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A Brief Account of the Origin of the First Combined Internal Medicine-Pediatrics Residency and Career Opportunities Made Possible by that Residency: Lawrence M. Cutchin, MD, FACP First Graduate UNC Residency 1962-1964 • 1966-1969



Abstract

Presented by
Allen R. Friedland, MD, FACP, FAAP

To the entire Med-Peds community including National Med-Peds Residency Association

American Academy of Pediatrics Section on Med-Peds

Med-Peds Program Directors Association

Dr. Cutchin’s goal: To establish a model Med/Peds primary care practice and a site for rural health services research
and community based medical education.

“Two roads diverged in a yellow wood, and I, I took the one less traveled by, and that has made all the difference.” Robert Frost

Dr. Cutchin grew up in rural eastern North Carolina. At age 14, he entered Culver Military Academy in Culver, Indiana and graduated in 1955. In the summers, he worked on his family's farm and thought he might pursue further education in farming and business, as his father, grandfather, and four generations before them. He also had given some thought to a career in medicine, combining his love of a rural life with the skills of a doctor practicing in those environs. He was accepted by the University of North Carolina at Chapel Hill and was invited to participate in the honors program. By carrying 21 hours each semester he could graduate in three years with no summer school. He entered the University in 1955 and took the required pre-med courses. Somewhere during his second year as an undergraduate, his interest in a medical career took hold. He graduated in 1958 with a BA degree and entered the School of Medicine that year. His goal was to become a well-trained general physician, practice in a rural area, and hopefully also to be involved in farming and agri-business.

His first clinical rotation was successful with the advice and mentoring of excellent residents, who took their responsibilities seriously and professionally. Stimulated by the clinical challenges he dealt with daily, he was determined to do his best to learn from every situation as he continued his path. During this time in his young career, he began to seek a path to prepare for future practice goals, yet something was missing in his search. He did not want to be a general practitioner nor a sub-specialist. What he did want was to be was a general physician capable of caring for the entire family as outpatients and inpatients on a par with the best. Unfortunately, there was no training track model that would get him there. During his fourth year of medical school, he met with the Chairman of the Department of Internal Medicine to discuss his concerns. The result of that meeting concluded by their agreement that he could plan his own path to his stated goals, and the Chairman, Dr. Charles Burnett, said he would be willing to help him reach that goal. That was the first of several turns down the road he pursued.

Dr. Burnett was aware that many young physicians rejected a career as general family and community physicians because there was no training track to prepare them well and recognize their additional training with eligibility for board certification. He and other UNC faculty members had been meeting regularly for some time to plan such a track, and had concluded that a combined program of primarily internal medicine and pediatrics, with some limited elective time for other needed skills such as office gynecology and minor surgery, would meet the need and be attractive to potential trainees. The UNC School of Medicine had established a mixed internship which offered six months of internal medicine and six months of pediatrics followed by further residency training in internal medicine and pediatrics. No one had followed through with the complete four year program,

however, and that dilemma became Cutchin's second turn in the road: did he want to be the first? Dr. Cutchin wanted assurance of the opportunity to achieve board eligibility in both internal medicine and pediatrics. Dr. Burnett assured him that if he completed the combined residency program, he would be given that opportunity.

Dr. Cutchin graduated from the UNC School of Medicine in1962 at the time the Vietnam Conflict was underway. He elected to take a two-year deferment from military service to allow completion of two years of training by volunteering to spend two years following that on active duty in the military. He began the UNC mixed internship on the medical service for six months, then switched to six months on pediatrics. He elected to take a year of pediatric residency in his second year. He especially enjoyed the teaching rounds with Dr. Floyd Denny, Chairman of the Department. Although he had had only a year and a half of pediatric training, he felt prepared to assume the position as Base Pediatrician at Moody Air Force Base in Valdosta, Georgia on July 1, 1964.

While in the Air Force, Dr. Cutchin gained valuable experience in pediatrics, adult medical care, as well as obstetrics because the Medical Officer of The Day shared in rotation by all of the medical staff, covered the practice and performed all deliveries on evenings and weekends. As the only physician designated as a pediatrician on that undergraduate pilot training base with lots of young student pilots and their families, he received all pediatric referrals and either cared for them locally or referred them to a pediatric sub-specialist elsewhere. He made contact with the University Of Florida School Of Medicine and attended CME (Continuing Medical Education) courses there when possible. During his last year, he also gained administrative experience by serving as the Chief of Medical Services. That gave him opportunities to get the hospital accredited and help design a new hospital which was underway when he left to return to UNC to complete his residency training.

