This is Jean McMillen interviewing Dr. Richard Collins at the Scoville Memorial Library on Wed. Sept 21, 2011.
JM:May I have your full name?
RC:Richard Deal Collins
JM:When and where were you born?
RC:I was born in Hartford, Ct. in January, 1936.
JM:May I have your parents’ full names?
RC:My father’s name was John Lawrence Collins, and my Mother’s name was Helen Cannon Collins.
JM:Tell me about your education, please.
RC:I was raised in Hartford and I went to the Loomis School up in Winsor, Ct. as a day student. Then I went to Yale University, and continued on to Yale Medical School. I graduated from the medical school in 1962.
JM:When and why did you come to this area?
RC:During the period of time I was starting to look around for a practice, my second to last year before going into practice, I was at Yale-New Haven Hospital as a senior resident. I knew that I would be looking for a place to practice within the next year or two. It was a period of time where we started to look a little more closely, and I heard good things about Sharon, Ct. in the northwest corner, and in particular about a group medical practice in that area called the Sharon Clinic. I had heard about that during my last year in New Haven from 2 doctors that from time to time came to take part in the teaching program for interns, residents, and medical students at Yale Medical School. They were Dr. Fred Gevalt and Dr. Roger Moore, both of whom were associated with Sharon Clinic. That was very much in the back of my mind, and in my final year before going into practice, I was at Harvard Medical School as a Fellow in Infectious Disease. I started to look at a number of other places; I looked at Manchester, New Hampshire, Beverly, Mass. some places in New York State, but decided in that last year to visit the northwest corner. That lead to a very favorable impression about both the area and the clinic, and hence my decision was to come here in July of 1968.
JM:You did work at the Sharon Clinic?
RC:I did. Now Sharon Clinic was in many ways quite a unique organization; it had been started after World War II by a group of 4 physicians all of whom had had a good bit of their specialty training at Columbia Presbyterian in New York City. The original four who founded the Sharon Clinic were Dr. Fred Gevalt, Dr. Robert Noble, both in Internal Medicine, Dr. George Fowler in General Surgery, and Dr. Robert Fisher in OB/GYN. They had a common interest in starting a practice in some place within reasonable distance from New York, and after a fairly wide search they settled on setting up their practice in Sharon. At that time the area was largely staffed by family practioners, the hospital was
quite small, and therefore it represented quite a sizable undertaking and a challenging one for these 4 doctors to come at the same time. Each of them was well trained and certified in specialty type of medicine, but I think in the long run the area and the hospital benefited greatly in terms of availability and quality of care that was available here.
JM:How long were you connected with the Sharon Clinic?
RC:I stayed with the Sharon Clinic from the time that I initially came here in 1968 until the time that the Clinic disbanded in the early 1980’s. At that point the Clinic doctors really divided into individual practices, grouped by specialty. I should point out that the Clinic was quite unique for Connecticut in that it was a group of doctors of different specialties, practicing together. The most common mode of medical practice then and certainly now was larger groups, and groupings of doctors with the same specialty. So for instance you would have gastroenterology associates of West Hartford, or general surgery partners of Stamford, Ct. To have a group practice involving multiple specialties, a very small size, we are not talking here about the Mayo Clinic; we are talking about a group of four initially. After it was started after World War II, the group expanded over the course of time. By the time I came in 1968, it had already expanded considerably. Dr. Roger Moore was added in internal medicine, Drs. George Haydock and Bill Gallup had established a section of pediatrics, and Dr. Peter Reyelt had joined Dr. Fowler in the surgical section of the Clinic. In addition to the Clinic doctors there were a number of other excellent practioners in the area on the staff of the Sharon Hospital. Certainly prominent among those were Dr. Lavallo, a general surgeon in Sharon, several family practioners Dr. Jim Linder, Dr. Gudernatch in Sharon, and a number of internists in the Lakeville area. Perhaps the Dean of the Lakeville internists was Dr. Harry Wieler at that point. In the late 1960’s Dr. Wieler was cutting way back and was just a year or two from retirement. Two other internists who had been in the community for quite a while and were very active were Dr. F.E. Smith who at that time in practice in internal medicine and also a physician for Hotchkiss, and Dr. Eddie Brewer, who was also helping with the medical care at Salisbury School. Dr. Peter Gott had come recently when I came; he had preceded me by a year or two and initially was working in partnership with F.E. Smith, but by the time I came within a short period thereafter, Dr. Gott established an independent practice here in Lakeville.
