Interview:
SCMA President Kirk Pappas, MD
By Steve Osborn
Kirk Pappas—born in Vancouver, BC, in 1961—grew up in San Mateo and attended UC Berkeley as an undergraduate, majoring in biology. He received his MD from Wayne State University and interned at the Detroit Medical Center. He then completed a three-year residency in Physical Medicine & Rehabilitation at Rush Presbyterian St. Luke’s in Chicago, serving as chief resident during his last year.
Returning to California in 1992, Dr. Pappas was in private practice in the East Bay for two years before coming to work for Kaiser Santa Rosa, where he has been ever since. As a specialist in Physical Medicine & Rehabilitation (also known as a physiatrist), his professional interests include non-surgical rehabilitation of the spine (including spine injection), sports medicine, and rehabilitation of injured workers.
An avid runner and baseball fan, Dr. Pappas has completed 33 marathons. He is married to Maria Pappas, a past president of the SCMA Alliance. They have three children: Ted, 16, Nick, 12, and Alexa, 10.
The following interview was conducted in Dr. Pappas’s office on May 13..
Q: Where and when were you born?
A: My parents were immigrants to this country. My father came from Greece, and my mother came from Germany. They actually met and married in Canada. I was born in Canada. Then within a year they came to the United States. That was in 1963.
Q: Where did you grow up?
A: I grew up in San Mateo. We lived in New York for just a year, and then we moved to San Mateo.
Q: What did your parents do?
A: My father was a self-employed electrician. Neither of my parents spoke English as their first
language. Neither of them graduated from high school. I am the first person to graduate from college in either my mother or my father’s family.
Q: When did you decide to become a doctor?
A: My parents kind of told me that I was going to be a doctor. My first recollection of talking about careers was my mother and father telling me how important physicians were to the community where they grew up, and that they wanted me to be a physician, because that was a way to contribute to the community and to be a leader.
Q: And you were how old then?
A: Ten years old. And there were no ifs, ands, or buts. That was going to be it.
Q: And you willingly accepted that?
A: It’s your parents. They’re your role models. I had a small family: my younger brother, myself, and my mom and dad. We had no relatives in California. Zero. It was us.
When I was in high school, my father had a job wiring some condos for Kaiser ER doctors in San Francisco. So my father introduced me to these doctors, and from that I got to do some volunteer work in the ER. I had a great time going to the ER and tagging around with these guys, and watching what they did. I knew I wanted to be a physician because they were enthusiastic and they liked what they were doing.
Q: So you are used to hard work.
A: Yeah, hard work is what keeps you going. I don’t know any other way to do it. My mother and father immigrated from Canada, went to New York. The story they told is they came to California with $22 in their pocket, and that was it. A car, a baby, and 22 bucks in their pocket. And now I am a doctor.
This is a great country, where stories like that can still happen. That’s why the flag hangs in my office.
Q: You are an advocate of exercise as medicine. What, in your view, are the main benefits of exercise from a medical perspective?
A: Exercise is the most powerful medicine to avoid chronic disease. There are three health indicators for longevity: genetics, the environment, and behavior. Genetics rules, right? The saying is, “You can’t pick your parents, but you can pick your friends.” With the environment, you have some control, but it’s a green issue. I don’t have control over the pollution. If you go to Bakersfield, the rate of pediatric asthma is different than it is in Santa Rosa. So I can’t control the environment. But I can control my behavior, what I put in my body, how I move my body, and my own attitude. I can control that.
Exercise is the most powerful component of those three indicators in terms of longevity, wellness, and avoiding chronic disease. I can show you the obesity data for the country and Sonoma County to tell you what kind of a problem we have. The only way we are going to address obesity down the road is going to be exercise and healthy eating. That’s why I believe we need to start with exercise as an indicator of health.
Q: Yet the American medical model right now is primarily pharmaceutical. There seems to be a mindset that every problem you have in life can be solved by taking a pill. What is your view of that model?
A: From a financing standpoint, it is really an unsustainable model. We put 17 percent of our GDP into health care, but our outcomes are embarrassing compared to countries that put in half as much. That’s why we need to reverse the pharmaceutical model and the way we look at health care.
