For more than four decades, physician Alan Blum has waged war against cigarettes and the companies that produce and advertise them. Family doctor, activist, medical editor, sketch artist, humanist, professor, and the creator of the Center for the Study of Tobacco and Society at the University of Alabama – Alan is a dynamo of energy and creativity. His friend, Jack Coulehan, asked him to sit down and share reflections on his wide-ranging career with readers of MedHum.

JC: Well, it’s great to see you, Alan, and thank you for agreeing to this interview. It’s been a long time since I saw you in person. I remember when we first met in 1992 at the Society of Teachers of Family Medicine meeting in San Diego. It was at a poetry reading, and we were both presenting our work there.

I’d like to begin by quoting an article that I saw in the Amherst student magazine from 2008. You had just received an honorary doctorate of science there. It goes like this, “AB’s combination of his education, his love of art, his passion for medicine and his wonderful sense of humor have made him a great warrior in the fight against smoking. Dr SmokeBuster offers an alternate view in the seemingly strict discipline of medicine. He embodies the philosophy of the liberal arts, using a variety of disciplines to communicate his message. Most importantly, AB brings poetry and artistic splendor to the often overly calculated role of science.”

I think that really describes your ability to merge your love of the arts and humanities with humor and your passion for medicine, as well as your public health activism and your career-long campaign against cigarette smoking. So how do you look at that? How do you view those interdigitating components?

AB: First of all, this is so unbelievable. If you told me that when I was struggling to figure out what to do in life, that I’d be interviewed by Jack Coulehan, I’m just really appreciative that you would take the time to do this.

I had great fortune in my upbringing and growing up on the periphery of New York City.

It was really a marvelous time. I thought New York City was where moms took their kids to go to see plays and museums on weekends. I didn’t realize people actually live there. Where I was born, at Rockaway Beach Hospital in New York, you could see the ocean from the hospital. My father, Leon Blum, MD, was an intern there and then a member of the medical staff. He was a general practitioner for 37 years in the very town in which he’d been raised, Rockaway Beach. And that’s where Jonas Salk spent his summers. And Burrill Crohn was from there, of Crohn’s disease fame. So it has a rich heritage. I grew up in a low middle income community, nearby Far Rockaway, where my father, Leon Blum, MD, knew everybody.

My dad was very literary. He would do the Sunday New York Times crossword puzzle, which I could never do. And I had great opportunities to experience culture. Of course, I thought museums were mostly about dinosaurs. I never realized that there were art museums. That was the awakening I got when I went to my first National Conference of Family Practice Residents meeting in Kansas City.

It was pretty boring. So I started walking around Alameda Plaza, and I came across this beautiful building that looked like a Greek temple, and it turned out to be the Nelson Gallery. And that was really my awakening in art.

JC: And you also had an early commitment to activism. It’s remarkable that even as a resident in the late 1970s at the University of Miami, you had already begun, kind of this dual career as a regular practicing physician and as a family practice resident, you organized a campaign against smoking and other unhealthy habits among adolescents. What was the origin of the idea for the Doctors Ought to Care movement?

AB: I think everything I’ve ever done is irony and humor, and even the title of my undergraduate thesis on Robert Frost was called “The Way of Understanding is Partly Mirth” (from a line of one of his poems). I don’t think I would have been able to get through being fired a couple of times, not getting into this or that school, not getting this or that job, missing the deadlines for exams that I had to take, and so forth had I not had a sense of humor.