JM:What caused the break-up or demise of Sharon Clinic?
RC:I think it was a number of changes; as I think back about 25 years that I practiced here, the practice of medicine was undergoing very gradual, but ultimately very dramatic changes. This had a powerful effect on the ability to recruit new physicians. At Sharon Clinic we had had considerable good fortune in continuing to attract people and adding people in the various sections of the Clinic, including in Pediatrics Dr. John Charde. We added Dr. Malcolm Brown, who did both in family practice and Pediatrics; Dr. George Longstreth came and joined the surgical section with Drs. Fowler and Reyelt. Dr. Rob Ryan came and spent a considerable amount of time with the Sharon Clinic before moving on, and summarily Dr. Martha Bennett spent a considerable amount of time in the Internal Medicine
section at the Clinic before she chose to go elsewhere. I think after that period of time those of us at the Clinic were aware of the fact that the younger physicians, the newer physicians, were leery, for a number of good reasons, were quite leery about coming into a multi-specialty clinic, small in size, especially where there was a fairly unique income-sharing philosophy and practice. Perhaps I should explain that a bit.
When the clinic was first started and when I first joined the clinic some several years after its formation, the compensation of the physicians working at the clinic was based on a formula of dividing the income that we referred to as 40-60. What 40-60 really meant was that a doctor, an individual partner of the Sharon Clinic. There was a period of time where most of the doctors were on a simple employment contract for the first couple of years; if things worked out, they were invited to become a partner. Each partner was compensated on the basis of receiving 40% of the fees generated in the preceding month. Then for each partner 60%, the residual, of the fees went into a common pot out of which all the expenses of the clinic, everything going out of the checkbook, all those expenses were met from the common pot, and the residual was then divided equally among each of the partners. This had been quite a successful formula certainly for the original 4 who were close friends. This pattern remained quite acceptable for a number of years as new physicians came, but increasingly it became both divisive within the group itself, and a detriment to attracting new physicians to expand, or to continue to expand, our capability and numbers in the various specialties. There was no question that the personal relationships between the partners remained very positive. Everybody understood that the physicians who were at the lower end of the financial capability or reality; that is to say new internists, or pediatricians. We all understood that they were very good, very hard working, very worthy people, but increasingly it was apparent that the gap between the earning potential of a pediatrician or first year internist and a sub-specialist or specialist such as an obstetrician, orthopedist, a general surgeon, or a senior internist. The gap was increasingly apparent; after trying a number of different compensation systems, it was generally agreed that we just were not going to be able to overcome the doubts, uncertainties, and unhappiness. In particular the concern was that it was going to impair our ability to attract new partners, or indeed that some of the partners might chose to leave on their own because of a sense of increasing frustration about their compensation. So over the course of a several year period the partners at the clinic agreed to subdivide and to go their separate ways by specialty, so that the surgeons would practice together, the obstetricians, the internists, the pediatricians. This turned out to be a very amicable process, so I think it was the time that had come. The relatively harmonious nature of the break-up was a reflection of the fact that there was a fundamental affection, respect, and feeling of good will between each of the partners. The goal of an orderly break-up as we saw it was to remain friends since all the doctors had planned to stay in the community. We wanted to remain and continue in our personal friendships and our professional friendships in the new practice setting. We wanted to retain our wonderful and long standing employees whom we all knew were absolutely crucial to our continuing success in our new practice form. We also wanted to retain many of our wonderful patients. With those particular objectives the process of the break-up into sub-specialty practices went off rather well.