There are a few things we can do to change the model from a financial standpoint. That’s the way you have to address it. It can’t just be individual physicians talking and role modeling about exercise and healthy eating. We are going to have to look at the media. What we allow the media to advertise around drugs, around fast food, around all of these things—that needs to change. It’s no different than tobacco.
How did we defeat tobacco? We changed the way that smoking was advertised. We taxed it. We had public policy around tobacco. And guess what? Tobacco use went down. We have to address exercise, diet, all those things, in the same way. From the bottom and from the top. The way you turn the pharmaceutical industry on its head is to work on public policy and legislation. We need to change some of the patent laws to prevent drug companies from spinning their look-alike drugs to maintain patents and profits. We need to federalize generics for the 50 million federally insured lives, and to negotiate drug purchasing in bulk for the nation.
These are the kind of policy changes we need to turn the pharmaceutical model on its head. You don’t even need to get me started on doctors and taking money from drug companies. You don’t see any drug pens in my office. That just needs to stop.
Q: Are you saying that responsibility for changing the pharmaceutical model also rests on physicians?
A: Absolutely. What does it mean if you have any pens from drug companies in your pocket? What is the message you are sending if you are doing that? What behaviors are we role-modeling?
I had a very prominent physician from the northern part of the state say to me, “You know, I hate taking this stuff from the drug companies, but I need the samples to give my patients to get started.” Well, there are lots of generics that these patients could get very inexpensively. You don’t always have to start with the most expensive drug to take care of someone. We know that generics work just as well for 80 to 90 percent of the people. The only people saying generics don’t work as well are the drug companies in their ads and the Op-Ed columnists in the Wall Street Journal.
Q: How do you advocate for exercise when dealing with patients?
A: The first thing all my patients know is that I exercise regularly. They see it in my eyes and on my website. They see it in my office. They see it in my exam room. They know that I am going to talk with them about their behaviors: exercise, healthy eating, positive attitude—all the things that impact their rehabilitation from their injury. What you eat, whether you can exercise and move your body, and your attitude about your condition are going to affect your outcome. So I have those conversations with patients about their responsibility, of the limits of what I can do. I have that with each and every patient.
Q: Have you found a strategy other than just being blunt and honest with these patients?
A: Every patient needs different tools and communication. That’s why physicians need to continually improve their ability to communicate, ability to listen. With patients, it’s not “Did you listen to them?” it’s “Do they think you listened to them?”
When I teach musculoskeletal medicine, I give my colleagues five caveats about their patients. The first one is, “Do they think you listened to them?” Next, “Did you touch them where they hurt, and did you look them in the eye?” Next, “Did you tell them what is wrong?” Next, “Did you tell them what’s a likely pain generator?” And lastly, “Did you give them a game plan?” I think that works for many things in medicine. If you can follow some of those caveats, you can connect better with your patient.
Q: In addition to advocating for exercise, you are also a proponent of “medical homes.” What does that term mean?
A: It means that when I ask “Who’s your doctor?” you can name someone. That’s what it means to me. When you have a doctor, you are healthier, you live longer, you are more likely to get the quality medical and preventive care you need, and have much better health outcomes. If you know who your doctor is, you are more likely to seek care with a primary care physician when you are having problems as opposed to going to the ER, as opposed to doing things on your own. That’s why everyone, regardless of citizenship, should have a medical home.
Q: Is the medical home always with a primary care physician?
A: Absolutely, because that’s the person who’s going to coordinate your care and make sure you get what you need. As the medical information world becomes more transparent, patients will need their physicians to help translate all the confusing messages.
Q: But what if patients are uninsured? How would they get a primary care home?
A: I have been volunteering for the last four years at Southwest Community Health Center doing specialty work. What I have seen there is an excellent setup to help people who are uninsured or underinsured get a medical home. There are many models to help people get a primary care physician, but it all starts with having health insurance. We need to work harder to insure everyone. People have primary care providers when they are at the Southwest clinic and the RCHC clinics. Having a primary care home is far more powerful than going to the ER.
Q: Kaiser is often criticized for not treating its “share” of Sonoma County’s uninsured patients. What is your response to those criticisms?