I was about a 7-year-old watching Brooklyn Dodgers games on TV with my father in the afternoons when he would rest after his 9 am-to-noon and 1 pm-to-4 pm clinic before his after-dinner office hours in our house, where the living room became the waiting room. We loved the Dodgers, and one day he said, “Look at that Lucky Strike commercial. Why don’t you take out our tape recorder and record it, because one day nobody’s going to believe that they would associate sports and cigarettes.” And sure enough, it only got worse as the decades went by. Meanwhile, I had begun an interest in smoking because my father had had a heart attack in his 40s, when I was 5 years old. He started smoking Chesterfields as a medical student and continued through his service in the Army in World War II in New Guinea. It just stuck with me that when and if I ever got to medical school, I’d learn a lot more about that. I never did. Only about 30 minutes of education at Emory was devoted to smoking, and it was a part of a lecture on lung diseases by Dr Brigitte Nahmias. She juxtaposed ads for cigarettes next to pictures of her patients with occupational lung disease and some who smoked. I thought that was a good way to demonstrate the contrast between the macho men in the cigarette ads and the wrecks that she cared for. So with the help of a pathology professor at Emory, I decided to create my own slide presentation of all the smoking-related diseases. By the time I was in my residency, I began speaking in elementary, middle schools, and high schools to try to talk to kids about not taking up smoking and other killer lifestyles that were being promoted to them in the mass media.

At a meeting of the National Conference of Family Practice Residents in Kansas City in 1977, I tried to share this work with the other attendees but was initially rebuffed. I was finally given a room after the main proceedings ended. It was filled to overflowing. Over 50 people came, and one of them was Rick Richards from South Carolina, who told me “You know, I’m going to go back to Spartanburg and do the same thing you do, and I’ll see you next year.” Well, by that next year, we’d organized several chapters, and we were asked to give the main talk at the conference. So DOC, or Doctors Ought to Care, became known for not just lecturing on the dangers of smoking, but also for ridiculing, satirizing and parodying cigarette advertising and the way in which the tobacco companies were getting away with murder. We were the first and only physician organization to confront the tobacco industry itself, and not just angrily, but using humor and MAD Magazine-style satire such as the Barfboro Man and the Emphysema Slims tennis team. These were some of the things that we created when the American Cancer Society was saying, “Oh no, no, you can’t do that. You’re going to get sued.” Well, we were sued, and that only brought more attention to us. We did a t-shirt parody of Miller Lite Beer, whose original slogan was, “Miller Lite. We’re having a party.” Our slogan had a guy with his arm around a toilet saying, “Killer Lite. I’m grabbing a potty.” Miller Brewing, which was owned by Philip Morris at the time, sued us in state and federal court. We won the case, but it was no fun being involved in litigation with the world’s largest cigarette company.

JC: That makes me want to jump ahead to some of the exhibitions in the Center for the Study of Tobacco and Society. I was reviewing the website last week and the whole thing is so impressive, but the humor and the irony in the titles and the text of some of your exhibitions is amazing.

So to get into that, let’s move to the beginning. I believe it was 1997 when you began the Institute for the Study of Tobacco and Society at the University of Alabama, let’s go back to Doctor Ought to Care.

Alan: DOC was started in 1977. I was in internal medicine after my graduation from Emory, and I loved my internship at McGill’s Royal Victoria Hospital in Montreal, but I kept on running into family practice residents at Montreal Jewish Hospital who seemed to be loving their experiences even more than I was. So when I was on vacation in Miami, I thought why not look up family medicine?

I walked into the Department of Family Medicine at Jackson Memorial Hospital of the University of Miami, and there was Irwin Redlener, who was actually a pediatrician. Irwin was filling in at the request of the chairman Lynn Carmichael. It turns out that this was the first family medicine residency in the United States. Lynn also helped found the Society of Teachers of Family Medicine and became the first editor of its journal Family Medicine. The residency had features found in few other training programs of that era such as sports medicine, podiatry, integrative medicine, pastoral care, an annual symposium on sexuality, extensive community outreach, a resident-run evening clinic, and a monthly book group to discuss The Person: His and Her Development Through the Life Cycle by Theodore Lidz. It was just amazing timing for me, and I never looked back.

