as a surgeon. A football injury left him with a damaged cranial nerve and double vision.

, Koop hit a patch of ice, landed on his back, broke his neck and was

                  a trusted adviser, Koop became a renowned

pediatric surgeon and an embattled yet influential figure who shepherded the U.S.



KOOP ON...

Since the first copies of the president's Health Security Act
were leaked to the press, Dr. C. Everett Koop has been at
the forefront of the Clintons' cause. In an exclusive inter-
view with The New Physician and at a subsequent press
conference, Koop took some time to address issues im-
portant to him and physicians-in-training:

The Health Security Act:

Without passing a single law or issuing a single
regulation, [Clinton] accomplished more in health-care
reform in _ . . four months than all of his living
predecessors put together. . . . It's a daunting task to face
runaway health-care costs, the vexing issue of universal
access, the malpractice mess, the mounting problems of
Medicare and Medicaid, the applications of outcomes
research, a sweeping reassessment of medical ethics, to
say nothing of rooting out fraud and waste and abuse
and greed.

Promoting generalism via one of his chief
goals-making medical school tuition-free but
havin f individuals pay for postdoctorate
specia ty study:
The [C. Everett Koop] Institute can only bring it about by
convincing government that it's right. We're in the
process of doing that. If the Clintons demand large
increases in the number of primary care physicians in a
climate where medicine is not attracting them, then they
ought to give the students an offer they can't refuse-free
medical education. Unfortunately, the barriers to training
all physicians at the taxpayers' cost is that many
taxpayers already think physicians make too much
money. But the kind of doctors I'm talking about in
primary care. . . are grossly underpaid.
Training future doctors to be more patient-
friendly:
The first thing we don't know about health-care reform is
what patients want. If you think about it, we've never
done a systematic study of it. We do know certain things.
We know that the No. 1 complaint of patients is, "My
doctor doesn't listen to me." The No. 2 complaint is,
"When I try to tell him something, he interrupts me."
Number 3 is, "When he explains something to me, I don't
understand it." So our problem is to make sure that

medical education makes communicators out of people,
but also makes them understand the absolute necessity of
communicating. You can have in your mind the best
possible regimen to solve a particular problem, but if you
haven't translated that to the patient so he can act on it,
there's no point in having seen him.

How medical students can help bring about
educational reform:

I'm surprised and pleased at how students are able to
bring pressure on faculties to change a curriculum, and I
encourage that. At least, I encourage opening and
maintaining a dialogue between faculty and students. I
think if we could . . . bring about mentoring relationships
between faculty and students, faculty would automatically
understand what the students' problems are.

His message to physicians-in-training:
They live in a very unusual time because, not only are
they facing some motor changes for the first time in the
history of health-care delivery in America, but they can
be the agents of change. So, become involved. The
President said . . . he wants a dialogue with doctors and
the professions of the American people. Help make that
dialogue happen.

medical knowledge, and more compe-
tent in such low-tech skills as doctor-
patient communication and health ed-
ucation.

This school year, CEKI has begun
working with first-year medical stu-
dents to start the molding process, and
Koop has lost no time getting his hands

on the clay In the first week of school,
he addressed the student body twice.
Meanwhile, students are participating
in a variety of hands-on projects, rang-
ing from visiting grammar-school
classes to tinkering with "telemedi-
tine," that will help transform an edu-
cational system traditionally weighted

toward the static classroom setting.

"There's been a lot of interaction
with students-a lot earlier in their
medical school experience," says Jason
Reynolds, a first-year medical student
at Dartmouth. Reynolds also spent the
previous two years doing Ph.D. work
in the department of pharmacology "I


can remember when the Koop Institute
was just a rumor," he says. "It's been
interesting to watch it start from the
ground floor."

K oop got the rumor mill going
     in 1990, after a brief visit to
     Dartmouth. Wooed by school
officials eager to work with one of the
college's most prestigious alums, Koop
was offered senior scholar status as
part of a program that would push the
type of changes in medical education
Koop had always espoused. Koop
seized the opportunity for a number of
reasons, not the least of which being
the controlled environment provided by
a smaller medical school like Dart-
mouth, according to Dr. John Duffy,
CEKI's director and Dartmouth's dean
of admissions.

"There's a certain facility in being
able to effect change at a small school
with 85 students in each class, instead
of a school with 200 students per
class," Duffy says. "Of course, it
helped that Dr. Koop owns a home
here, his children live here."

