, but early on, there weren't other women clinicians. So we got a lot of OB patients because they didn't particularly want family medicine- and I don't think they knew enough to know that- but they wanted a woman delivering the baby. And [I] really got to be part of that transformation of OB being pretty medicalized to OB being a little bit more permissive. When I started, men weren't in the delivery room. And women all got shaved, and an enema, and tied down with their IVs. And so again, it just was a very more medical process, and really devoid from trying to have any kind of sense of this kind of miracle that you were happening- You're bringing it- And trying to maybe think about safety, but it may not be all data informed. So anyway, I think that's different. But I think there just is the recognition, even now, that young parents go through a lot. Any parent goes through a lot, but young parents in particular go through a lot. And there's- probably worse in some way now because there's all this information and social media and stuff. And so I think the advice you get is not necessarily maybe the best advice. And I think a lot of the advice also seems to be, like a lot of social media, into suggesting that maybe you're not doing it right. Which I think tends to create more guilt in people than maybe the women a generation ago used to be. But I think the idea that most developed countries give a lot of parental leave, and this country lags far behind that. And yet we have worse infant mortality rates, worse maternal mortality rates than a lot of third world countries, let alone first world countries. There's something wrong with that picture, and how we need to back off to be really family friendly and pro-life after the baby's born, [laughter] not just at conception? I think there's- To me, it's incongruous to say you're putting all this effort on whether an embryo is a person, but once they're here, there's no support for moms and families. So I think that's all part of it. But there was a resident here who got very involved in pushing parental rights for residency trainees. I had gotten involved with another group nationally to try to do this. And it was really a pleasure to get to be part of that as a couple of groups got to the same place. And I think my addition was looking at the boards, and having gone to the boards, and gotten the board leadership to get interested in this topic. And I'm curious why some boards did it one way and one board did it another way. And it was really then the boards that came to a common understanding of leave time for residents. Because ultimately, you do residency to become board certified in something. So boards came to a common understanding, at least at a minimum, and then that was about six months before that residency group decided to endorse pretty much the same kind of a plan. But I think it really helped pulling in the board piece, and in particular getting the board to be out there and on top of things. And then I would- Life is just fortuitous sometimes because I wound up on the board of the group that credits all residency and fellowship. So that time kind of overlapped this period of time as well. So I think, again, my interest in this, my history with this, just made this be a good time to be trying to sort some of this out. Not that it's perfect, not that it's enough, but it's a step. And I think that's the other thing maybe I've learned when you talk about what have I learned versus back when I did it is I'm a very black and white thinker. And sometimes I have had to make peace with baby steps or iterative steps rather than I only want all of it or none of it. Sometimes it's enough to be a move in the right direction I think. And I don't think that's just capitulation because I'm at my age. I think it's just a more honest sense of how change often occurs to very large, highly entrenched organizations and institutions. CO 1:05:55 That makes sense. And sort of along those lines, what do you feel like have been some of the biggest challenges and successes over time with the GME program? KA 1:10:33 Nationally or here? CO 1:10:35 At Duke. KA 1:10:35 At Duke? Well, I think funding is always the problem. I think funding is always a problem. Just based on the way the federal government provides funding. First of all, we're lucky to have any federal funding. But the way they provide funding is- it feels really capricious. It's all based on what formulas they derived in the mid-1990s, and how the institution accounted for residency time back then. Which, in retrospect, was probably not the way they would have chosen to have done it if they realized that future funding was going to be based on what they put in on the paperwork back then. But they did it. That's water under the dam. We live with that now. And then they also allocated how many slots that you would get as an institution. And so we lived with the slots that we had. And we were successful getting a few more slots along the way, but that's not an easy thing to do and probably won't happen too many times again. But I do think that there's- I'm very much intrigued with the idea that residency education should be about education, and good education should mirror exceptional patient care. You can't learn to be a doctor, really, unless you've got exceptional care. And we have such brilliant care here and such brilliant faculty and such great ways of reaching out, from everything from heart transplantation- where I think we're the number one in the world- to community engagement, that it seems like this could be a great learning lab for education. And I think we ask residents to do a lot of things that are not educational, if truth be told. I was part of being here when the duty hours came. So people were not working 120 hours or 130 hours a week, but they were doing only 80 hours a week. Well, the sky didn't fall. The organization still exists. A lot of money got into replacing residents- who were here, in very creative ways. And we probably still could look at that 80 hours and say there's probably not all 80 hours here created