Lynn tolerated me pretty well for my activism on tobacco after initially chastising me for trying to convince his secretary to stop smoking. He eventually admired what I was trying to do, which was to bring our knowledge about health into the community to try to make up for the health and socioeconomic disparities in the neighborhoods around the inner-city hospital.

Dr. Richards and I were soon joined by another family physician, Dr. Tom Houston, and through the National Conference of Family Medicine Residents we were able to disseminate our activist approach to tackling the killer habits. In the 1980s we wound up having close to 100 chapters of

DOC in medical schools and family medicine residency programs, some of which still exist. Our approach was to use humor and satire, as opposed to all the staid organizations like the American Cancer Society, the American Heart Association, and the American Lung Association, which still relied on pamphlets, posters, and unpaid public service ads on TV that usually aired at 3 in the morning. DOC was the first health group to purchase counter-advertising space on billboards, bus benches, TV, and radio. No one else had ever done that. We were also the first to involve teenagers in our work and to tap the highest level of creativity and commitment of every family physician we could find. In 1978, I co-hosted a conference with a junior high school student that was attended by 150 students from 30 schools in South Florida to train them to help raise the awareness of their peers about the targeting of young people by the purveyors of cigarettes, alcohol, and junk food.

Flash forward to 1997 when I was on the faculty at Baylor College of Medicine. I was invited to give the family medicine residency graduation address at Tuscaloosa. I shared my sketches and stories of patients and also gave a grand rounds on the physician’s role in ending the tobacco pandemic.

Afterwards, the chairman, Jerry McKnight, asked me if I wanted to stick around. I thought he meant going for a beer, but he wanted me to apply for a new endowed chair position in family medicine.

When I moved to Alabama two years later, I started the Center for the Study of Tobacco and Society. DOC was still going, but I also wanted to do something different such as researching the history of smoking and efforts to counteract it.

I began to organize the vast amount of material that I had amassed over the years through what I called a daily biopsy of the smoking pandemic – the largest collection on the tobacco industry, cigarette marketing, and anti-smoking advocacy at any university. This was all pre-internet and pre-ebay. I had tens of thousands of items, and the University of Alabama was kind enough to provide some space. I thought of this as both a museum and an archive, and for the next 15 years I hired graduate students from the School of Library and Information Studies to start cataloguing the collection.

The main work product of the Center is exhibitions. We began with an exhibition at the annual convention of the Association of American Editorial Cartoonists called “Cartoonists Take Up Smoking!” It took ten years to research and involved acquiring over 300 original artworks from the nation’s newspaper editorial cartoonists. The exhibition then went to the National Museum of Health and Medicine in Washington for a year and traveled to ten other venues. So we had a great opportunity to share our work, but then it dawned on me in 2015 to do online exhibitions to reach a much larger audience. We’ve now done nearly 40 exhibitions, and I’ve never looked back.

JC: And I think that that those online exhibitions, each of them, seems to be a massive enterprise with so much richness in the visual material, in your text, comments and so forth. It’s remarkable that you have been able to collect this much essentially social history and curate it in such innovative ways.

Alan: Well, here comes the trigger warning, because I do this mostly for me, partly because. I don’t think most people understand the smoking issue. I really don’t. I don’t think there’s much to cheer about, in spite of the progress that we’ve made in reducing adult smoking from over 40% in 1964 to less than 15% today. Just this year, an investigative report was released about how low-tar cigarettes are bigger than ever in China, because they’re still pushing the absurdly fraudulent notion that there can be a safer cigarette. Even the Journal of the American Medical Association bought into this for awhile back in the 1970s. It’s such a tragic history in this country that I cringe whenever I hear public health people saying that the reduction in cigarette smoking is the greatest public health triumph of the 20th century. Not at all. In my opinion, it’s just the opposite. 