And so the institute was born as a
two-sided entity, one that is a part of
the Dartmouth educational system,
while at the same time fulfilling a sep-
arate and independent think-tank func-
tion, removed from the academic mi-
lieu. "We're quite schizophrenic,"
Duffy admits. "On one hand, we are
driven by the national and international
reputation of Dr. Koop. Organization-
ally, however, the institute is very much
a part of Dartmouth Medical School
and the college."

Duffy and Koop seem to delight in
this administrative schizophrenia, and
it appears to work well for them. Al-
though CEKI purports to have no na-
tional agenda for changing medical
school curricula, Koop certainly does.
As a result, the CEKI office serves as
a convenient command post for Koop's
post-surgeon general agenda. Faxes
and phone calls pour in from around the
world, all vying for his attention. He
has been consulting with the Clinton
administration on health-care reform
since May and is currently traveling the
country touting the president's plan. At
an age when most doctors are content
to play the back nine, the septuagen-
arian surgeon is a blur of activity, quick
on his feet, sharp as a tack, well-

versed in current medical issues.
Everything he believes, he believes in
fiercely and to sit in a room with him
is to be infected with that fierceness,
whether you agree with hi or not.

And not everyone does. Like most
people who succeed in life, Koop has
the reputation of thinking quite a lot of
himself. Given his curriculum vitae,
though, he may be justified. His ex-
perience gives him a great deal of
viewpoint, and it's hard not to foist it
on others. Despite his trademark
beard and bow tie, he is like nothing
so much as a retired general: still ca-
pable of command, of hokliig the room
in his thrall. But he misses the uniform
. and needs a cause to anchor him. For
Koop, there's none better than re-en-
gineering medical education.

"I have to agree with Georges Cle-
menceau, the great French leader, who
said that moving a graveyard is simpler
than changing a curriculum," Koop
says. "But when you have to impart 20
times the knowledge that I was given
in medical school-and you're still im-
parting it the same way-something's
got to give."

As far as reformers are concerned,
that first thing will have to be the at-
titudes of most medical schools. "Even
at Dartmouth, there's been resist-
ance" to the kind of sweeping changes
CEKI advocates, Duffy says. "There
are within the faculty really terrific
teachers. But historically med school
curriculum has been dominated by
what works for the faculty and not giv-
ing a damn about the students."

For the most part, though, Dart-
mouth medical school faculty say they
welcome CEKI onto their campus. Dr.
Harold Sox, chairman of the depart-
ment of medicine at Dartmouth, paints
an appealing picture of faculty coop-
eration with the institute's reform ef-
forts. "We're learning a lot by working
with Dr. Koop," he says. "He's very
effective at articulating his ideas, and
we've got people on the faculty who are
eager to translate those ideas into pro-
grams."

Dartmouth currently offers no fam-
ily medicine clerkship on site and no
residency in the field at all-a discrep-
ancy the school is trying to resolve as
part of its nascent "New Directions"
curriculum, for example. This plan par-
allels the institute's goals of integrating

more clinical experience at the Dart-
mouth-Hitchcock Medical Center and
cultivating more generalist physicians.

The level of cooperation CEKI has
seen from the medical school at Dart-
mouth surprised many people familiar
with the workings of academic medi-
cine. "Usually, when someone asks
`How do we bring about change?' it's
easier not to answer the question and
to keep teaching the way you've always
taught," says Dr. Edward Stemmler,
executive vice president of the Asso-
ciation of American Medical Colleges.
"Each institution has an internal cul-
ture all its own that is very hard to
change. For real change, somebody's
got to have a vision."

A number of other schools also have
this vision. Harvard University, Johns
Hopkins, New York Medical College,
Northwestern University, the Univer-
sity of Arizona and a consortium of
medical schools in Philadelphia are just
a handful of the institutions that, lie
CEKI, are bucking the current educa-
tional system.

N ationally, organizations like
   the Kellogg Foundation, the
    Robert Wood Johnson Foun-

dation (RWJ) and the American Medi-
cal Student Association (AMSA) are
promoting medical education reform.
AMSA, for example, established a
Generalist Physicians In Training proj-
ect to encourage schools to promote
family-practice directives. Meanwhile,
foundations like RWJ provide seed
money to medical schools for commu-
nity-oriented training. With $100,000
or so, schools can experiment with
their curricula and qualify for an imple-
mentation grant: up to $2.4 million
spread over six years.