Dr. Charles Burnette resigned from his position of Chairman of the Department of Internal Medicine at UNC School of Medicine in 1964 and died in 1966. Dr. Tom Farmer served as Interim Chairman for one year and in1965 Dr. Louis Welt was appointed permanent Chairman. In August of 1965 Dr. Cutchin received a telephone call from Dr. Welt informing him that upon assuming his new position as Dr. Burnette’s successor, he found a letter in his desk drawer addressed to whomever might replace him as Chairman. In the letter Dr. Burnette stated that he had promised to support Dr. Cutchin in his effort to complete combined internal medicine and pediatric residencies, and he wanted that promise to be honored. Dr. Cutchin shared with Dr. Welt concerns regarding the question of eligibility for board certification in both specialties that had made him give consideration to going a more traditional route. Dr. Welt expressed reassurance of support and urged him to think it through and decide the career track that would give him the most satisfaction. After the call ended, Dr. Cutchin sat for a while considering his options and came to the conclusion that the combined route he had embarked upon was what he wanted to pursue. He called Dr. Welt back and accepted his offer to return to UNC. Dr. Welt expressed his pleasure with the choice. He told Dr. Cutchin he had been so concerned with the difficulties so many young men were having with the same kind of choice with no clear pathway to follow he had written him a letter, and since it was written, he was going to send it anyway. He did and Dr. Cutchin has kept and treasured that letter in his file since that day.

Back at UNC, Dr. Cutchin became a Junior Assistant Resident (JAR) in internal medicine, and joined other JARs who were advancing from a year of internship. One faculty member tried to discourage him from completing the combined residency rather than going straight internal medicine. He assured him that he had made a commitment and intended to see it through. That became the third turn in the road. He moved on to become a Senior Assistant Resident (SAR) for a year, working closely with other teachers who exposed him to a wide range of patients with clinical problems and procedures under the careful supervision of attending physicians and subspecialty fellows. He became more convinced that in addition to providing excellence in clinical practice, the well trained primary care physician of the future must be firmly grounded and prepared to be a leader in implementing the concept of Community Oriented Primary Care (COPC) which is assessing and addressing the health needs of the community served as a patient as well as each individual patient seen.

The fourth turn in the road came in the mid-60s through a federal program funded during the administration of President Lyndon Johnson, and provided the opportunity to expand his understanding of COPC. Initially called the Heart Disease Cancer and Stroke Program and known as The Regional Medical Program in North Carolina, it was created to improve the level of education and practice in those diseases by creating regional cooperation of providers of care and educational support for those cooperative efforts. UNC School of Medicine Dean Ike Taylor had secured funding and engaged Founding Dean Emeritus Dr. Walter Reese Berryhill to lead community outreach at UNC as Director of a newly created Division of Education and Research in Community Medical Care (the Division). Dr. Berryhill secured additional funding from the North Carolina Regional Medical Program to greatly expand the scope of The Division. This was the forerunner of the North Carolina Area Health Center (AHEC) Program. The initial staff of the Division included a small core group of UNC faculty concerned with community health care needs and health service research. One of them, Dr. Carl Lyle, was also an experienced pilot who secured funding for a Cessna airplane and piloted Dean Emeritus Berryhill to multiple locations around the state to lay the foundation for future development. Dr. Cutchin was introduced to their activities and began attending their weekly staff meetings. He was soon accepted as a member of the Division and was allowed to accompany Dr. Berryhill on community visits as time permitted.

About this time, the North Carolina Legislature Research Commission on the Physician Shortage in Rural North Carolina approached the UNC School of Medicine to learn more about what they were doing to train primary care physicians for community care, particularly in rural underserved areas. Dr. Cutchin was asked to attend the meeting conducted by several Senators with school leadership to describe and discuss what was being done toward this effort. He expressed to them his concern that although he was being supported in his efforts, there was still no clearly established career track for that kind of training and no one else on the path that he was on at the time. Several months later, Cutchin was asked to meet with the Commission Chairman, Senator Hugh Johnson, along with Dr. Berryhill, and he expressed once more the need for a more formally structured program to encourage general primary care training. The end result was that there was added pressure to establish a Department of Family Medicine at UNC-Chapel Hill. Funding was needed, however, if they wanted to go forward with that proposal.

