Dr. Fred Kephart, internist: The Importance of Time

A young Dr. Kephart

Soon after general internist Dr. Fred Kephart announced that he was retiring early he received a few touching note cards from his patients. They said they had appreciated him, that they appreciated his steady caring for them over the years.  He told me that, reading these handwritten notes, it felt as if he was attending his own funeral. His patients liked him and were going to miss him. “Well,” Fred thought, maybe he “wasn’t such a bad guy after all.”  Perhaps he should practice medicine a while longer. He smiled as he recalled this ambivalence for me.

Dr. Kephart left the practice of medicine in 2012 at age 62. His mother had died a year after she retired at 65, and he told me he did not want to go with his “boots on.” But no longer being needed by his patients, he said, required an adjustment that he hadn’t fully anticipated.

As the oldest of four, with two sisters and a brother, Fred had a lot of responsibilities as a child. He told me that “there was no room to make a mistake,” and that “you had to behave.”

He was born and raised in rural Huntingdon County, Pennsylvania, roughly in the middle-lower part of the state, as were his parents. His mother’s family had migrated to the area before the Revolutionary War and his great grandfather’s family came up from Maryland’s Eastern Shore as farmers. 

Fred’s father William (1926-2018) enlisted in the Army in January 1945 and served as an M.P. in Korea until his discharge in December 1946. When he returned home he worked in a hardware and appliance store, sold furniture for 30 years, was a candy distributor, and, finally, was the County Sealer of Weights and Measures. After the kids were raised, his mother, Emilie (1928-1994), trained as a stenographer, became the high school receptionist.   

With that non-medical background, I wondered how Fred ended up choosing medicine for himself.

Well, he was (of course) a “good student” in high school. One day his kindly chemistry teacher said (with nobody else around), “Freddie boy, you should be a doctor or a dentist.” So, as he heard this advice, this prodding, more than once, it sort of became his duty. But there was a serious obstacle; he recalled that he was standing in the kitchen with his mother when she said, “We want you to go to college, but we can’t afford to send you.”

And yet with mowing lawns (starting at the age of ten for 85 cents an hour), and caddying at the local golf club across the street from his home (for two dollars for a round), and with grants and loans, Freddie boy was able to pay for college himself and, later, with somewhat more lucrative weekend work (as we will see), even medical school. 

Education

He doesn’t remember that anyone offered advice about where to head for college; there was not even a word from the school guidance counselor.  So he applied to a single school, Juniata, a good private liberal arts college in, of all places, Huntingdon.  

View of the Juniata campus in bucolic Huntingdon County

As a freshman in (turbulent) 1968, Fred didn’t do so well. He had breezed through high school, but he was not prepared for college work. He realized that he had to make a change and that he had to leave the comfort of his hometown.  And he saw that his chance of getting into medical school was poor with his mediocre grades. 

(Image from hmbd.org)

So in his sophomore year at Juniata, he applied to pharmacy school.  He was accepted and transferred to the Philadelphia College of Pharmacy, the nation’s first pharmacy school and still top-ranked (now part of the University of Sciences). Fred studied there from 1970 to 1973 and he enjoyed the work. He figured out how to study, and graduated near the head of his class. With renewed confidence, he sent in medical school applications. 

He got into Hahnemann (now  Drexel University College of Medicine) where he helped pay his way working as a registered pharmacist on Sunday afternoons at Pat Tancredi’s pharmacy in South Philly for $6.36 an hour.

Looking back, Dr. Kephart thought that it might not have been the best decision to go to college immediately after high school; that he might have done better at Juniata with some time off first (it was the late 60s, after all).

A sort-of epiphany

Anyway, one day as Fred took the rotations through the specialties that help a young student decide on a career path he had an epiphany; an attending nephrologist showed him how to proceed methodically, step-by-step, to make an accurate diagnosis (and to avoid a serious mistake). 

The students were taught that practicing internal medicine demanded one to think logically. You listened as patients told their stories and gently guided them with a few probing questions. You examined them meticulously to help narrow your hypotheses. You then reviewed lab work and x-rays or other images. Finally, you put all of this together and came up with a list of the likely possibilities, a “differential diagnosis.”  Additional studies might be needed to pin down a diagnosis, and the treatment options would follow. That was how it worked.

From a video by Dr. Edward Strong at Stanford

When it was time to choose a residency Fred said he “never considered” something that he would simply like to do, such as orthopedics. In the 1970s it was understood that “you’re not going to be a real doctor unless you go into internal medicine.” And Fred was going to be a real doctor.