We learned everything we needed to know about smoking by 1964 when the Surgeon General’s report came out. My dad taught me everything I think I needed to know when I was much younger than that. I wrote my first article on smoking when I was editor of my high school newspaper, The Woodmere Academy ECHO. And I think I’m the longest running individual on this issue, because I’ve been doing this with a passion for over 60 years – – fortunately, I haven’t had to earn my living from my anti-smoking work. And that’s where my trigger warning comes in, because it’s hard to imagine how thoroughly the field has been professionalized. You have to have a Master of Public Health or a Doctor of Public Health degree to get a job in it, as compared to the hundreds of grassroots activists from all walks of life across the country who led the way for decades in passing local clean indoor air laws. And guess what it’s called now: “Tobacco Control.” Of course, it’s not about controlling tobacco. It’s about curbing smoking and its promotion. This issue is something that medicine hadn’t addressed before, because unlike an infectious disease it’s a human behavior that’s taught to us by an industry that’s making an enormous profit. So I believe my contribution was to shift the focus away from lung cancer and smokers and instead onto Marlboro and the people in the tobacco industry who promote it. I think that was an exponential leap from where we were before then.

There were quite a few health care professionals who were opposed to smoking. Thoracic surgeons Alton Ochsner and Michael DeBakey were warning that cigarette smoking caused lung cancer beginning in the late-1930s. For their trouble, they were ridiculed by the medical profession. Organized medicine didn’t want anything to do with fighting smoking. (For one thing, their medical journals accepted lucrative cigarette advertising revenue until well into the 1950s; for another, two-thirds of physicians in the 1940s smoked.) So what I think we did in DOC was to shift the focus to monitoring the tactics of the tobacco industry. Our strategy gave permission for everybody else to point the finger at the industry as the source of the problem. But the federal government never devoted any funding to fight smoking, and there was relatively little effort. So leading the way was that band of people who hated going into restaurants or getting on airplanes and breathing tobacco smoke. It was that activist group of people– – not the public health people, not the physicians – – who started the nonsmokers’ rights movement. And then there was a guy like me who was looking at the advertising and promotion of tobacco products. But most of those working in this field today are focused on regulation and legislation, even in this non-legislative era. Then there are the full-time smoking cessation researchers, who are practically studying nicotine receptors on toenails rather than looking at the larger picture. They’ve medicalized and “pharmacologicalized” smoking cessation. As a result, physicians no longer take an extra minute or so to encourage their patients to stop smoking. They just prescribe a drug. And I don’t think that most people in tobacco control are looking at the fact that we could have done so much more in these 60 years. For example, the first time the government ever spent a penny on paid advertising to fight smoking was in 2012.

In 1998, the state attorneys general forged a $206 billion settlement with the tobacco industry which sounded great. But although most of that money was supposed to go to fight smoking, only 2% of that has been allocated by state legislatures for tobacco use prevention and cessation. It’s all about the money.

JC: It’s all about the money.

Alan: An internist colleague, Ed Anselm, made this marvelous comment, “The most addictive thing about tobacco is money.” And he wasn’t just talking about the tobacco industry, but also about the people who say they’re fighting smoking but are really just fighting over the grants to write policy papers telling legislators what to do about smoking.

It’s a dark field.

JC: It sounds, from what you’re saying, you know, the image I have is Socrates, as a gadfly in Athens talking about the gods and so forth, and his questions threatening the status quo. One thing has improved though, you haven’t been convicted. You haven’t had to take the hemlock.

Alan: No, I was arrested, though. I’ve been arrested a couple of times for demonstrating (but never charged), once with a city councilman in Houston when we went to the Astrodome to protest a Cinco de Mayo festival sponsored by RJ Reynolds’ Camel cigarettes. Let me just give you an example of the absurdities I’ve experienced: I was fired as editor of the New York State Journal of Medicine after three years, having produced the first theme issues on smoking at any medical journal, and which brought national attention to the Journal. As editor, I had to attend the monthly board meetings of the of the Medical Society of the State of New York (MSSNY), which published the Journal. To paraphrase the Borscht Belt comedian Henny Youngman, the average age of the board members was deceased. I was about 20 years younger than the next youngest person in the room, and all they were talking about were economic matters like the high cost of malpractice insurance. It was not at all about health and medicine and helping people, in my opinion. But I’m grateful to MSSNY for having had the opportunity to do these theme issues on tobacco problems. Following the second one, though, I was fired for having spent too much time on smoking.

