From Alaska to Oregon-Champion of Community Oriented Primary Care
LJ’s practice, Dunes Family Health Care on the Oregon coast, was one of the 13 model rural practices funded by the Robert Wood Johnson Foundation’s Rural Practice Project in 1977. In 1993 he joined the Department of Family Medicine at Oregon Health and Science University. In 2002, LJ was selected to start a practice-based research network at OHSU, the Oregon Rural Practice-based Research Network (ORPRN). In 2005 Dr. Fagnan was named “Family Doctor of the Year” by the Oregon Academy of Family Physicians. He has been an investigator on 50 ORPRN studies with a principal investigator role in 20 of these studies. Co-author of a landmark paper published in the Journal of the American Medical Association (2007), “Practice-Based Research— ‘Blue Highways’ on the NIH Roadmap”. LJ’s research portfolio includes studies and publications related to population-based health, dissemination and implementation of evidence-based medicine into practice, quality improvement, and rural health care systems.
He was the co-director of the Certificate Program in Practice-Based Research Methods Fellowship. The inaugural 2015-2016 program graduated 16 fellows. The 2016-2017 program accepted 54 fellows from Canada and the United States. LJ was the founding director of the Meta-network Learning And Research Center (MetaLARC), a consortium of seven practice-based research networks in Canada and the United States. Dr. Fagnan retired as director of ORPRN in 2018 and from OHSU in 2023.
“The major thing that my exposure to the native people of the Yukon-Kuskokwim delta provided was a lesson in how be a doctor. The Yupik Eskimo culture taught me how to be community-centered.”
You had a remarkable start to your career, an experience that had an enormous influence on your lifes work…
Lyle (LJ) Fagnan: I started my medical school career over 50 years ago. We had a 51st class reunion and I was reflecting on how I got started in medicine. I went to school here in Oregon. It was at a time when Family Medicine was just getting off the ground. I think it was 1969 that this specialty was recognized and I graduated in 1971. So, when I came out of medical school, hanging over my head was the military draft. I wasn’t excited about the possibility of ending up in the Army, I was married and had a one-year-old son. I met a pediatrician from the Anchorage Alaska Native Hospital who thought that might be a good option, and the United States Public Health Service was considered part of the uniform forces, so I did a rotating internship in Hartford, Connecticut, and then went from Hartford straight to Alaska and ended up in a place called Bethel which has about 4,000 people and is on the Yukon–Kuskokwim Delta. I was very young, I went to medical school after three years of college and I hadn’t had much in the way of life experiences, but I was pretty interested in different ways of doing things. Bethel was a center of 48 Eskimo Villages, I was a general medical officer, I became the community health director, and in my first week there I ended up doing three appendectomies under spinal anesthesia. The major thing that my exposure to the native people of the Yukon-Kuskokwim delta provided was a lesson in how be a doctor. The Yupik Eskimo culture taught me how to be community-centered.
It was the center of 48 Villages, and there were eight of us general medical officers, and we divided up the villages. One of us had radio traffic for a week and we would visit with the Health Aides and hear who they were seeing. I had six villages and I made one or two trips a year out to each village, by plane mostly and sometimes by river, because when the river was frozen solid you can drive in the winter to some of the villages. The Eskimo people were really kind and accepting of people like myself, even though they knew that we were transient, that we would only be there for a couple years. In my case I was there for three years but I really got to understand how communities operate and it influenced the rest of my career; that immersion into the native into the native culture and appreciation that ‘it takes a village to raise a child’ and I came away having lived that mantra.
“The Eskimo people were really kind and accepting of people like myself, even though they knew that we were transient, that we would only be there for a couple years. In my case I was there for three years but I really got to understand how communities operate and it influenced the rest of my career”
I didn’t want to go right into practice, I knew there were Family Medicine residencies. I would visit with a leader of Family Medicine in the early days, Ted Phillips, who was a family doctor in Sitka, Alaska, and later went on to be the department chair at the University of Washington and was then the Dean of the School of Medicine at the University of Washington, after having been a country doctor.
I’d visit with Ted every year and he said, LJ there aren’t any residencies for you. There weren’t any openings but I did get to apply to one they were just starting in Boise, Idaho, and I used that time there to think about what kind of practice I wanted to have because I had a lot of clinical experience from my time with the Indian Health Service. I wanted to do a residency and I kind of knew a lot of the clinical things and even in Boise they let me continue to do things like C-Sections and some of the things I did in Alaska. But the major thing I got to do was to think about what practice was like.