Where should he go for the needed training? After taking electives at several Center City university hospitals in Philadelphia and at a few in community settings he sensed  that the patient care was better and that the general tone was more relaxed (and more his style) away from “the ivory tower.”   

Residency and program director

So he looked at several small internal medicine programs in rural (and familiar) Pennsylvania settings including those at Reading, Geisinger, and Robert Packer. It was during his OB/GYN rotation at Pennsylvania Hospital (home of the nation’s first medical library) that Fred first heard of the York Hospital; a resident whose brother practiced in York had good things to say about it. 

Dr. Samuelson
(1927-2022)

Fred visited and liked the program, and came to York in 1977 for a three-year residency in internal medicine.  He went through the different medical specialties and as he worked closely with Dr. Miodrag Kukrika he noticed that the “cancer patients were the most motivated” he had seen. Fred thought briefly about doing an oncology fellowship but there were several very strong generalist role models at York (including Drs. Leo Samuelson, Ben Hoover, Jack Kline, and Ronald Reinhard) and he felt that he would be satisfied enough to follow in their mold. He sensed that it would be a good fit, that he could practice in York, and that he would have a fulfilling career.

But, there was another important reason for him not to leave York for further training. You see, Dr. Kephart’s first encounter with his future wife, Dr. Cynthia Patterson, occurred during his second year at York. She was a first-year Family Medicine resident and she called him from the ER to ask about the dose of a medication for a patient suffering acute alcohol withdrawal. The Internet wasn’t available until 1983 and there were no smartphones so you had to rely on smart people when you needed to know something important right away (if you couldn’t find your tattered spiral-bound Washington Manual). When later, by sheer chance, Fred and Cindy took an elective together they hit it off (but wisely kept their relationship quiet).

So after he finished his internal medicine residency in 1980  Fred stayed in York and took over the position of program director. There were very few applicants for the training positions that year and they “matched” only one or two of the five available slots. As a result, Dr. Kephart had to run the so-called Residents’ Service himself. 

A break before private practice

Ron

After he decided to step down and go into private practice with his close friend, Dr. Ron Benenson, he wanted a break. Cindy had finished her residency and the two chose to take a year off to travel. They first spent the first months (July to September 1982) on the road with Ron and his wife Tracy as they logged about 10,000 miles visiting friends across the country and touring several National parks. (The two couples currently live next door to each other and there is no fence between the homes). 

A month after they returned home, Fred and Cindy left for a six-month medical mission in South Africa. Cindy had done an elective there during her training.  Her stint was facilitated by Dr. Victor Gordeuk, a hematologist specializing in sickle cell disease who did his residency at York.  They worked in the bush with the Tsonga people in Gazankulu, one of the Black self-ruled homelands cunningly devised during apartheid by the ruling white minority to deprive the black majority of full South African citizenship and voting rights.  

Presbyterian Swiss missionaries brought the Gospel to the Tsonga and they had set up several hospitals and community health centers.  So when Fred (a life-long Presbyterian) and Cindy were in South Africa they stayed in a cottage on a medical compound. Dr. Kephart recalled that deadly snakes, including puff adders and black mambas, slithered through the grass and would sometimes sneak right up to the cottages. The serpents had to be carefully avoided as antivenom was in short supply and their bites could be fatal. (Yes. it’s often a rope, but sometimes it really is a snake.)  

Feared Black Mamba (from wallpaperaccess.com)

Fred manned the rural medical clinic three days a week where he (with an interpreter) took care of ten patients an hour (there was no paperwork). While there, he saw nearly 200 cases of typhoid fever, encountered exotic parasitic diseases such as schistosomiasis that he had read about and thought he would never see, managed patients with tuberculosis (still, in 2022, the leading case of death in South Africa), and (after hurried on-the-job training from a real surgeon) did 24 C-sections (with Cindy deftly handling the anesthesia).

The intrepid couple also saw patients who were wasting away and dying without a  diagnosis and Fred believes that these unfortunate souls had AIDS. (Even now, nearly forty years after the HIV virus was identified, 20% of the South African population is HIV-positive, the largest ongoing epidemic in the world.) 

Fred’s experience in South Africa from October 1982 to June 1983 as he lived amongst people “with very little” helped him further appreciate what he had. It was, he said, “quite an experience.” And, since then, medical mission work with the church has been a vitally important activity for him and his family.