JC: I think we can agree that that money talks, and we lived in the mid-20th century in a culture in which smoking was not only acceptable, but it was really highly touted. For example, most doctors smoked Camels, but on the other hand, don’t you feel that that your campaigning, and your creativity has contributed to cultural change, even though it’s been at a slow pace?

Alan: I did a teaching fellowship in family medicine at the University of Miami after graduating from the residency program. And what I learned was how to give a good presentation and how to write learning objectives. These skills may seem simple, but that’s deceptive. First, there is the cognitive objective (imparting information), which 99% of lecturers think is the entire lesson they are supposed to teach. Then there’s the behavioral objective, which can teach learners how to do a procedure or demonstrate a skill. But what they’re missing, I think, is the attitudinal objective. I came away from that fellowship understanding that every presentation, every paper, every research poster I would ever do would have the reader, viewer, or the listener going away saying, “Gee, I never thought about it like that before.” That’s an attitudinal objective. I wanted to change the way people looked at an issue.

It’s something that stays with me every time I advise a resident on giving a presentation. I also do this in my exhibitions on tobacco in the hope that the viewer can see the ironies and learn the lessons from decades of foot-dragging by organized medicine, the public health community, and academia – and their fear of confronting the tobacco industry – that can be applied to tackling other challenging health problems such as gun violence, obesity, emerging and re-emerging viral diseases, and digital media addiction. There are many ways we can look at the smoking issue. Our failure to address it for so many decades is a metaphor for how we’re dealing with the wired epidemic of kids having the attention span of a fig.

JC: In 1964 when the Surgeon General came out with his first report, I believe 45% of adults in the US smoked, and now it’s approximately 11%, and the images that you have in your in your exhibitions show how trendy and culturally appropriate smoking was at that time. Now, you have to admit that there is a significant cultural awareness that smoking isn’t the thing to do, and that at least if you do smoke, you have to go out to the back, and you can’t smoke here or there, and there’s a certain kind of negativity against it. I consider that a cultural change. And of course, all of the tobacco corporations have had the time over those 60 years or so, to adapt to these new conditions and to spread their tentacles elsewhere. But it seems to me, it does constitute a change.

Alan: Jack, we look at our time now as an age of disinformation and regression, and dare I say, the word “retribution,” because we have willful ignorance that I haven’t seen in my lifetime. I lined up at my school in Woodmere, Long Island, to get my polio vaccine as a five-year-old. I was in the original Polio Pioneer trials. We have people today who are saying they’re “doing their own research” as to why they won’t get a Covid vaccination that has saved millions of lives even though these vaccines were developed in record time, thanks to our knowledge of previous epidemics, especially SARS in the early 2000s. Most of the time developing the vaccine for Covid was taken up with the trial, not with the development of the vaccine.

I think the missing element today in countering this horror is humor, and that’s why I like to think that MAD Magazine was my leading medical journal for many decades. I actually got to meet the editors and the publishers of MAD because I wrote a letter to publisher Bill Gaines and editor Al Feldstein when I was editor of the New York State Journal of Medicine. I asked, “Why don’t you resurrect those great parodies of Marlboro and other cigarette brands?” And they invited me to have lunch with them in New York City? It was fun. And they then resumed doing those parodies.

I had a lot of other influences growing up. On the radio, Jean Shepherd (best known as the author and narrator of “A Christmas Story”) was kind of every adolescent’s hero. Every night, he would tell stories of his time growing up in Indiana, and I think that’s how I got a lot of my storytelling ability.

