Jada Bussey-Jones, MD (Host): Hello, this is Jada Bussey-Jones, the past president of the Society of General Internal Medicine and the host of SGIM's President's podcast. We engage SGIM's former presidents who are leaders across healthcare, public health, policy and academia. As we lead up to the organization's 50th anniversary, we hope to capture insights from our national thought leaders so that our organization, our members, and healthcare and society broadly, are in a stronger position to grow, innovate, and meet the challenges of our time. To our listeners, thank you so much for joining us. Today, I'm delighted to talk with Dr. Martin Shapiro, who is Professor of Medicine at Weill Cornell Medical College in New York City, and the Associate Director of the Primary Care Research Fellowship at Weill Cornell. Previously, he's had decades of leadership, serving as the Chief of the Division of General Internal Medicine and Health Services Research, and Founder of UCLA's Primary Care Research Program.

He has had pioneering health services research, over the years, including in areas as accessibility of care and health inequity, scientific misconduct and authorship ethics, pharmaceutical advertising and influence. He has over 300 peer review publications, advancing understanding of access, quality and policy in American medicine.

He's the author of the Present Illness, American Healthcare and Its Afflictions, which is a critical exploration of structural inequities in US healthcare system.

 Dr. Shapiro's work has reshaped how the field views the intersection of clinical practice, public policy, and social justice. And importantly, his leadership has inspired a generation of academic physicians to pursue equity driven health services research. Thank you so much. This is so great to read about your legacy.

I would love to start off this discussion with just a simple question, which is tell me about yourself, how you got started in your career in medicine, and how you started on your leadership journey.

Martin Shapiro, MD, PhD: Well, I don't think of it as a leadership journey. I was a kid who grew up in, Winnipeg, Manitoba. I'm still Canadian. There were no near relatives who were physicians. I didn't have a strong sense of what I was going to do for a living. But I, I went off to Montreal to McGill University, to study and started out in physics and switched into math.

I found myself not satisfied with either of those. I did complete, medical school requirements, but was very lukewarm in my interest in going to medical school. I, I only applied to one, which was at McGill, but I really thought I would go off and do something else because I was, I became involved in national politics.

I became involved in student government. And all of this was very exciting. And this was in the late 1960s when the world was in turmoil. And I was having a blast. But as I finished my degree, I needed to decide what I was going to do. I wasn't sure. I thought since I was very interested in politics, perhaps I should go to law school.

But I made a commitment to staying at McGill and they have a law school, although their law there is different from the rest of Canada. And I had thought I would go elsewhere, but I committed and applied to the law school at McGill. I had other options I was interested in, and they sort of fell by the wayside.

And I thought I was goingg to go to law school. But as the summer before I would start school went on, I began to have reservations. If I'm not in politics, what will I do? Can I do civil liberties? Maybe, what will the opportunities be? By the end of the summer I was quite confused and I asked my parents for advice and they wisely wouldn't tell me what to do.

The night before I had to register for school, I stayed up all night obsessing over this major life decision. I got up in the morning and decided to register for law school, which I did, it was on a Thursday. And they were supposed to have an orientation, but they told me that they would only orient the first half of the alphabet that day because it was a large class.

So I went up to the medical school to tell them I wasn't coming. I was looking around for the registration area, but there was nothing going on. Everybody was just going about their business. I wandered up to the dean's office and I said, where's registration? And they asked me who I was. And she said, well, where have you been?

Classes started three days ago. You understand? I was a 21-year-old male with poorly developed executive function, and I still have relatively poorly developed executive function. So, she said, you need to talk to the dean of students. I said, well, I'm thinking of dropping out. I went in to see the dean of students and I was embarrassed that I was three days late.

That was my major concern. I figured I'd denied someone else a place in the medical class. And I said to him, well, I'm having serious reservations about whether I want to go to medical school. He asked me if I had other options. I said, well, I've given some thought to the possibility of going to law school, lying a little.

And he said, well, when do you have to let them know? And I said, orientations tomorrow, classes start Monday. He said, well, you have today and tomorrow. Why don't you go to the medical class and see how it goes? And then he said, sometimes the people that are most ambivalent about medical careers can make the most valuable contributions.

And that resonated for me. Not that I was going to make contributions, but that it's not a terrible thing to be ambivalent. One thing led to another. I ended up going to the anatomy lab that morning, much to my surprise, and sticking with it, but all along I was unsure about what I wanted to do in medicine.

Most people seemed very certain about what they wanted to do, but I was very confused. As I went along, I decided I liked internal medicine and pediatrics, I think also because it involved a lot of ongoing care for patients. But at some point I went and spoke to the chair of the Department of Medicine and said, what should I do?