Colorful Tsonga dancers (from facebook.com@TsongaDance)

(Nelson Mandela had been in prison for 20 years and had seven more years to remain incarcerated when Fred and Cindy witnessed the pain and fear of apartheid. Among his often-quoted sayings is this: “What counts in life is not the mere fact that we have lived; it is what difference we have made to the lives of others.”)

Return to York and how doctors think

When Fred returned to York, he and Dr. Benenson started to build their practice of general internal medicine. They took care of “everything” as they could continue to manage their patients after they were admitted to the hospital, even when they were in the ICU or the acute cardiac unit. The practice soon became busy and Fred and Ron added more like-minded generalists who were capable of taking care of the entire patient; generalists who were, we might say, (with no disrespect towards other physicians) “real doctors” (of their time).

A digression regarding doctoring and diagnosing: 

Accurate diagnosis, of course, precedes treatment and Fred was, as we have seen, introduced to the concept of an orderly logical diagnostic process as a third-year student.

After the interview, as I pondered Fred’s story I wondered if this is really the way doctors work? Is this the way internists think when they see a patient? My husband (always ready with a book about this or that) slipped me Jerome Groopman’s insightful and well-written How Doctors Think to help an outsider understand what happens in a doctor’s mind. 

Many times, a diagnosis arises effortlessly without deliberate reasoning, almost automatically. It appears with surprisingly little information for the physician to go on. It is believed that this happens by pre-conscious pattern recognition, by intuition, by a rule-of-thumb, by what is called a “heuristic” or a shortcut. This “fast thinking” relies on the doctor’s experience. The almost-automatic diagnosis is often correct, but sometimes quite wrong. 

And the diligent physician recognizes when things don’t fit. He knows when to ignore the evolutionarily adaptive and reflexive response of ancient deep brain structures and to turn, instead, to slow analytical cortical frontal lobe thinking (loyal followers of these stories knew, by now, that some neurology stuff would be sneaked in). This is the rational problem-solving deductive method Dr. Kephart was shown as a student, the approach of the well-trained general internist when dealing with uncertainty. The two modes make up the dual-process theory.

Homer Simpson vs. Mr. Spock (from BehaviorDesign)

And, says Groopman, as the physician searches for a diagnosis he recognizes when he has reached the limits of his knowledge and when he needs help. He is keenly aware that uncertainty is built into the system; that we don’t know, we can't know, everything.

The effective clinician learns that a key to not missing a diagnosis is getting the story right. So he listens attentively to the suffering patient before him. And Dr. Kephart confided in me that he believed that over the years he became a good listener. (As we sat together and talked I saw that he, in fact, was.)

Practice

Getting back to his story…

Despite his experience, his skill, and his thoroughness, the practice of medicine was “always kind of stressful” for Dr. Kephart. You will recall that young Fred wasn’t allowed to make a mistake and as he used the two modes of thinking mentioned above, dual-process thinking, there were still “tough patients.”  He was aware that he didn’t always know enough and there was “a nagging sense of inadequacy.” Looking back on his career, he hoped that he “was honest” about where he was “deficient” and that he mostly “did the right thing.”  But even as he felt burdened, he appreciated the close relationships he had with patients.

(As Dr. Groopman notes:  “Uncertainty sometimes is essential for success” as “paradoxically, taking uncertainty into account can enhance a physician’s therapeutic effectiveness because it demonstrates his honesty, his willingness to be more engaged with his patients, his commitment to the reality of the situation rather than resorting to evasion, half-truths, or even lies,” p. 155.)

The first issue

Anyway, as American medicine continued to change to become a lucrative big business enterprise and more and more competitive his practice was bought by WellSpan Health.  The insistent corporate push to be more “productive” followed, and Fred and his partners did their best to resist this pressure. He felt that the physicians at ( what was initially) Gotham Internal Medicine  (the name, said Dr. Kephart, reflected a local street, not  the Batman comic) were able to maintain their “culture.” 

During the early years in practice, reflecting his residency training and the respected general internists he had modeled, Dr. Kephart took care of “everything.” But as full-time hospital-based internists were hired Fred and his partners were no longer permitted to manage their patients in the hospital. And as they had less and less time to spend with patients in the office, Fred was distressed. The importance of having enough time to be with patients was ironically made more obvious when they began using the electronic health record (EHR) in 2008. 

Busy screen shot of the "Single Sheet Medical Exam"

Adapting to the electronic record

Because the EHR was new and it was felt that the program might be cumbersome for the doctors at first the practice manager reduced the number of patients to be seen in a day for a while. Fred told me that by booking only two patients an hour he had enough time to explore side matters that needed attention without worrying about (or being distracted by) getting the next patient in.  