When I was finishing up medical school I became acquainted with a physician called Larry Weed who was the father of the Problem Oriented Medical Record and wrote a book in 1968 on medical records that teach and provide comprehensive care (Medical Records, Medical Education and Patient Care. Lawrence Weed- see side panel).
I was fascinated by him and indeed I had the opportunity to invite him to come to the medical school I was at to give a talk. He had had an article in the New England Journal of Medicine in 1968 that talked in detail about his vision of the Problem Oriented Medical Record and the use of the computer.
He was early in this phase of computerized medical records and I also became acquainted with one of his proteges, Harold Cross, who had a practice in Hampden Highlands, Maine, who wrote a book on the problem oriented medical practice. (The problem-oriented private practice of medicine: A system for comprehensive health care. J Bjorn HD Cross- see side panel). While I was doing my residency I contacted Dr Cross and he invited me out to spend a month with him to see what his practice was like and he had one of those models that I wanted to adopt. He did a comprehensive evaluation of every patient. He had a document called the ‘Principles of Practice’ that guided he and his partner John Bjorn and so I thought about that during my residency after that month. Later, I was rifling through my Program Director’s desk and I came across the Robert Wood Johnson Foundation application for a project called The Rural Practice Project and they had a goal of subsidizing 30 practices in the United States. They came upon the premise that it was hard to be in rural practice, people weren’t succeeding, and we needed to change the model. They came up with a set of criteria and they would provide a four-year stipend of about $500,000 which, back in 1977 , was a lot of money. They had a goal of 30 practices and the criteria were that you had to be non-profit, you had to have an administrator, you had to have a practice team, and so I became one. I don’t know if you can see the book but I became one of 13 practices that the RWJ funded. They could only find 13 practices that met the criteria that they wanted to fund. I went into this community on the Oregon coast, a community of about 4,000 people. I said I wanted to set up practice, again I’m just out of residency, and so I met with the people, I created a community board and I became an employee of the community. This practice, in 1977, had myself, a wonderful administrator I was fortunate to work with who was really great, a physician assistant Susan that I hired from Seattle, a health educator, a nutritionist, two- part-time psychologists, a dentist, a medical assistant, and a receptionist. We started out with what people view now as these model practices, and this was back in 1977.
“Early on I had this exposure to people that were pretty thoughtful about the discipline of family medicine and trying to create the evidence for what we did and do and that was foundational for what I’m doing, what I did later.”
During the early days of the RWJ Rural Practice Project we would meet as a group, it was administered out of the University of North Carolina School of Social Medicine (under the guidance of Don Madison) and we would meet each year, the 13 practices, and talk and share what we were doing. There was a lot of camaraderie and when the funding went away I got lonely. I was contacted by Larry Green who was directing the Ambulatory Sentinel Practice Network of North America (ASPN) that had Canadian and US practices, and I became practice number 29 with ASPN, doing practice based research.
Early on I had this exposure to people that were pretty thoughtful about the discipline of family medicine and trying to create the evidence for what we did and do and that was foundational for what I was doing, and what I did later.
DMacA: That model of practice that you introduced way back was very far ahead of its time. Larry Green’s network of research practices was really innovative, but then you ran with it yourself and the Oregon Practice Network grew from your ideas…
LJ: Exactly. I was able to get a position at Oregon Health and Science University and my first job was to set up the first Primary Care Center for the university in the community of Portland and we took half the residents with us. I did that for the first nine years I was there, and then in 2002 established the Oregon Rural Practice Based Research Network (ORPRN)and was able to get some funding from the Agency for Health Care Research and Quality, not much money but enough to get started. It allowed me to stay focused on my rural roots. We really did grow this network into something that had a lot of meaning for practices that wanted to be connected to something bigger. As rural practices they felt like they couldn’t identify with others very well. We were having a round table and, one physician, John, had tears in his eyes as he said- “this is the first time I’ve been connected with other folks that are thinking like I am and want to do something different and create a better way of doing things.” It was quite gratifying to be able to work with these rural practices. Every time I went out to visit one, I came back inspired. I was able to share with these practices some of what I did during my early career, the principles of practice that we set up, the community orientation, those principles of practice that we had talked about, how we had a responsibility to teach, we had a responsibility to do research, and we had a responsibility to the community.
“…those principles of practice that we had talked about, how we had a responsibility to teach, we had a responsibility to do research, and we had a responsibility to the community.”