And he knew me. He knew who I was, and he said, well, I know you want to change the world. So there's really two choices. You can get yourself a soapbox and stand in a soapbox and yell at people and be ignored, or you can get some serious research training and produce evidence that might be useful to change the world.

I thought that the second option was a better option. That led me ultimately to going to UCLA to join the Clinical Scholars Program, fully intending to return to Canada after I'd finished my research fellowship. But I must say I was shocked when I got there. The first day there was a lecture from, a health economist and I came to realize how conservative the American healthcare system was and how far away it was from a adapting, some sane just system, that would involve universal health insurance like Canada had recently adopted.

I thought I'd made a big mistake coming to the states. I was ready to go home. One of the faculty there, Shelly Greenfield, past president of SGIM, who died recently reassured me and he said, hang in. You'll have a chance to do some of the things you care about. And so I hung in there. One thing led to another and I eventually joined the faculty at UCLA.

But I always thought I was going to head back to Canada as soon as I, I couldn't take it anymore, somehow I persisted. It was very, very exciting. I mean, I was interested. I did a PhD in history along the way and I was very interested in the role of social sciences in medicine.

But I also got involved early on in health services research and there were a lot of good collaborators there that I could learn from and, good opportunities, still struggling to find my way. When I had joined the faculty, Ronald Reagan was becoming president and my primary interest was access to care.

And of course, there was no money to study that, so I had to scrounge around for a while, look for money, look for opportunities, look for data sets. And I found things to do here and there. HIV showed up, wasn't even called that at first. It was AIDS. I got involved in some studies of that and ended up spending, the better part of 15 years doing research related to that, mostly on inequities in care and access to care and disparities in care and so on.

And, at the same time I was a doctor. I loved being a doctor. In those days, a general internist could do inpatient and outpatient medicine, and I did both. I loved the education, I loved the opportunities to relate to my patients, and to the students, the resident's patients as well. I felt like I had a career in which every day was interesting.

I loved what I was doing. I had no intention of becoming a division chief. There were all these senior people around, but they all moved on and they needed someone to lead a division. And was willing to do that. And, I had my biases. Obviously when you're leading a division, part of what you do is, keep the wheels turning, the motors running, and so on. But I also felt like it's really important to try to do something about social justice. So when we recruited faculty, we would set up a committee in the division and, we very often were interested in focusing on people who had that kind of an orientation and turned out there were a lot of people who had those interests, and we were able to attract a diverse and really talented group of people and, continue to work in that area and make some useful contributions, I think.

SGIM wasn't around and when I was a fellow, but as I was ending my fellowship, and I was over at the meeting of the American Federation for Clinical Research and Shelly Greenfield said to me, Hey, there's gonna be a meeting across the street at the Shorham Hotel of this new organization, which was Epsom. You oughta come, I think you'll like it. And, and I was blown away.

There were all these general internists who not nearly as many as now. There were may be a hundred at that meeting, who really cared about primary care, who really cared about general internal medicine, who really cared about justice in healthcare, and wow, it was wonderful.

Host: I can relate. And thank you so much for sharing that story about your uncertainty or ambivalence but still making your way to medicine, to leadership in medicine, even though it sounds like that was not a path that you originally sort of set your sights on. So you made your way to SGIM, found, it sounds like many of us, myself included, that it was, your professional home, a lot of like-minded people. Tell me about your leadership and engagement there, when you think about, any successful experiences that you reflect on or that you're proud of, either as a leader or just as a member over the course of the years that you'd like to share.

Martin Shapiro, MD, PhD: First of all, it was always wonderful to go to that meeting and see these people because they were my brothers and sisters, they really were. I, presented my work there and, that was the place to present because those are the people who understood the relevance of this kind of work.

So I loved that. I became a member of the council in the early nineties and that was, uh, very good experience as well. Served on a variety of committees, related to science and research and so on. So that was always very good. Eventually, sometime after I'd been on the council, people approached me and asked if I would run for president, and I said, well, okay, sure.

so I ran and I lost. And it was okay. I lost to, a very good person, Sanky Williams, the next year they called me again and they said, will you run for president again? They said, really? They said, yeah, we'd really like you to run. So I ran again and I lost again.

Host: Oh wow.

Martin Shapiro, MD, PhD: That time to Kerr Gronky. So, the next year they called me again. I was feeling like Howard Stassin, who was the guy who ran for President of the United States every four years and always lost. And it took a lot of convincing to get me to run a third time, but I did. And I was elected. I joined the council and the job involves a year as president, elect, a year as president, and a year as past president.