And reading newspapers. I would often buy all nine New York dailies on a Saturday just to see the different sportswriters’ take on the Dodger games and to see the sports cartoons by Willard Mullen in the World-Telegram & Sun. Some of these were resurrected in my exhibition, “Cartoonists Take Up Smoking!” .Also, I was a magician growing up doing birthday parties and school assemblies, inspired by my father who would do little tricks for his patients. I really loved that. Once I even got to open for pianist Peter Nero at the Rheingold Music Festival in Central Park. I wasn’t very good that night, but I still get to say I performed for 3000 people.

JC: Well, it’s clear that we take ourselves too seriously. We’ve lost the ability to look at ourselves and our culture with that kind of ironic distance. And in addition to that, when you were talking about the development of the Covid vaccine, the disinformation, to me, seems to be a malignant outgrowth of some of the technologies that we’ve developed and we’ve made accessible to the world, and the ability of people to spread disinformation with such great facility and power.

Alan: I think that we need to match the reality of the society that we’re living in with the strategies to counteract it, and I don’t think we’re doing that. We’re too ideologically split, and I don’t know where common sense has gone. I don’t think the media have risen to the occasion. Our newspapers are gone. I don’t do social media. But I just am horrified. I used to think I wasn’t very literate because I looked at all my fellow English majors, like you, Jack. They were omnivorous. I did pretty well, but I just never felt that I was that knowledgeable about poetry and literature. And I see now that I was pretty good compared to what people are spending their time doing today. There are no humanities to speak of in medical schools, except for the honors courses for the self- selected students who are already interested in humanities, and you and I have spoken about the fact that out of 22,000 entering medical students today only around 500 majored in a non-STEM field. It’s mind-boggling. It’s terrible.

JC: That brings up a point I’ve been meaning to take up in this interview, and that is, we’re both medical school professors. I’m emeritus. You’re still active. In my career, I have tried to imbue in students a love of humanities, the use of the arts and humanities to develop empathy, to develop reflectiveness and resilience. And of course, I’ve gotten a lot of feedback on that, or blowback, I guess I should say, because people say, well, that’s not going to work. It doesn’t matter. These guys are going out into a different medical world in which they are going to be subjected to stresses, to constraints and so forth. So even if they go into this with that kind of humanistic perspective, they won’t be able to effectuate it in their practice. And of course, having looked back on my career, it’s kind of difficult to hear that. I’m not sure that I believe it, but I wonder what your thoughts are on that matter.

Alan: Ann Walling has an excellent review article on ageism in the July 2024 issue of American Family Physician. She compiled a checklist of questions to ask an older person. She wrote it because she was struck by many of her older patients telling her how they did not feel respected by some of the younger physicians. But I noticed she didn’t include “How do you spend your time?” or “What was your occupation?” A person’s identity is paramount. I don’t think they consider their identity is being a patient.

I find that students are trained to be good mechanics about diseases, and that they can look up anything about diseases and how to treat them. But that doesn’t involve reading things that aren’t only related to the patient you’re addressing at that moment, and that doesn’t involve pleasure reading.

My point is that we no longer live, if we ever did, in the same neighborhood as our patients. We are in not just an ivory tower, but it’s got a moat around it, and they have to come to us. So I ask every resident, “How did the patient get here today?” And you know, after the first 20 or 30 eyerolls they realize it’s relevant. Or, “Who’s at home?” Many residents initially say, “That’s too personal.” This is family medicine that I’m talking about, and they’re saying to me that just asking who’s at home is too personal, or asking about the father when a newborn is brought in by the mother or grandmother or great-grandmother for a well-child visit is too personal.

You couldn’t get any further from my father’s education at Downstate in the 1930’s (when it was Long Island College of Medicine). He would walk two to three blocks to make house calls or even deliver babies. I may be romanticizing, but I think we’ve moved so far away from them, the patients, that now it’s all about us.