Many of CEKI's programs involve
the community, such as a voluntary
project that provides apprenticeships
with local family practitioners. Another
program, Advisers to Families in Dis-
tress, is slated to begin this year. "1
think going out and doing respite care
and helping a family through a health
problem, for example, is ever so much
more important than learning certain
intricacies about the anatomy of the
hand that you'll never use in your life,"
Koop says.

Another community-oriented vol-
untary project CEKI has established is


the Ray School Initiative, to help stu-
dents teach health education. Last
year, several students worked with lo-
cal elementary and secondary schools
to teach health promotion and disease
prevention, sex education, smoking
cessation and other subjects. "We
were paired up with public school
teachers and had to create a curricu-
lum that would get the information
across," explains Megan Sandel, a sec-
ond-year medical student at Dart-
mouth. "For example, we had to teach
immunology, but hrst we had to break
the information down to the second-
grade level."

Not only do such experiences make
students better teachers, Koop as-
serts, it also makes them better com-
municators. "If they can explain it to a
first-grader, they can explain it to any-
one," he says.

All of Koop's ideas, however di-
verse, orbit around a common theme:
enabling medical students and physi-
cians to play a more active role in their
own education. "The volunteer pro-
grams in place so far give us a high
level of empowerment," says Eunah
Kang, a second-year student at Dart-
mouth Medical School and a chairman
of CEKI's Community Service Com-
mittee. "When Dr. Koop first came
here and the institute was just starting
to articulate its goals, one of the most
important aspects was establishing the
voluntary programs to give students
the choice of determining what they
could do-how they could help oth-
ers-with their free time."

K oop wants to expand the
    number of opportunities stu-
   dents have for voluntary ser-

vice by making bigger holes in the cur-
riculum so students can participate in
them. He also has worked out the ram-
ifications of integrating computers into
medical education-and they just hap-
pen to include ways that medical
schools can draw more students into
primary care.

The most promising of those meth-
ods is telemedicine. Using computers
and interactive video, rural doctors can
confer with larger medical centers on
specific cases or for updates on the
latest medical knowledge. (See "Re-
mote Possibilities," September 1993. >
"Look out into the countryside and

In addition to his work on medical education reform, Koop has consulted with the
Clintons on their health-care reform package since May.

ask what is failing," Koop invites, ges-
turing out his office window, to the hills
of northern New England. "We're not
attracting the primary care doctors we
want and we're not keeping the ones
we've got. Why? Because primary
care in rural New Hampshire is not
exciting and rewarding and fulfilling.
Talk about empowerment: What we're
trying to do-with telemedicine and
supercomputing-is to take the medi-
cal center to the family physician in his
office or clinic out there."

And Koop clearly means to use his
consulting status with the Clinton
administration to push nationwide ac-
ceptance-and government funding-
of the technology: CEKI recently put
on a telemedicine display for Ira Ma-
gaziner, the administration's senior
health-care adviser. "We showed him
12 different ways that high-resolution
TV and supercomputing can carry
medical messages to remote areas.
The technology's available, it's fairly
cheap, and it keeps rural doctors in
touch with the rest of the medical
world."

But Koop has that graveyard to
move first. The push for computer lit-
eracy as part of med school curriculum
change is a slow one, mired by older
generations of medical faculty-Koop

notwithstanding-who have neither
the time nor the inclination to learn a
new trick. At Dartmouth, however,
tbat trick-at least for students--will
be mandatory

"1 proposed that students take a 30-
minute multiple-choice questionnaire,"
Duffy says. "Those who do not achieve
a passing grade will have until the end
of May to take one of the courses of-
fered by Dartmouth to fulfill the re-
quirement of becoming computer-lit-
erate."

It's just one of the messages Koop
intends to convey to his students as,
resplendent in his Dartmouth-green
bow tie, he ambles across the campus,
preparing to give them another
speech.

Koop is the first to admit, however,
that computer-literacy, as with other
types of medical reform-including the
federal legislation he currently cham-
pions-is not always openly embraced
by the health-care community Un-
fazed, the general sets his steely gaze.

"It's not something that catches on
in a lot of places," he agrees. "So
where it doesn't catch, you just push
it."                   0

Stephen C. George is an associate editor
of The New Physician.

Reprinted with permission, THE NEW PHYSICIAN/December 1993, Vol. 42 NO. 9, pgs: 16-20