JM:It sounds it. Now did you have an association with Sharon Hospital?
RC:Our practice was absolutely linked and our good fortune was linked to the presence of the hospital. Even as the economic changes and financial turmoil led to the new realities at the Sharon Clinic and eventually the break-up of the Sharon Clinic, the whole area of medicine was changing and it would have a profound effect on providers, both physicians and hospitals, and the nature of compensation for hospitals.
When I first came, Sharon Hospital had approximately 90 beds and appeared to be for the most part quite full at most times. It is important to realize that at the time of the late 1960’s and extending into the next 10 years was what many would come to look back on and call sort of the “Golden Area of Medicine” because it was a relatively uncontentious time. To put that into some perspective most people had a Blue Cross type of insurance. The relationship between Blue Cross and physicians and Blue Cross and hospitals was for the most part was very non-controversial. If you went into the hospital and had an operation, the physician submitted a bill. If it was considered usual and customary, the bill was paid by Blue Cross Blue Shield with no controversy. Conversely the Sharon Hospital would submit a bill for all the services provided in the hospital and for the most part was again fully compensated. During that” golden era” there was what some would later on cynically call almost a sweet heart relationship between the financial intermediaries and the medical providers, both practioner and the hospital level.
Over the course of time that would change dramatically between that period and later on in the 1970’s and 1980’s with the onset of managed care where the overall cost of health care was skyrocketing. There was a clamoring and a necessity to do something to #1 to take a closer look at what was driving these costs and #2 to see what joint practices or new models could be used to reduce the cost. To put this into perspective in the 1970’s if you needed to have a relatively simple operation, let’s say the repair of a hernia; the adult was going to be scheduled to be admitted to the Sharon Hospital by Dr. Fowler or Dr. Reyelt or Dr. Lavallo for surgical purposes, they would be admitted to the hospital the night before surgery was scheduled. The patient was to be admitted to the hospital, the necessary physical examination, clearance for the forth coming surgery, the laboratory work; the electrocardiogram would all be carried out at a very leisurely pace inside the hospital while the patient is an in-patient in the hospital. The patient would be visited by the surgeon, visited by anesthesia, and then the following day the hernia would be carried out at the regular time. The patient would be kept in the hospital for perhaps one or two nights, seen daily by the surgeon, and cleared to return home.
We know that today in that same setting that same patient with the need for a hernia repair will be asked to report to the hospital one to two hours before the knife is dropped; the necessary clearances, the laboratory work, the physical by the attending physician or the personal physician that would all have been carried out dictated and typed up and all assembled by a very excellent and expeditious group of pre admission specialists at the nursing level and the laboratory level so a nice neat very complete folder would be there to greet the patient at 6 A.M. when the patient stepped into the
Sharon Hospital for the first time and was in the operating room at 8:00.Then from the operating room to the recovery room, and in almost all cases, barring either a very unusually complicated patient. In most instances that patient is on his way home in the early afternoon with careful instructions of how to take care of the wound and with appropriate medication for discomfort and an ice bag. I think you can see by those 2 examples of what it was like when I first came here and what it is like today. You can get an idea of how dramatically things have changed.
Let’s look at that example and see how the changes are also reflected and what is paid to the surgeon who performs the hernia repair and what is paid to the Sharon Hospital for providing these services, albeit in a very short period of time, a very tightly compacted timeline. The physician will submit a bill which he is entitled to place any amount down. Let’s say the surgeon submits a bill for X number of dollars. It goes to Blue Cross or Blue Shield or if the patient’s subscriber to Medicare, it would go to Medicare. It is no longer a period of time her in most instances where whatever X is, X will be paid directly to the surgeon. Now every fee for every procedure has been established as a customary and regionalized allowable charge for that procedure. In most instances, instead of receiving X number of dollars for performing the surgery, the surgeon would receive X minus Y. The Y in many cases would be a substantial write down. In many cases the surgeon would submit a bill for X and end up being paid X minus Y which might be only 50% of what his original fee was.