I felt like it was probably important to identify just a couple of things, that might be accomplishable during my time. And the two things that I, picked, one was, there was a lot of uncertainty about the future of general internal medicine in American healthcare and so on. So I set up a commission that was led by, Eric Larson, another past president on the future of GIM and it was a really good group that they put together and produced a very valuable report, components of which were published in the Annals of Internal Medicine and in JJIM. And I think it did have some impact on the way people thought about it. I was talking to Eric, just a couple of weeks ago, and he said that that report was pretty aspirational.

Of course, the health system has moved in all these unexpected ways in making it hard to imagine us, residing in all. Basically they talked about the different sub roles that people could play as a generalist and certainly many people do along the lines that they wrote about. But there are all these pressures that the system is putting on us and the system and generalism in general, that's making some of this difficult.

The other thing we instituted was a program of long distance mentoring, for people in SGIM who might not have the right mentorship in their own institution. Sanky Williams led that and it did pick up steam over time. And, I think, was a useful contribution to the society.

Host: I can say from personal experience that I've benefited from the latter, so thanks for that. I am wondering, as we approach our 50th anniversary and you're reflecting back on your leadership, can you offer any advice for SGIM, either the organization itself or its current or future leaders? If you could offer any advice, what would that be for the organization?

Martin Shapiro, MD, PhD: Well, SGIM is, uh, it's an unusual organization. It's a moderately sized organization, but it's not, it doesn't encompass all of the generalists in the country by any means. It really represents the academics. And I think, we've made gestures towards trying to reach out to a larger group in the past, but I don't think that'll happen.

But SGIM is, is a valuable voice, for generalism and for a broad spectrum, or a broad set of issues that generalists care about. And I think we have to keep doing it and relentlessly do it. there's obviously a tremendous problem that folks want to try to solve of the disparity in income and, institutional support for generalists compared to the specialists.

You know, I hear this from the students I work with that they go to, the dermatology clinic or the ENT clinic and the doctors, they're very happy to be in clinic. They have scribes there, they do their procedures. They don't have to spend a lot of time, they don't necessarily have to be getting a lot of phone calls from their patients and so on.

And then the generalists often feel beleaguered. Part of what happens, is that in a lot of institutions, the generalists take on the care of the disadvantaged, where the specialty clinics often try to avoid it. Disadvantaged have more problems. They're more complicated to take care of, but it's the right thing to be doing.

Trying to get that point across to society would be good. I think we all understand that the reimbursement system is, makes no sense that there's no reason why some specialties earn three times as much as others. we have to keep fighting that battle. But also, the other things that we often have worked on in terms of trying to, to the extent that we have a fee for service system. I if every doctor was paid for their time, that would be good. That would be good. That probably isn't going to happen. Which isn't, which is not to say we shouldn't advocate for that. But for looking for ways to increase the amount of support within the payment system, but also within institutions.

I recall at UCLA, they brought around group of financial consultants at one point to advise on how they could improve their business, and they were told that they were overpaying their general internists. That, that was, of course, that was ridiculous. The chair of our department even understood that, but the medical school kind of went along with this, ignoring the fact that all their specialty procedures depended upon having doctors who are taking care of patients on an ongoing basis. So I think, you know, we're always slogging up a hill. We're always pushing very big boulders up hills. You just can't give up. But you can also continue to advocate for a broader, more rational system.

And, SGIM has a good voice. It's not the loudest voice, but it's a relevant voice. And, yes, we should still stand up because it's really we're standing up not only for ourselves, but also for our patients to get the kind of care and the kind of support that they desearve.

Host: I think that is so important and you kind of talk about these and other issues in your book that I mentioned in the introduction, which is kind of a widely discussed book. I think it taking decades of your research and examining and critiquing the US Health System. So I don't know if there are any additional takeaways or, from the book that you'd like to share other than in addition to what you've already described as, you know, issues for general medicine, but also for healthcare, broadly speaking.

Martin Shapiro, MD, PhD: Yeah, yeah. The book again, it's called The Present Illness, American Healthcare, and its Afflictions. And, in it I identify three themes that I think are pervasive problems in American healthcare. One is commodification. And commodification not only affects the pharmaceutical industry and the hospital corporations, but also individual doctors and also, certainly all the other industries associated with healthcare, but also in many ways, many patients who want to get their share of the goods and make demands for the scan, the extra day in the ICU for someone who isn't going to benefit from it because they're dying or, recovering and, and all that kind of stuff. So that's one problem, one set of problems.