When I was a new faculty member at Baylor I didn’t know anything about Houston, so I started exploring the city. I began in January. By July, I proposed doing a community field trip for the incoming interns and new faculty. I chartered a school bus and took them to a Black radio station, an art museum, the city desk of one of the two daily newspapers, the county health department, the city council, the jail, and the criminal court. I did this for 12 years. I’d change the itinerary a little bit, and the only requirement was that they would write a reflective statement. When the residents were getting their exit interview from residency after three years, the community field trip – – that one day that they had as interns – – was one of the highest rated activities.

I think it’s so important to recognize with humility that we don’t know very much about our patients anymore. I’ll give you one quick example. I was attending in an ICU at Baylor and one of the residents was rattling off endless laboratory results. The patient was intubated, so we couldn’t talk to him. Finally, I just said, “Who is this patient? You’ve told me every laboratory result known to mankind, but you’ve never said a word about who he is.” Tomorrow morning, tell me who he is.” And I walked away, I was so angry.

And the next morning the resident excitedly said, “You wouldn’t believe who this guy is. He’s the architect who designed this hospital!” I mean, he was absolutely incredulous. And it wasn’t anything great that I’d said, other than to stop presenting people as numbers. Stop talking about people as “diabetics.” Just say, “the patient with diabetes.” It doesn’t take that much of a leap to talk about people with a disease, rather than who they are as a disease. And again, I’m not the first to suggest this, but it’s also astounding that we can’t dissuade residents from presenting people by race and gender. Warren Holleman, Marsha Holleman, and Bill Monroe wrote a terrific essay, a critique of how we present and discuss patients, in Literature and Medicine in 1992 called, “Is there a person in this case?”

My father was practicing narrative medicine before there was narrative medicine, I would come home and say, “Dad, tell me about what you did today,” and he’d talk about all these fascinating people. It wasn’t having to “construct a narrative.” It was letting the patient share his or her story.

JC: With regard to the bus trips and the field trips, in 1968 when I was a second year medical student at the University of Pittsburgh, we had a community and preventive medicine course in which weekly or biweekly we would go to nursing homes, to neighborhoods, like the so-called Hill District, which was the African American neighborhood in in Pittsburgh, and so on. What I’m trying to say here is that many of these ideas we’re coming up with and saying this would be something new, were practiced in the past, but have been lost. The other thing has to do with interviewing patients. I wrote an article in the early 1980s in the Annals of Internal Medicine called “Who is the Poor Historian?” And I pointed out that that when you’re interviewing a patient, which of you is the historian? Well, obviously, it’s the doctor who is collecting the data and who is trying to assemble and interpret it as a historian does. So again, this was 30 years ago.

Alan: This is so amazing. We should collect all these. One of my favorites is “well- developed, well-nourished and in no acute distress,” which should only ever be used to describe an infant in the neonatal ICU. Instead, imagine calling a woman “well-developed, well-nourished…” And you see this on every chart. This is what the dopey electronic medical records populate.

We are so beyond reclaiming the medical record. I did a grand rounds a few years ago about scribes. For the past decade, I’ve been privileged to have had an incredible experience with medical scribes. These are mostly pre-med students at the University of Alabama who have been one better than the next. One of them wasn’t even going to go into medicine but I urged her to apply, and she did. It’s a terrific way to help mold their thinking about medicine. I don’t like the idea of shadowing, which is passive, whereas being a medical scribe is a commitment, and it’s not easy. I’ve watched these students closely, and it has been a great joy. I confess that I initially opposed having a scribe, because I thought it was going to violate the patient-physician relationship and confidentiality. But it’s a wonderful experience that I wish we would be able to expand.

It’s absolutely astounding how we’ve become so absorbed in populating medical records with minutiae that very few people read. In auditing records of residents, I look past the templates. I want to read their narrative. I want to see that this was generated by a human being.