Fred was happier for a while, and he said that by being employed by a large system with resources there were benefits in terms of, for example, physical office space and financial rewards (including a stable income and a reliable retirement package). But It wasn’t long before the manager increased the workload. As expected, physician satisfaction dropped. 

As EHR documentation became more complex and intrusive, requiring real-time data entry and way too many mouse clicks, wrestling with the process became arduous and burdensome. As the nature of practice was altered and he saw that “every little thing has its specialist,“ Fred still thought that he became “pretty good” at taking care of his patients with hypertension, heart disease, and diabetes. These three conditions make up the bulk of the outpatient practice for the internist and the treatment options (the pharmaceuticals) have become exceedingly complex since Fred’s early years.   

Regarding the EHR, Dr. Groopman warned: “Electronic technology…risks more cognitive errors, because the doctor’s mind is set on filling in the blanks on the template. He is less likely to engage in open-ended questioning, and may be deterred from focusing on data that do not fit on the template”( p. 99).

Thoughts about the future

As Fred witnessed the evolution of the role as a general internist since the late 1970s and has had time to reflect on that change I wondered what he thought about "the future."

Fred said that he was pessimistic. But he wasn't talking not about the future of medicine. He was pessimistic about “the future of our country.” He lamented that “there is no truth anymore” as each person has their own version of things. And, chillingly, he feared that misinformation is taken as fact when it is repeated over and over. He reads history, and he said that this reminds him of reports of Germany in the 1930s.

Innocent German boys reading "Der Stürmer" propaganda posters 
(from the US Holocaust Museum c/o Julien Bryman Archive)

The generic term “provider” is now in widespread use when referring to physicians. According to last month’s issue of The American Journal of Medicine, handed to me by my husband, this word was first employed by the Nazi regime in the 1930s to debase German-Jewish pediatricians. By 1938 as their medical licenses were revoked instead of being called “Arzt” (i.e., “doctors”) they were “Krankenbehandler,” mere “practitioners” or “health care providers.” The term was later applied to all German physicians of Jewish descent. Mass deportations followed. Words, the authors of the editorial noted, have societal implications.

When we contemplate the future we think, of course, about our children. Fred and Cindy have three adult children, a married daughter (the oldest and now running the math department at the Salk School for Science in Manhattan) and two unmarried sons (both living in Austin; one trained in web design and the other, as a musician). There are no grandchildren yet. 

I asked Dr. Kephart if there was anything particularly special he learned as a parent of three. He calmly told me that “it doesn’t matter what you do” since kids have “personalities and minds of their own.” And he added, later, that “one hopes you have given them a good foundation.” (We send them on their way; they eventually find their own paths.)

Leaving medicine 

Dr. Kephart, of course, has a mind of his own, and I suspect he feared that this independence was threatened by the demands of practicing internal medicine inside an expanding health system whose goals and means didn’t always mesh with his. And yet, after he left his practice at 62 he felt, as noted above, that he lost his role, his identity; that there was “a void.”

“So what do you do now?” I asked. He reads (mostly biographies and histories). He goes to the gym routinely, still wearing a mask during the current surge in COVID-19 cases (though almost nobody else there does) despite being fully vaccinated and boosted.  He drives the two hours or so back to Huntingdon weekly for a friendly round of golf with his childhood buddies. And he remains intimately involved with his church and mission work with Cindy, where he feels needed. 

And, quoting Jefferson in Jon Meacham’s biography of our third president, Fred, since he retired, loves"the ineffable luxury of being master (of his own time),” (page 453).

Dr. Philip A. Tumulty the master physician who ran the storied internal medicine program at Hopkins offered third-year medical students in 1970 this wisdom:

The "ability to listen and to talk, so that valid clinical evidence is gathered, anxieties are dissipated, and understanding and motivation are instilled, are the clinicians' greatest assets."  Deep meaningful communication of this sort takes time. 

Time is, indeed, of the essence.

References and Suggested Reading:

1. Groopman, Jerome, M.D. How Doctors Think. Houghton Mifflin. New York, 2008. (Engaging.)

2. Meacham, Jon. Thomas Jefferson: The Art of Power." Random House, New York, 2012 (p. 453) (Dr. Kephart's suggestion.)

3. Tumulty, Philip A., M.D. "What is a Clinician and What Does He Do?"  New England Journal of Medicine 1973: 280, p. 20-24. (Sounding an alarm and setting the bar nearly 50 years ago.)

By Anita Cherry 2/13/22