equally, and there may be ways that we could look at changing up some of what they do because maybe not all of it is, again, of educational value. I hate to throw Electronic Health Record under the bus, but I'll throw it under the bus. It takes a lot of time and effort to work on that electronic health record- which was never designed to be a communication tool with physicians. It was designed to be a billing tool- And again, I think we ask residents to do a lot of that documentation and teeing up the record and whatever. And I think we could save some time, particularly some mundane time, with people and maybe get a better quality series of notes if we just looked at an alternative way. Maybe that'll be AI. There's now AI as a tool being used in some places to do it. But again, I think we need to look at what the work is they need to do. And I think we need to look at better assessments of how competent they already do it. And so I think in the perfect world, there would be more models of competency-based education. So somebody could progress through residency based on how they developed competency and not on these maybe artificial distinctions between the first year, and the second year, and the third year, and the fourth year, but when they became competent, realizing you may get competent in six months. It may take me a year to get competent. But the idea is you need to get to a certain level of expertise, then you focus on good assessment at the level. So I think we have more people passionate about education. We've got more people with educational credentials now. I think those are all good things. We have a teaching academy with Dr. Diana McNeill. I think that's good. We have some promotion criteria which now reward education and mentoring, and also activities that reflect advocacy, and inclusion, and work in diversity, which we never did before. So I think those are all good things that help all of education- not just residency education, but all education. And I think we have a number of amazing subspecialties. And I think the flip side is that I'm always going to hope that we did more engagement with the community. I feel like a measure of our success would be that Durham would have the highest possible health metrics in the country. If we were a superb academic health center, it wouldn't just be the brilliance of our publications and grants or whatever. But we would also have the lowest infant mortality. We would have the lowest substance abuse numbers. We'd have the least number of unhoused people or unsheltered people. We would have the least amount of violence. We would have the highest success at education in our public school system. We would have all of those things at the very top of the chart- what I think now, we would say "the social determinants of health" or "social drivers of health"- but all of those would be the very best. And to me, that would be a reflection of how we as an academic health center, and all of our learner programs, including the residencies, were actually making an impact on the health- not just healthcare, but the health- of our community. Evy [Evelyn] Schmidt used to say that Durham was called the "City of Medicine,’ [but] it should be called the "City of Health." And I would agree with that. And I would further say that that's how we should be measured, whether it be in U.S. News & World Report, or Forbes, or whatever list they want. But we should be widely recognized as our whole community benefits from our success. Because health is such a large part of the GDP that everything that we do- whether it be the people who we bring into our cafeterias to serve, or how we pay and reimburse our own workforce- all of that should be- I was glad to see that we increased the minimum wage at Duke. That's great. But I worry whether that's a minimum living wage in Durham, particularly given the increase of costs now in housing and food. And it didn't cost that much proportionally, even five or 10 years ago. So it's nice we've increased that amount, but whether that amount can be stretched to a reasonable amount of money where people can truly support families or support themselves on that- that's what I worry about. So I think again, we should we should be having the best. CO 1:16:56 That makes a lot of sense. [Break 16:56-17:21] What has your involvement been like in bias education programs at Duke? KA 1:17:36 Like the anti-racism initiatives or whatever? Yeah, I've certainly gone through a lot of them. Probably the most meaningful to me was this Teaching for Equity Fellowship that I did a couple of years ago- what were sort of a year long series of workshops with a cohort. And we worked over time. We did a lot of review of the literature, sharing personal experiences, and reflections. And it was a group of people I largely didn't know before. And I just gained- and really some very good facilitators- so I gained a lot. That was probably the earliest thing I did. That was probably around 2017- 2016, 2017- I would say. I used to do sort of a version of ally bystander training. But I think that the ones I've gone through more recently have been better, and I think those were good. And then the efforts to really look at curriculum and what one really does in curriculum. I think my instincts have been pretty good. When we started this Master of Biomedical Sciences program, I felt like I knew I needed to get- I value diversity. So I felt like I needed to have a diverse faculty and diverse teams. And I tried to go about recruiting them to join in this project, particularly because that's the audience of students I wanted. I wanted the students to be able to find themselves in that. But I think in terms of maybe being more intentional, I think some of these programs have been helpful to me in that. Even knowing what kind of a reading list or where to look for things has been good. Because it certainly isn't a checklist. It's not a one and done, "Okay, I've done that now. Put it back on the shelf." But it's a continual process. And I do think about what are the things I'm doing today that I'm going to look