Summarily the hospitals are now compensated; when managed care became the rule rather than the exception, under managed care the hospital receives a bundled fee based on the average cost, the regional cost, for the same services in similar communities of similar size and of similar stature. The hospital is at risk; it will no longer be compensated on the basis of the bill as they see it for each of the services they provided. Both the hospital and the provider are now, under managed care, and mind you there is a reality and a necessity for these changes. I don’t think anybody could question that the continuing escalation of charges and the old practices had to be changed. The new reality was that hospitals had to watch much more closely the amount of services that they provided because they would only be compensated for a fixed fee. It did mean that the hospitals had to become a lot more efficient than they used to be under the sweet heart arrangement with Blue Cross and Blue Shield.
JM:That is fascinating to someone who hates hospitals and doesn’t want anything to do with them. Tell me how the medicine has changed from the 1960’s when you started to now. I know that have been a lot of technological changes.
JM:Expatiate a bit on that, please.
RC:Well, again as it so happened when I came in 1968, it was a period of time when things were transitioning from the old style to the new reality. In 1968 it was considered a good idea for a new doctor in the community, especially in a primary care specialty; I was in internal medicine but this would apply to a family practioner or a pediatrician; it was considered appropriate, courteous customary for a
new doctor to make the rounds and introduce himself. When I came, Dr. Gevalt explained to me that I would be part of the clinic but in addition to its main office where everybody worked in Sharon, the clinic maintained an office in Millbrook, New York, and more recently an office in Canaan had been established by Dr. Bill Gallup who had established his presence there in pediatrics in a very small office on West Main Street in Canaan. Dr. Gevalt explained to me that I would divide my time between the Sharon office, and I would also work several days a week to join Dr. Bill Gallup in the West main Street office in Canaan to expand the practice there from just pediatrics to pediatrics plus adult medicine. So although I was joining a group practice, I was still very much a new figure in the northwest corner in primary care. It was deemed to be good practice to get out and meet some of the other doctors.
I can remember very vividly trudging up to Norfolk, calling ahead of time, and most respectfully introducing myself to Dr. Frank Ursone who was a well-known, very senior, quite elderly family practioner in the brick office on your left as you drive in on 44. It is still right there: it was a combined residence for Dr. Ursone and his office. I can remember to this day that his wife very kindly greeted me at the door; it had arranged in advance for my visit to introduce myself. It was happily on his day off, a rare event in itself for him to have a day off for someone who was as busy as Dr. Ursone, and there he was padding around in his bathrobe and slippers. We probably had a cup of tea or coffee. I introduced myself as, medically speaking, and the new kid on the block. I indicated to him that I was pleased to meet him. If I could in any way help him when he needed a hard-earned day off, I was right there in Canaan, not that far away, and would be happy to help. Dr. Ursone was very pleasant and welcoming.
As we look back on those times today, perhaps with a greater degree of cynicism, in the modern vernacular someone would say, “Are you trying to establish a market share, expand the market share?” Well, sure in the final reality I had lots of time; any new doctor in the primary care has lots of extra time on his hands, so it is considered good form, customary and courteous. In the same context I can remember calling on Dr. Barstow who was also in the Norfolk area and practiced out of the Winsted Hospital. He was a very respected figure in the area; I had good relationships with both of those doctors. I introduced myself to doctors right there in Canaan, Dr. John Elliot who was still very active. In fact he was still fully involved, but I think he may have given up obstetrics which he had done for many years, but otherwise he was very active in the full bore sense of full family practice services. He used the Sharon Hospital, but he was cutting back and wanted to spend more time in his office and more time with his family here in Lakeville. He was very pleased to have me introduce myself, and over the course of his remaining years of his practice, he referred a lot of patients to me from the Canaan area, and when his patients were admitted to Sharon Hospital, he would very frequently ask me to provide a medical consultation or assist him in the care of his patients while in hospital. That gives you an idea of what things were like when I started practice.
