Position: President, Institute for Urban Family Health
New York, N.Y.
Dr. Calman and three of his colleagues showed up in the South Bronx almost 20 years ago and developed an idea. That idea was to start to improve the health care of one of our nation's neediest communities. They did it with their own money, their own labor, and their own ability to inspire others to join them. By most standards it was an impossible task.—President, [New York] Committee of Interns and Residents
Dr. Calman's clinic is the only place in town that you can go if you're on Medicaid or "sliding scale" without fear of mistreatment. It is a joy to go to the clinic. I believe that it is the way it is because of Dr. Calman and his beliefs about the way people deserve to be cared for.—Patient
Neil Calman, MD, one of the first recipients of the Robert Wood Johnson Community Health Leadership Award, has devoted his life to serving New York City's urban poor with high quality medical care. Dr. Calman's sense of social commitment was a part of his upbringing. His grandfather served as an alderman in New York in the 1920s, and was arrested several times for his social activism on behalf of the poor. One of these arrests was for exposing a fake coal crisis. As Dr. Calman tells it, "He photographed all of these stockpiles of coal and led this huge protest march, because people in tenements couldn't get coal."
Dr. Calman's parents also embodied values that he admired and later emulated. His father worked as an oral surgeon in the Washington Heights section of New York City. His mother assisted in the practice, and provided an extra dimension of personal attention to patients, most of them working class. "It was really amazing to watch her," Dr. Calman recalls. "She would go home at night with the phone numbers of the patients who had telephones and call them up and find out how they were feeling after their surgery. There was something about that kind of service that really attracted me."
Dr. Calman's desire to serve led him to the University of Chicago. There, as an undergraduate in 1969, he became involved in protests against the University's real estate acquisitions, which involved tearing down much of housing in the school's neighborhood, displacing its mostly black residents. Dr. Calman joined sit-ins led by Students for a Democratic Society (SDS), demanding an end to such activities and reinstatement of a faculty member who had been dismissed for her activism. As a result of his participation, Dr. Calman was suspended from school for six months. This served as a "scarlet letter" on his transcript, and made it hard for him to get into medical school after graduation. Fortunately, the new medical school at Rutgers University was looking for socially committed students such as Dr. Calman, and the door to his future opened.
After two years at Rutgers' medical school, in 1973 Dr. Calman returned to Chicago, enrolling at Rush Medical College to complete his clinical education. There he again ran into trouble as an activist, asserting the need to question certain procedures by the Department of Obstetrics, and alerting the newspapers. This led to the establishment of the first research review board at Rush. It was the first major institutional change that resulted from Dr. Calman's activism. It would not be the last.
While at Rush, Dr. Calman became interested in the concept of family practice, a relatively new area at the time. He understood that it would enable him to practice a wide range of medicine. His route to learning more about it was, typically, unusual—in 1974 he answered an ad in the New England Journal of Medicine for a doctor at clinics sponsored by the United Farm Workers Union. He traveled to California, where he met with Caesar Chavez and was invited to join the union clinics. Working at the clinics, he delivered babies, sutured serious wounds, set and cast fractures, took x-rays, and did his own lab work. This two-month immersion provided him with a new understanding of the political context of medical problems and care. "I think that was actually the single most important thing that ever happened to me in my career in medicine," he later said. "We were taking care of people who had no access to the general health care system. None of them had health insurance. I developed this enormous sense of confidence that physicians could do more than what you saw them doing in sub-specialty areas of medicine. And every Monday afternoon I marched with the union through the streets."
For his family practice residency Dr. Calman then moved to Montefiore Hospital in the Bronx, N.Y. There, from 1975 to 1978, he worked with other physicians who shared many of his values. With them, he supported a strike by the Hospital Employees Union—and was fired. Eventually, though, he and the others were re-instated by order of the National Labor Relations Board. Also while at Montefiore, he worked with three other residents to get federal funding to start a community health center in the Northeast Bronx. Things did not go well. In spite of their success in getting the funds together and the program mounted, they did not adequately account for community input in their planning process. "It was one of these real lessons that you never forget," Dr. Calman remembers. "When you are in a collaboration, it's not how fast you move, but rather how well you gain consensus at every step." When the community felt excluded from key decisions, the community leader said, 'Thank you very much. You've done a great job, but I don't think we want this program the way you've designed it.'"
Despite the failure of the program, Dr. Calman discovered that he had a talent and love for both services development and administration. In 1981, he became the founding medical director of the community-directed Soundview Health Center in the Southeast Bronx. Dr. Calman and his professional associates viewed the center and the hospital as excellent training sites for medical students and residents in family practice. But the community board decided it did not want residents "practicing" on the community members. This conflict made an indelible impression on Dr. Calman."We outran them. We were incredibly self-assured and incredibly aggressive, but we forgot to include them in everything that we were doing. When you are in a collaboration, the collaboration moves at the pace of the slowest partner. I really saw at that point that I had two choices in my life. One was to continue to be frustrated working for people who didn't move as fast as I did. The other was to start my own operation."
He developed the nonprofit Institute for Urban Family Health (IUFH) in 1983. It combined elements of a community health center and a private practice group, thereby allowing for residents to be trained there. Drawing upon the relationships Dr. Calman had built at Montefiore, IUFH worked closely with community organizations, but kept the administrative arrangements in the control of professionals. IUFH's mission was to improve the quality and availability of family practice services in response to the needs of medically underserved populations. IUFH began by starting a new family practice residency-training program at Bronx Lebanon Hospital. It also started a Family Practice Department there, something no other New York City hospital had at the time.