The recommendations of that Commission on the Physician Shortage in Rural North Carolina included “funding to the University of North Carolina at Chapel Hill to be used to develop and expand the program and facilities of the School of Medicine to provide a family medicine professorship.” Furthermore, “in subsequent legislation, funds were appropriated to create a Department of Family Medicine in the School of Medicine at the University of North Carolina at Chapel Hill in 1969.”

Early in Dr. Cutchin's SAR year, he began looking for a future practice location in eastern North Carolina. After considering other areas, he decided on Tarboro. The Tarboro Clinic was receptive to a combined internal medicine and pediatrics practice. Furthermore, it was in his home county near the farm where he grew up. Moreover, the clinic physicians were open to the practice innovations, health services research and UNC off-campus teaching program he proposed. Another turn in the road delayed his plans when he was asked to stay at UNC another year as Chief Resident of Internal Medicine. He countered with being the Chief Resident of Internal Medicine for six months and Pediatric Chief Resident for the next six months, while continuing to work, as time permitted, with the Division of Education and Research in Community Medical Care. He did serve as Chief Resident of Internal Medicine for six months, and continued working with the Division. However, Dr. Floyd Denny, Chairman of Pediatrics, had already promised the position of Chief Resident of Pediatrics to someone else. So he returned to pediatrics as a SAR for the last six months. This secured his pediatric board eligibility.

One last event, or another turn in the road in 1968, was an invitation to meet with a site visit team of dignitaries, led by Dr. Robert Haggerty, then Chairman of The Department of Pediatrics at the University of Rochester School of Medicine and Dentistry in Rochester, New York, visiting Chapel Hill to consider a proposal to select UNC for federal funding of one of the first Health Services Research Centers in the country. Dr. Cutchin met with the team to describe the Tarboro Clinic and the serious needs for health care in that region, the opportunities and plans for change and community based health services research with the enthusiastic endorsement of his plans by the physicians there. It is now well known that UNC was selected as the site of one of the first Health Services Research Centers (HSRC) to be federally funded in the United States, now known as the Sheps Center.

Even though Dr. Cutchin had been verbally assured that the HSRC would provide funding for his proposed practice transformation and health services research efforts in Tarboro, firm commitment was slow in coming, To move things along, he produced a white paper titled “Proposal for Development of a Rural Community Based Comprehensive Health Care Delivery System”, and sent it to many key UNC Division of Health Affairs and medical school leadership connected to the project. It took further moves on his part to succeed in getting the funding, including a trip to New York City to meet with Dr. Cecil Sheps, the first Director of the Center now named for him. And when Dr. Howard Hussey, then President of the Tarboro Clinic, along with other physicians there, signed an agreement, in early 1969, for an off-campus teaching and health services research program to be implemented, that proved to be the first step toward the establishment of the first Med/Peds practice anywhere, creation of the Area L AHEC, one of the first three North Carolina AHECs established in 1972 and one of the first in the United States.

The Med/Peds program at the Tarboro Clinic began with only one physician, Dr. Cutchin, carrying out the initial phases, such as being on call, days and weekends, and then bringing in more Med/Peds physicians to that clinic. After two years, the UNC School of Medicine began flying four first year students to Tarboro from Chapel each Friday afternoon, where Dr. Cutchin held a seminar with them on primary care practice, Community Oriented Primary Care, the evolving Tarboro-Edgecombe Health Care System, followed by a guided tour to each of the components of the community health care system (Edgecombe General Hospital, The Tarboro Clinic, Nursing homes, County Health Department, pharmacies, and later, the satellite clinics). The rest of the afternoon, the students were put in white coats and assigned to observe patient care with one of the physicians seeing patients that afternoon. For the next fifteen years, he had the entire UNC first year class in Tarboro, four at a time, each Friday afternoon. Some returned the following year for instruction in physical diagnosis and in their third and fourth years as “acting interns”. One month electives for residents in internal medicine and/or pediatrics were offered as well.