back in five years and go, "Why did I do that?" So where are the opportunities now? CO 1:19:33 What has it been like setting up the graduate medical education programs at other universities? KA 1:19:41 So do you mean like the master's program here or- CO 1:19:43 Yeah, or- KA 1:19:45 Okay. Well, I only did it here, but I've been able to be a site visitor to some other programs to evaluate them. So I guess I've got that little glimpse too. I think here, it's been really great because the dean [Dr. Nancy C. Andrews] was very generous in setting it up and giving us some amount of time. And the hardest part was getting it approved through the university process and Academic Council, to be honest. But once we did that, it's been pretty reasonable. I think, for us, the big challenge was- like many people- was COVID. And I think the fact that our budget was decreased. Which I totally got, but it just seemed to have been a little bit of a challenge to get it restored now that we're totally back on campus and doing things. But the real joy of it is really just seeing the students flourish. And particularly students who I think had a lot of impostor syndrome and really didn't see themselves as going on in this career successfully, and seeing them surprising themselves with just how capable they are with just some resources and some people believing in them. So I think Dr. [Melanie] Bonner has been brilliant. And she's a person who's able to bring a lot of skills, and learning differences, and optimizing learning, and figuring out more effective strategies at retrieving memories, and studying for standardized tests. And the advisors are wonderful, and it's a very diverse group of advisors. And so again, I think it's been really, really good. We have a med school that's taken some of our students, probably many of our students compared to maybe some other schools out there- we're in 60 different schools of our graduates- but this school has a special place in my heart and does real holistic review, and if we [Duke Graduate Medical Education] were in med school, we would be this other med school. But they did a bus trip last weekend- not this weekend, but the weekend before- down to Charleston, South Carolina to tour the new African American museum [International African American Museum] there. And so a bunch of us drove to Greenville, and then took the bus trip down from Greenville, South Carolina to Charleston. But on that bus were some of our grads. And [they] are now at the four different years of med school of that class, and then students in my program, who are going to go to Greenville, South Carolina next year, to the med school. And so it was fun to see where they're all at now and to feel really excited that- to have had a part on their journey to where they've gotten so far. It was very illustrative of- my frustrating days- it's like, "Oh, my gosh, they're doing so great." It's like, this is why we're going through the little tussles with trying to get somebody back in the budget for X issue or Y issue. CO 1:22:31 You've talked a little bit about some of the committees you've been on over time. At this point, how have you noticed- how have some of those diversity committees at Duke that you've been a part of changed over time? Have you felt like they've been productive? KA 1:22:53 Well, I think we have more diverse people sitting in those committees, so if you look around the room, it isn't a bunch of old white guys talking about diversity. So you actually have infusions of people by age, and ability, and sexual orientation, and race, and ethnicity. And you have not just participation on committees, but you have actually leadership on some of these committees. So that's been great, too. And you have people with very senior leadership roles who actually demonstrate the inclusive excellence that we say we want. So I think that's all good. I still think if you look around the chairs, you disproportionately have white men, but they're not all white men. And again, I think that- and I'm not trying to disparage white men, but as a class- but I just think there is more diversity than there was. So I think there's not just the intent to be diverse, but I think you can actually see that in actuality. I think having a very strong Office of EDI is important. And I personally think pathway programs are important. I wish the pathway programs were a little more connected to one another. I think they're all very siloed and seemingly random. But having them is better than not having them, so I think that's great, too. But in terms of trying to weave them into a strategic asset, I think there's still opportunity to connect them a little bit more. Like they introduced this new way to get workforce development with Durham Tech and high school to community college linkages, and I think that's brilliant. And I would love to see some attention to- and this I'm sure will [inaudible] happen- but attention to a pathway after that. So some of these students who may have an associate degree now through this program and join our workforce, maybe there will be opportunities for them to enter PA school, or PT school, or OT school, or MD school, or whatever. But some very intentional linkages set up to allow people to continue to progress. So I think those are- I had the opportunity to see a program somewhat similar to that, but it was out of a community health center in California. And I loved it because they will not let any of the students fall behind. So if somebody- family loses a job, and they can't commit their time to their education, because they have to go back and work a job to make up the money for the household, the program will pause for them and let them catch up when they come back. Or if they have a baby, and they need to take time off for the baby, they'll help arrange childcare for the baby, if that's what the parent wants, or whatever the parent wants. They'll catch back up when they're ready to go again. So they will not let somebody quit who wants to stay involved just because life happens. They'll try to help around the life happening part. And