Two months later, IUFH bid on the Sidney Hillman Health Center in Manhattan, which was going bankrupt. Sidney Hillman had formerly served union members of the Amalgamated Clothing and Textile Workers Union. Now IUFH was chosen to operate the facility for the benefit of all the community's diverse residents. IUFH immediately began running Sidney Hillman on a primary care model, decreasing the cost of care and eliminating unnecessary medical procedures. Soon, Sidney Hillman was operating within its budget. By 1988, IUFH had received approval from the New York State Department of Health to operate Sidney Hillman as a comprehensive family practice center, open to the public, offering all patients a greatly expanded range of services that included limited specialty, laboratory, and radiology services. IUFH's model, then as now, included grouping family physicians and family nurse practitioners in provider teams, on call for their own patients 24 hours a day.
In 1991, IUFH made an organizational commitment to develop small health care sites based on the family practice model within the fabric of the community. New site development was accomplished through collaborations with community-based partners in medically underserved areas. As of the fall of 2000, there were six sites operating in the South Bronx and Manhattan, as well as nine satellite clinics for the homeless in Manhattan.
In July 1992, IUFH received funding through the Ryan White CARE Act, Title I, to provide care to hard-to-reach and homeless patients affected by HIV. Since then, all IUFH physicians have participated in an ongoing program of in-service training. This training consists of a series of workshops on risk assessment; HIV counseling, prevention and treatment of HIV and its associated opportunistic infections; cultural sensitivity to different types of patients; and the social, emotional, and legal issues likely to affect patients and their families. The Institute is now also offering clinical case management, supportive counseling, health education and other support services, as well as mental health services to persons living with HIV.
Soon after its founding, IUFH developed a regional training program designed to improve the teaching skills of family practice faculty throughout the metropolitan area. Participants include family practitioners from most of the family practice residency training programs in the tri-state area, and more recently, from nurse practitioner, midwife, and physician assistant programs as well. The structured curriculum includes workshops, seminars, tutorials, and practice teaching in family practice training sites.
When it became clear that medical students in New York City were not choosing family practice training due to the lack of departments of family practice in five New York City medical schools, Dr. Calman promoted the development of a department at Albert Einstein College of Medicine. In 1991, with a grant from the United Hospital Fund, IUFH launched its National Family Practice Education Program, dedicated to sparking interest in the specialty of family medicine and providing students with extensive family practice experiences. Although initially directed toward the four remaining New York City medical schools without such departments, with funding from the Josiah Macy Jr. Foundation, the program has now expanded far beyond the metropolitan area to include such eminent schools as Harvard, Yale, and Johns Hopkins. As of Fall 2000, approximately 400 students have come through the program.
Over the course of his career, Dr. Calman was also becoming a forceful advocate for the needs of the underserved. He served as president of the New York State Academy of Family Physicians, and later as chair of the Health Policy Committee of the Community Health Care Association of New York State, and chair of the Health Reform Subcommittee of the New York State Council on Graduate Medical Education.
By 1993, Dr. Calman's efforts were attracting wide notice. In that year, Beth Israel Medical Center sought out IUFH to initiate a Family Practice Department and residency-training program. Thus, Sidney Hillman became the base of the Alfred and Gail Engelberg Department of Family Medicine, the Phillips Family Practice, and the Beth Israel Residency in Urban Family Medicine—all in addition to its ongoing activities.
Also in that year, Dr. Calman was selected to receive the Robert Wood Johnson Community Health Leadership Award. Winning the award brought increased recognition and credibility for Dr. Calman's efforts. He was soon the subject of significant media coverage, including an appearance on public television's "MacNeil-Lehrer Report," and he found himself increasingly in demand as a speaker. The award also sparked other significant funding, which in turn enabled program expansion. Within a short time, Dr. Calman won major awards from the Pew Charitable Trusts and the American Academy of Family Physicians. "RWJF gave credibility to our whole package of programs," Dr. Calman says, "because there had been a lot of people who believed we were trying to do the impossible."
Since 1993, IUFH has expanded its activities even further. In 1995, it opened its own managed care program, ABC Health Plan, to keep up with the changing face of American health care. In March 2000, IUFH won a REACH 2010 Award from the Centers for Disease Control and Prevention (CDC), which is enabling it to develop a plan to reduce the impact of cardiovascular disease and diabetes in the Bronx.
IUFH currently has an annual budget of nearly $15 million and employs 25 full-time family physicians, 6 family nurse practitioners, 28 family practice residents, and a support staff of close to 200 people. Eric Walsh, Dr. Calman's founding partner, attributes IUFH's success to Dr. Calman's vision: "He created a model where none existed before. The group of patients who benefit from Dr. Calman's vision has grown to include thousands of families in the Bronx and Manhattan, patients with AIDS, patients in nursing homes, and in their own homes, the homeless, inpatients, women in labor, the working poor, sexually abused children from a day care center, and many other groups and individuals. The core of that vision remains essentially unchanged: the patient is at the center."
Dr. Calman believes that passion and a sense of adventure are at the core of his successful leadership. He is especially excited about IUFH's latest effort—part of its ongoing research activities—to measure health outcomes of the people who use IUFH's services. As he puts it, "The evidence is that we may not be addressing the kinds of issues that actually are most critical in terms of reducing the gap in health care." The main issues, Dr. Calman feels, are racism, patient education, and distrust of the health care system, all of which have been exacerbated by cuts in services for the poor. Under Dr. Calman's leadership, IUFH is shifting its focus to tackle these intractable issues. The change, according to him, has re-energized IUFH for the years to come. "This reformulation around another seemingly impossible goal has all of our juices flowing again," he says.
With leaders like Dr. Neil Calman in charge, it would seem that no goal is truly impossible to reach.