“Today there are over 10,000 practicing Med/Peds physicians across the United States, and 84 Med/Peds residency training programs graduating over 300 physicians per year.” (These figures have changed since he wrote this.).

Dr. Cutchin left the Tarboro Clinic in 1986 and over the next 20 years built and led a North Carolina Medical Society sponsored and physician-owned managed health care company that eventually reached throughout North Carolina, South Carolina and part of Virginia. In 2006 he left that position and returned to Tarboro with plans to retire. He was invited by Dr. Dale Newton, a former partner in the Tarboro Clinic, to work part time as a clinician and resident preceptor in the Med/Peds program he led at Brody School of Medicine, East Carolina University in Greenville, NC, only 30 miles from his home. There in 2008 he also assumed the position of Chief Medical Officer for The Community Care Plan of Eastern North Carolina where he was responsible for clinical oversite of out-patient nurse care management and medical practice transformation in 27 counties over the next eleven years. On March 31, 2019, two months before his 82nd birthday he retired.

Dr. Cutchin practiced his skills as a physician and has held many position as a “mover and shaker”, but none so important to him as the path he carved out for future physicians to consider.

Appreciation is extended to
Patricia M. Miller for her dedicated assistance in the preparation of this document.

PUBLICATIONS

Cutchin, Lawrence M., M.D. “Carolina Doctors Care IPO.” North Carolina Medical Journal. Vol. 51, Number 10, pp. 537-541. October 1990.

Ballard, David J., M.D.; Strogatz, David S., PhD; Wagner, Edward H., M.D.; Siscovick, David S., M.D.; James, Sherman A., PhD; Kleinbaum, David G., PhD; Cutchin, Lawrence M., M.D.; Ibrahim, Michel A., M.D., PhD. “Hypertension Control in a Rural Southern Community: Medical Care Process and Dropping Out.” Am J Prev. Med. Vol. 4(3). pp. 133-39, 1988.

Siscovick, David S., M.D.; Strogatz, David S., PhD; Wagner, Edward H., M.D.; Ballard, David J., M.D.; James, Sherman A., PhD; Beresford, Shirley, PhD; Kleinbaum, David G., PhD; Cutchin, Lawrence M., M.D.; Ibrahim, Michel A., M.D. “Provider-Oriented Interventions and Management of Hypertension.” Med”Care. Vol. 25(3). pp. 254-58, March 1987.

Ballard, David J., M.D.; Strogatz, David S., PhD; Wagner, Edward H., M.D.; Siscovick, David S., M.D.; James, Sherman A., PhD; Kleinbaum, David G., PhD; Williams, Carolyn A., R.N., PhD; Cutchin, Lawrence M., M.D.; Ibrahim, Michel A., M.D., PhD. “The Edgecombe County High Blood Pressure Control Program: The Process of Medical Care and Blood Pressure Control.” Am J Prev Med. Vol. 2(5). pp. 278-84, 1986.

Williams, Carolyn A., PhD, R.N.; Beresford, Shirley A., PhD; James, Sherman A., PhD; LaCroix, Andrea Z., PhD; Strogatz, David S., PhD; Wagner, Edward H., M.D., MPH; Kleinbaum, David G., PhD; Cutchin, Lawrence M., M.D.; Ibrahim, Michel A., M.D., PhD. “The Edgecombe County High Blood Pressure Control Program: III. Social Support, Social Stressors, and Treatment Dropout.” Am J Public Health. Vol. 75(5), pp. 483-86, May 1985.

Strogatz, David S., PhD; James, Sherman A., PhD; Elliott, Dianne, AAS; Ramsey, Diane, B.S.; Cutchin, Lawrence M., M.D.; Ibrahim, Michel A., M.D., PhD. “Community Coverage in a Rural, Church based, Hypertension Screening Program in Edgecombe County, North Carolina.” Am J Public Health. Vol. 75(4). pp. 401-2, April 1985.

James, Sherman A., PhD; Wagner, Edward H., M.D.; Strogatz, David S., PhD; Beresford, Shirley A., PhD; Kleinbaum, David G., PhD; Williams, Carolyn A., PhD; Cutchin, Lawrence M., M.D.; Ibrahim, Michel A., M.D., PhD. “The Edgecombe County High Blood Pressure Control Program: II. Barriers to the Use of Medical Care among Hypertensives.” Am J Public Health. Vol. 74(5), pp. 468-72, May 1984.