JC: My sense is that, as a result of my own experience, what we have done in teaching the human aspects of medicine and providing role models and images of what that could be, is that we have influenced a percentage of young medical students and residents who have been malleable in a way and made them better doctors. And that percentage, I don’t claim that it’s large, but I think it’s a real contribution.

We’ve talked a lot about the difficulties and the disparities and in a sense of atrocities, really, of modern medicine, but I’d like to leave this conversation with a positive note. So I guess I’d like to ask you, Alan, what kind of positive note can we end on from your experience?

Alan: You know, every day I must count my blessings. I give thanks for the opportunity to experience the moments that I get with patients, with residents, with colleagues. I’m

a critic, but I’m also probably the biggest fan of what we do in family medicine. When it was founded as a specialty in 1969, there was a kind of a nostalgia for, and resurrection of, the old general practitioner. So I’m really living at least in some way like my dad lived and appreciating these experiences with people. I don’t think medicine is anything other than that. I admire radiologists, especially those that want to see a picture of the patients that they’re reading the films on. I admire every sub-, sub-, sub- specialist there is, because, gosh, it’s good to know that if you need them, they’ll be there. But what a privilege it is to be able to see people from all generations at any given moment. I never know from one day to the next who I’m going to see, and on a single day about two years ago I actually saw patients of four generations in the same family: great grandmother, grandmother, mother and daughter. So I think that I’m a commercial for family medicine, but I’m not a commercial for making medicine into a disease-oriented, as opposed to a people-oriented, field. I think we can’t get to the diseases until we know who people are.

JC: I agree. I’m not sure we can return to the past or to the more holistic view that we recognize in your father and some of the doctors that I encountered when I was young. But I think we need to keep working and seize any opportunity that presents itself to get our message through. I’d like to thank you for this discussion. We could continue for several hours on these topics, and that would be very interesting, but in the interest of time, we have to conclude now. So thank you.

Alan: And I want to thank you and Lucy for thinking of me in this context. I also would be remiss in not thanking my wife, Doris. We’re going to be celebrating our 49th anniversary (in September 2024) with a few days in the Adirondack Mountains. Also, my three sons, Leon, David, and Sam, my late father and mother, Eric Solberg (my colleague and co-author in DOC for over 25 years), and the many mentors I’ve had: English professor Chick Chickering at Amherst College; cardiologist and poet John Stone at Emory University School of Medicine; Howard Rusk, the pioneering rehabilitation medicine physician in New York; Sam Nixon, a president of the American Academy of Family Physicians; and Bob Rakel, who was the chairman who took a chance on me after I was fired as editor of the New York State Journal of Medicine, even though I hadn’t worked in a hospital or clinic for several years.

I’ve been incredibly fortunate to have all these individuals in my life. There was also Kurt Deuschle, chair of community medicine at Mount Sinai School of Medicine. When I was fired as editor, I called him, looking for a few words of sympathy and encouragement. Instead, Kurt sternly replied, “It’s your own damn fault.” I was crestfallen and speechless. But then he explained, “You got too far away from patients.”

I’ve never forgotten that advice.

Alan Blum, MD, is a family physician and professor of Family Medicine at the College of Community Health Sciences, which also functions as the Tuscaloosa Regional Campus of the University of Alabama School of Medicine. He is the first holder of the Gerald Leon Wallace Endowed Chair in Family Medicine at The University of Alabama College of Community Health Sciences. One of the foremost authorities on tobacco problems, Blum is the director of The University of Alabama Center for the Study of Tobacco and Society, which he established in 1999.

Links
1964 Surgeon General’s Report
University of Alabama Center for the Study of Tobacco and Society
Irwin Redlener’s Bio on Wikipedia
Alan’s stories and sketches of patients 
Alan’s website about an artist who was a patient for over 50 years at the state mental hospital in Tuscaloosa

Intro photos from Covering Cancer? exhibition at Center for the Study of Tobacco and Society