The second set of problems is what I refer to as consciousness, which is the attitudes, the values, the expectations, the perceived needs, the interests of all the players in healthcare that tend not to bend the arc towards justice in healthcare. And the third one is communication. And it's not only communication between doctors who are selling procedures in patients, but also between the pharmaceutical industry and the public with these absurd ads that they run as they, put their price, their new product prices through the roof, between the scientific community and the public about what, for example, basic science has to offer as opposed to doing a better job of providing treatments that work to a large population. And it's this sort of interaction of communication with commodification and consciousness that produces a whole range of problems that I talk about in the book.

And I argue that we need to solve them all but no one can solve every one, but everyone can take some of them on. And so, I mean, I had this encounter with my progressive uncle at the time. I finally decided I was going to stick with medical school and he said, well, it's good that you chose medicine because in many careers, you pretty much have to take the jobs that you can get. But in medicine, you'll have choices and you can choose to go out and make a lot of money, or you can choose to serve humanity as best you can and based on the choices that you make, we can judge your worth as a human being, which was, you know, a lot to absorb as a 21-year-old.

 But it was a gift. I still think about it and I still ask myself, am I doing enough for humanity? I know I gave a talk once at SGIM where I told this story and I said, well, what, what would my late uncle say now about my worth? And he would say the matter is not yet settled, because there's still more that you can do.

Host: More to be done.

Martin Shapiro, MD, PhD: Yes.

Host: I love it. First of all, I'm so glad that you chose this career. And, I think your, the legacy of your leadership and your research and the impact, from my perspective has really been without question. And so I, value very much the time that you've spent even talking with me today, I maybe shift a little bit to something a little lighter, which is just, maybe what do you do for self-care? Because some of the things, all of these societal issues, the things that we are trying to make an impact on, but may not doing as much as we can, or much as we would like you sometimes you can't get caught up in that. You have to think about yourself as well. So what are you doing for self-care?

Martin Shapiro, MD, PhD: Well, I try to exercise. I'm in my seventies at this point. It's, by the way, it's scandalous and SGIM should do something about this. It turns out that life is far too short.

And I'm not sure whether we can influence that, but it's shocking how just goes right by. I, do try to exercise, I'm not consistent about that.

But I can still run, on a treadmill, as much as five miles. It's not bad. But then I don't do it for a month and then I have to start building up again. I did, run 10Ks when I was younger. I haven't done anything like that in a long time.

I even one time when I was living in LA in 1984, they had the Olympics and I was running a lot then. So on the day of the Olympic marathon, my friend and I went for a run down the course. We ran about, I don't know, eight or 10 miles. People were already lining up for the event. Eventually the police told us to get off the course because the runners would be coming soon, but I, I do say I, I did run in the Olympic marathon, but, apart from that I love theater.

Being in New York makes it really easy. I still support one of my favorite, counter-cultural theaters in Los Angeles. Earlier when, when my kids were growing up, I coached them in, youth sports and especially baseball, which I love. And I, go to baseball games regularly.

I was a fan of the Montreal Expos when they existed, but when they moved to Washington, the allegiance did not transfer. And I became a fan of the LA Dodgers, who of course this year are in the World Series.

Host: I was gonna sayyou must be.

Martin Shapiro, MD, PhD: and everyone in the country. Does everyone in the country love the Dodgers?

Well, given that they're referring to them as the death star these days, it seems like not everybody, but then again, those of us who have been Los Angeles Dodgers fan will go to our graves still resenting the Astros from 2017 and how they won that series. So, those are a couple of the things I love to do.

Host: That's awesome. I really, again, appreciate your time today and want to offer you one, last opportunity for any final brief reflections, as we wrap up our time together today.

Martin Shapiro, MD, PhD: To all my colleagues and especially the younger folks, remember that you're doing God's work. You're trying to improve the universe. If we all have the luxury of an opportunity at the end of life to reflect on what we've done, you can be proud of the fact that you have been on the side of justice, you have been on the side of making the world a better place.

And of course it's difficult. it's not going to get to where you or I want it to get to, but the struggle is worth it. The journey is worth it. It's a great career. we don't have as many Porsches or as fancy homes as some other people and that's really okay.

Host: Well, thank you so much for those thoughts, and thank you again for joining us today. I want to say thank you to our audience as well, and thank the SGIM staff and Ros Bogle, our executive producer and our entire production team. Also, thank you to our listeners. You have been listening to SGM's President's podcast.

If you like what you've heard, please rate us and leave a comment wherever you listen to podcasts. It helps others to find us. Also look for us on the SGIM website SGIM.org and follow us on X.