DMacA: Those three principles are absolutely fundamental. But it’s not just the network of education and community, you did some very interesting research. You did some work on heart health…
LJ: One of the advantages of a Practice Based Research Network, and having connections with organizations like the Agency for Healthcare Research and Quality, is that you get to see what opportunities are out there. We had what was called Evidence NOW, the largest quality improvement study, I think, that’s ever been done around heart health. I was able to partner with a physician Michael Parchman, who was in Seattle at the time, and we had Healthy Hearts Northwest which was one of the groups that participated in Evidence NOW and a lot of papers have come out of that that led by some very thoughtful people
DMacA: You’ve always been ahead of the game, you’ve always been that step ahead of the rest of the posse. One of the other things that fascinated me was that you were way ahead of the game with decision support and Shared Decision Making…
LJ: I see people out there that I admire and I look at their work and think, you know, I want to know them better. I got to know France Légaré through my interest in Shared Decision Making and I was able to be one of the demonstration sites for the Shared Decision Making group out of Harvard that Michael Barry led.
I think we had maybe six or seven demonstration sites- there was Stanford, the Massachusetts General, Dartmouth, and others, and ORPRN became the rural component of that demonstration project- to show that you could introduce Shared Decision Making aids into small town practices, and they would get used, and that patients and the clinicians and staff that use them would value them.
“I think we had maybe six or seven demonstration sites- there was Stanford, the Massachusetts General, Dartmouth, and others, and ORPRN became the rural component of that demonstration project- to show that you could introduce Shared Decision Making aids into small town practices, and they would get used, and that patients and the clinicians and staff that use them would value them.”
DMacA: There’s another aspect of some of your work that must have been considered very radical by your colleagues and peers and that is, when you introduced the idea of having a Pharma free practice…
LJ: Back in 1977 when I started this practice in Oregon with the Robert Wood Johnson Foundation, one of the principles of practice was how to deal with pharmaceutical representatives. This was early on, and it said that we would schedule them once a month, and they could drop off their samples, and the samples were only to be used for people that didn’t have money but who needed the medication, and we would dictate what samples we wanted. This was in those early days and, then when I set up the practice at Oregon Health and Science University, one of the first things I did was to say that we will not have pharmaceutical representatives coming in on their own. We were fortunate to have a PhD pharmacist so we set up a once-a-month talk where we would invite the pharmaceutical representatives to come in and they would come in as a group and they would share what they were going to present, but they had the other pharmaceutical representatives around the table. It only lasted about three months before they decided they didn’t like that format but, we didn’t take any samples. Indeed, one of the practices in a small central Oregon community, David Evans, he wanted to go Pharma free in his practice and he published two papers that we worked with him on about how he went about that and measured the effects of that decision on prescribing practices, and this was one of the early efforts to realize that there’s ‘no free lunch’ when you’re dealing with pharmaceutical representatives.
“…and this was one of the early efforts to realize that there’s ‘no free lunch’ when you’re dealing with pharmaceutical representatives.”
DMacA: Looking back at all these enormous steps forward that you made, where do you think Family Medicine is going now. What are the challenges facing young doctors?
LJ: I’m very concerned about the discipline. Concerned because of the corporate presence in the discipline. It’s very hard to make decisions about what’s best for your practice, and for your patients, because you have the ‘mothership’ that’s dictating that whatever you do has to benefit everybody, and the ‘mothership’. So, there’s been a loss of autonomy on the part of family physicians. Medicine’s got a lot more complex and I understand that, and things have got a lot more fragmented these days. We no longer have the family physician who does everything, taking care of patients in the office, covering the emergency room, taking care of patients in the hospital, taking care of patients in the nursing home. That is a pretty rare model these days, even in rural practice. The fragmentation of the discipline is of concern. Few Family Physicians do obstetrics, some Family Physicians have given up taking care of children. We have an aging population so a lot of us have gravitated towards a geriatric practice. I wish we would embrace the community oriented primary care model where there was less focus on the practice and more of a focus on our responsibilities of taking care of the community, regardless of who those people are, regardless of whether they come to our practice, that we are focused on community health and that’s what we measure and not necessarily the quality metrics on individual patients and the people that come into our practice, but on how it looks for the entire community.
DMacA: That’s a wonderful note on which to end our conversation. LJ, it’s been an absolute pleasure talking to you, as it always has been. Thank you very much for sharing your life, and your interests, and the great steps forward that you made on behalf of Family Medicine in the US, and for all of us.