then they guarantee them jobs, which I think this program is going to do too. But they do look at some opportunities for pathways beyond that much more intentionally. So someone just doesn't stop with that associate's degree, but the sky could be the limit for them, whatever their continued interest may lead them. I hope we do that, too. I don't even remember what the question was. But I think that's a good thing too. CO 1:26:04 Definitely. [pause] I was wondering too what it's like- Obviously, within thinking about diversity, you have learned to pay very close attention to the identities of people involved in those efforts. What has it been like for you as a white woman being involved in diversity efforts for marginalized racial communities? KA 1:26:34 [Pause] I think people with platforms need to advocate, and people need to find ways to sponsor other people so they can have their voice and their own advocacy. So I think the community health mantra is "Nothing about us without us," and I think the same thing is true in that, too. But if I'm the person who has the position or the foot in the door, then I think my role is to make sure other people get their feet in the door, too. But I think I can't- I don't want to not use that platform that I have to try to make sure that we're looking for other people as well. But I realize I'm not going to be the advocate for everybody. But I think I have a responsibility to make sure that the whole system is providing advocacy for many different kinds of voices. The ACGME [Accreditation Council for Graduate Medical Education] is looking for a new president. This current president's [Dr. Thomas J. Nasca] been there for 15 years. And so as a member of the executive committee, I was asked that- all of us were asked to give potential names forward. And I intentionally went through my mental Rolodex of people that I think are brilliant, and that are people who represent diversity. And I don't think I'm the only person who's going to come up with that list, but I think there aren't a huge number of diverse people on that committee that I'm on. There's some, but not many. So I feel that providing 15 names of people that I think the recruiting committee needs to go talk to I hope is a way to elevate some voices that they may not be heard. Am I the only person to do that? No, but I feel like they've asked me [laughter], so I'm gonna take the opportunity to give them a list of names of people that I do think would either be interesting candidates for them to consider or potentially would have their own Rolodex of 15 other names that I don't even know about, but who would be great candidates too, if that makes sense. CO 1:28:59 Definitely, yeah. I was wondering too- you've been involved in some research involving opioids and addiction- I was wondering how you got involved in that kind of research. And what it's been like with your experience with, going back to the start of HIV/AIDS, research and clinical work involving people who use injection drugs, [and] now [going] into doing opioid research. What it's been like being involved in addiction research now- what has that been like in terms of thinking about diversity and community health? KA 1:29:53 Yeah, I guess the common theme is, as a family physician, I can be interested in anything. That's the great thing of my discipline. I'm not pigeonholed into one type of gender, or one type of condition, one type of age, one type- So I can follow where I'm interested in. I think the theme is I have a lot of interest in people that are more marginalized for whatever reason. I did a lot of OB, and I did a lot of OB for under-resourced communities, and I did early HIV/AIDS, and really learned so much from that and had wonderful experiences with patients who taught me a whole lot. I was interested in geriatrics for a long time. And I [inaudible] an OB book, and I had my geriatric boards temporarily. It's like, ok, only a family doc would do this. I did occupational medicine for a while. But I think substance abuse is another group of people who are highly marginalized. And they have some intersectional issues with people that have HIV/AIDS or with people who had challenges with OB care or whatever. And it's just so ubiquitous. It's just so- all of our patients are- just a lot of people have it or have a family member that has it or something. So, yeah, I'm really interested. But it's another way of trying to say how can we reach a difficult population? How can we establish trust with people so they'll even tell us that this is a condition that they have? Or them feeling it's so stigmatized, they can't mention it. What is the own ethical issue when we've been complicit in making this happen? I think of pain as a vital sign, and all of the issues that get raised with the prescription drug abuse of which physicians were co-opted, intentionally or not intentionally, about prescribing medications to people which created some level of addiction issues for them as well. So, I think it's just- what can you learn? How can you help? How can you try to use that as a fulcrum to teach and reach learners, recognizing some of them may have their own substance use experiences as well, either themselves personally or in their family. So my clinical work now is at TROSA [Triangle Residential Options for Substance Abusers, Inc.], and some evening clinics with TROSA, which is a residential facility for individuals with substance use disorders in Durham. Which is an interesting model. But it's a way that I'm trying to continue to learn about how better to more effectively reach this population. CO 1:32:26 That makes sense. KA 1:32:27 And two of them came and talked to my current students. So it's always good to hear that, and just how compelling that is for the students to hear and find out people are- have such different pathways to having that problem. And that could be you, or your sibling, or your family member. And how challenging it is for them. Then having that issue to get on with the rest of their life. CO 1:32:54 That makes sense. And it's interesting, too- It sounds like, in