Wagner, Edward H., M.D.; James, Sherman A., PhD; Beresford, Shirley A., PhD; Strogatz, David S., PhD; Grimson, Roger C., PhD.; Kleinbaum, David G., PhD; Williams, Carolyn A., R.N., PhD; Cutchin, Lawrence M., M.D.; Ibrahim, Michel A., M.D., PhD. “The Edgecombe County High Blood Pressure Control Program: I. Correlates of Uncontrolled Hypertension at Baseline.” Am J Public Health. Vol. 74(3), pp. 237-42, March 1984.

Fowler, Wesley C., Jr., M.D.; Cutchin, Lawrence M., M.D., Crocker, Daniel L., M.D.; Hall, James B., M.D.; Begun, James, PhD; Freeman, Anne C., MSPN; Hulka, Barbara, M.D.; Kalozny, Arnold D., PhD; O'Keefe, Shirley P., MSPN; Symons, Michael J., PhD; Lee, Ging Yuan, MSPN. “Cancer Control and Community Physicians in North Carolina.” NC Med J. Vol. 44(6), pp. 357-61, June 1983.

Cutchin, Lawrence M., M.D. “Forming a Rural Satellite Network.” Group Pract J. Vol 29(12), pp. 15-18, December 1980.

Kagey, Betsy, MSPN; Cutchin, Lawrence M., M.D.; Young, Hugh G., MPH; Hogue, Carol J., PhD; Cale, Barbara. “Infant Care Study.” NC Med J. Vol. 37(11), pp. 605, November 1976.

Berryhill, W. Reece, M.D.; Lyle, Carl B., Jr., M.D.; Smith, Robert, M.D.; Wilson, John B., MBA; Shaw, Robert A., M.D.; Pickard, C.G., Jr., M.D.; Cutchin, Lawrence M., M.D.. “The Regional Medical Program and the Division of Education and Research in Community Medical Care.” NC Med J. Vol. 29(12), pp. 489-95, December 1968.

Other publications for documentation of information
sited in this Document

1. “A Legacy of Caring
The First Fifty Years of the Kate B. Reynolds Charitable Trust”Profile: Lawrence M. Cutchin, MD Whitakers Clinic, page 120-122 Copyright 1997 Kate B. Reynolds Charitable Trust 128 Reynolda Village Winston-Salem, NC 27106-5123

Library of Congress Cataloging-in-Publication DataKateYopp, Jan Johnson A Legacy of Caring: The Kate B. Reynolds Charitable Trust 96-80389

2. “Better Health for the People. W. Reece Berryhill, The UNC School of Medicine and the North Carolina Good Health Movement” William Mclendon, Floyd W. Denny, Jr., William Blythe

Distributed by
The University of North Carolina Press Chapel Hill, NC 2751-2285 1-800-848-6224 www.uncpress.unc.edu
References to Lawrence M. Cutchin, MD pages 296-207, 325, 329-331

3. “Medicine in Chapel Hill: The Department of Medicine
and the University of North Carolina 1952-2007
Edited by James A Bryan, II, William W. McClendon and
Katherine D. Savage Published by The Department of Medicine School of Medicine T25 McNider Hall • CB3 7005

The University of North Carolina Chapel Hill, NC 27599-7005

Library of Congress Control Number 301599-7005 References to Dr. Lawrence Cutchin pages 160, 265-266, 292

4. Community Oriented Primary Care, a Practical Assessment, Vol. 2 Case Studies 1984 Paul A. Nutting, MD and
Eileen M. Conner Division of Health Care Services
Institute of Medcine

April 1984 National Academy Press
both volumes 1 and 2 available at Amazon and at https://www.ncbi.nlm.nih.gov/books/NBK217648/

The development of the Tarboro-Edgecombe Health Care System and Dr. Lawrence M Cutchin are profiled as Study number 7

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abstract
non-peer-reviewed

A Brief Account of the Origin of the First Combined Internal Medicine-Pediatrics Residency and Career Opportunities Made Possible by that Residency: Lawrence M. Cutchin, MD, FACP First Graduate UNC Residency 1962-1964 • 1966-1969


Author Information

Allen R. Friedland Corresponding Author

Medicine-Pediatrics, ChristianaCare, Newark, USA


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