I might jump ahead to say that 25 years later things had changed again dramatically in terms of the practice mode. By that time no new physician would have ever thought of going and ringing doorbells of the other practioners in the area in order to advertise his or her services. Everybody by the time I retired from practice in this area in the summer of 1992 all the doctors were straight out and very
busy. I was not only, but I had five years prior to that had stopped going to the Canaan office. The Clinic had subdivided into specialties, and at the same time I decided not to continue the practice in the Canaan office, but to stay in Sharon and divide myself between the hospital and the office. This business of going back and forth on the road was time-consuming was very stressful and also put the physician under a lot of pressure. When an accountant would evaluate your practice to see if it could be made more efficient, they were quick to point out that traveling back and forth in the car from a purely financial model was a very inefficient system. You should stay put in one place and let the patients come to you. Again we saw the effects in the last several years that I was in practice in Sharon. There were a number of doctors who said, “Look I am going now with managed care; I have many fewer patients in the hospital that I used to.”
So instead of dividing my time between the office and the hospital, when the rare event happened that one of my patients needs to go into the hospital, I’ll have one of the doctors who are in the hospital most of the time, the most experienced and sub specialty oriented physicians or so-called full time hospitalists, take care of my patient. I might drop in and make a social visit or two, and when the patient leaves the hospital, I’ll pick up the care and collaborate with Doctor X or Y who looked after my patient in the hospital. In the meantime I’ll stay in the office setting where internal medicine is increasingly complicated specialty, but a specialty which is not compensated on the basis of a lot of procedures. If you are a surgical sub specialist or a dermatologist or a radiologist, your compensation is based on the number of procedures that you perform.
If you are a primary care physician, you can find yourself talking to a patient who appears in your office for a scheduled appointment who has a very complicated family situation, a complicated socio-economic situation. His wife has recently passed away, he is under a lot of stress; this is not something that you can really deal with within the tightly specified category of an office visit of 15 minutes. You just can’t do it, but the outside payment agencies, principally Medicare and surely this would apply to Medicaid and many insurance policies, will say that “That’s just too bad.” Yes, you ended up spending 45 minutes and even then didn’t really feel… You felt and indeed committed yourself to a couple of follow-up telephone calls or talk to a family member. There is not going to be anybody that will compensate you for that time. In that situation there is no way you can submit to anyone, Medicare or otherwise, a bill for that kind of service. You are going to compensate on the basis of routine 15 minute office visit. It is going to amount to a relatively small amount of money relative to the intensity of the encounter and the amount of time that you put into it. That indicates that managed care created problems and put pressure on the providers, both physicians and hospitals. In certain specialties which were procedure bases were better able to survive and prosper under these new rules, the new realities. Pediatricians would say that was always the way; it was with them. A lot of their patients couldn’t afford to pay them; they still felt obligated to provide the service regardless. Now a lot of primary care physicians in internal medicine and family practice found that since their skills were basically cognitive, that is taking time to think about what is really going on here, and I had better call a family member, I’ll make a note here call a family member tomorrow and try to corroborate what I am hearing from the
patient today. All this time, no procedure, no scalpel, no biopsy was involved, but a lot of time was expended.
So after 25 years I found myself spending a considerable amount of time in the office on long drawn-out and relatively poorly compensated visits. In addition to that, I had the further new reality of our community was the emergence of two excellent nursing care facilities, Geer in Canaan, and Noble Horizons here in Salisbury, wonderful institutions, non-profits, hard working. I think at the time I closed my practice I had over 30 patients in those two facilities. They had to be seen once a month so there was a huge number of routine visits which were required. Appropriately you had to see the patient and make rounds with the nurse, and find out if anything new was going on, rewrite the orders, try in your own mind get a sense of whether there was any fundamental change in the patient’s condition. Now the nature of practicing in nursing homes is that these patients live a long time so there were many a patient that I had seen once a month for two or three years with problems related to dementia, the aging process, but in an essentially static condition. What was truly a challenge, as I would pick up the pen and try to write a note about such a patient, was to find something new.
Tape ends there.