terms of institutions with certain amounts of power, you've had a lot of experience getting to be a voice within those institutions, but also at times having to fight against them. What has it been like in those times that you've had to be a voice standing up to some of those institutions? KA [Omitted 1:33:26-1:34:24] KA 1:34:24 I think I'm not always a good negotiator. So I think what I've tried to do is I've tried to learn better techniques to raise issues of justice in ways that I think would be more persuasive to the people that I'm having a conversation with. And I don't think I'm good at this. I think that I come at this from, “Wouldn't everybody want social justice?” And if so, why don't we just do it, whatever it is. But I think what I've learned is that it is often better to come up with issues that seem more- difficult for me to even think about- but like an economic reason. Like, "Give us half the money you spend on unreimbursed medical care in the emergency room, and let us see if we can't make sure you lose less money next year." That's not why I wanted to use that money and do those projects. But that was a more persuasive way to get the money. So I think some of this is learning what can be the most persuasive to the audience that I'm trying to persuade. And in a sense, it's no different clinically. If I want somebody to get the COVID vaccine, I can't use the same strategy to have that conversation with somebody. I've got to understand what's motivating them. And it doesn't feel disingenuous to me to talk to somebody in the context of helping keep the disease from their family members versus somebody that you're really trying to get the personal reason for doing it versus- I'm very used to doing that in a clinic setting. But I think in trying to negotiate with a bigger system or bigger structure, I think that that's- I think the other is just trying to believe- although this is harsh. Sometimes you may- trying to believe that there is probably some good intent, even if I don't see it. They may not be the most malicious people in the world, even if they see things differently than I do. But what is that? And can I push on that a little bit? I see this a lot in really wanting to not use standardized tests so much, and really seeing the standardized tests really come with a whole lot of linkages to socioeconomic status privilege, all that. But the people who believe in that, not all of those are bad people, and not all of them are trying to be mean-spirited. Some of them really believe that it's a good measure of some effective foundational knowledge [so] that somebody's not going to get into an educational setting which they're not going to be prepared to handle. So how can I help with that? And there's some data, certainly on MCATs, [that] say the middle third people do about as well as the top third people, even though most people won't look at the middle third people. But they end up doing fine. There's also like, well, why would you possibly take people who you thought were a little more tentative, and just put them into the system, as is, without trying to find some ways of adding some resources, or coaching, or learning optimization, or whatever? Maybe you could create it to be better for them, and, frankly, better for everybody, by looking at how to modify the environment to be more conducive to learning. So I think those two things- I've had my share of disappointments, things that blew up, things that didn't work out. I think, again, trying to look at taking away from the personal sting, and trying to say, "What could I have learned from that that I can apply the next time?" And to really try to remember that, in all humility, this is not about me and my ego, but it's about a cause that I believe in. And if I believe in this cause, how could I be a more effective advocate for that cause? And really engage more of the constituency that I need to engage. CO 1:38:22 That makes sense. And as one of my final questions, what do you hope for for the future of medical school admissions [and] diversity efforts in the medical school? KA 1:38:40 Before the summer [Students for Fair Admissions v. Harvard decision issued June 2023], I would have said that I think that our clinicians need to look like the patients we serve. And always the "look like" shows up. So it can be race, ethnicity, rural born, first gen, veteran status, linguistically, people with different abilities, gender identity, sexual orientation, all of the above. So I think that the more inclusive our environment is, I think there's data at least relative to race and ethnicity that not only does that mean that there's more opportunity for racially concordant care and ethnically concordant care- which may result in better health outcomes- but there's also great data that students who are in school with more representation actually themselves do better for health care outcomes for diverse communities. So I think even to be self-serving about it, it helps care for everybody. Even the majority students in the class do better having been in classes that are more diverse in terms of the health outcomes of their future patients. So that's what I would hope for. I would hope that we have the opportunity to learn from diverse colleagues and different life experiences. Because ultimately, I think the goal for all of us is really doing the best possible care for the patients that we will be caring for in the future. Or with whom we're going to be doing the research and the basic science and the investigatory stuff that's going to provide the new ways to care for those people in the future. And if it's too homogeneous, we just rob ourselves and our patients of the opportunity to have their care truly as good as it can be. That's my hope. CO 1:40:26 Is there anything else you would like to tell me about that I didn't already ask. KA 1:40:29 No, I think that's probably pretty much it. It's a little uncomfortable being too autobiographical here. But I think hopefully, that gives you enough of a flavor to see some of the journey. CO 1:40:43 Absolutely. Thank you so much.