A: There are well over 2,400 children in Sonoma County who have health insurance through Kaiser who don’t pay for it, who are subsidized by us through Healthy Kids. These are not people who fall into President Bush’s category of “Just go to the ER.” They have a primary care doctor at Kaiser Permanente. Aside from Healthy Kids, more than 6,000 other patients receive subsidized insurance and care at Kaiser Permanente in Sonoma County. They have a primary care physician.
We also have given more than $3.8 million in the last four years to support the local community clinics. Why? Because they are doing a great job taking care of their patients, and we want to support them as best we can. The clinics are federally qualified health clinics. They receive federal matching dollars, so our investments are magnified with these dollars, and the clinics can expand their services.
That’s just the beginning of what we do. Think about where the residency would be today if it wasn’t for the $2.9 million the Permanente Medical Group gave to the residency. We have over a dozen physicians who are working through the residency. Walt Mills, one of our primary care physicians, spends half his job now working as interim medical director for the Southwest Community Health Center, and as associate program director for the residency. He’s working in the community, improving community health. That’s really the way that we look at this. We need to float everybody’s boat up. We can do it through money, we can do it through insuring more people, we can do it through policy.
When you look at the CMA level, Permanente’s closest allies in the CMA House of Delegates are the solo and small-group physicians. We started kind of far apart seven or eight years ago, but now we’re on the same page because we are all about physician-driven health care. I think we can ally with the communities to demonstrate that when physicians work together, we become more powerful advocates for our patients.
The more that SCMA and CMA can drive physicians to collaborate and cooperate together, the better off the community will be. When physicians are driving health care, rather than insurance companies, our patients will be better off, and we’ll feel better about what we are doing.
Q: What is your perspective on the debate over Medicare rates?
A: It’s really interesting when you look at it from a policy standpoint. The Republicans believe that Medicare HMO is the solution to Medicare. The Democrats would prefer to go back to a fee-for-service mentality around Medicare. On a national basis, the AMA is very much anti-HMO because there are more solo and small-group physicians in this country.
The problem with fee-for-service is the differential rates of Medicare utilization by geography. As a specialist, it is sometimes hard to admit this, but we drive Medicare costs up by doing more stuff to people. This is a hard thing between primary care and specialty care, this natural stress, because primary care has all the cognitive stuff: talking to the patient, educating the patient. There is not enough time in their day, and they don’t get paid for that. But specialists just do a few more of X or a few more of Y, and they can continue to maintain their practice.
That stress is going to have to be addressed sometime in the future. It’s been addressed in Permanente by all of us being in the same group, using quality outcomes, using evidence-based medicine to decide what we are going to do, and having physicians drive what we are going to do. But this stress between primary care and specialty care in the non-Permanente world has to be addressed. There will be some challenging conversations.
I can see this issue from both ways because I am very much invested in people having a primary medical home. But I also understand from my specialty colleagues in the community that in order to have a sustainable practice you need to have enough work.
Q: Do you have any particular projects in mind for your year as president of SCMA?
A: The thing that I would ask every physician to do is to sign on at www.exerciseismedicine.org and begin to experiment with having more conversations around exercise with their patients. Whether you’re an ophthalmologist dealing with a diabetic eye, or whether you’re an OB/GYN or a pediatrician, you need to talk about exercise.
I sit on the Sonoma County Health Action Council, and I have been working with them around the concept of “Know your number.” And your number is 150. It’s not your cholesterol, it’s not your blood sugar. It’s how many minutes a week you should exercise.
Whenever I have a chance to speak, I am going to be relentless in talking about exercise, and the power of exercise. And the fact that it’s not going to be a pill. It’s not going to be easy. You are going to have to make an effort. It takes effort to exercise. I didn’t run 33 marathons by rolling out of bed one day.
Q: What are the most satisfying parts to you of being a physician?
A: I enjoy when, as a teacher physician, I can get people to engage in caring for themselves more. So the interaction with the patient last night who had a stroke, encouraging her to walk more, to be more independent, is far more satisfying than when I do the sweetest spine injection on the face of the earth. That’s not as satisfying as engaging with that patient and helping them improve themselves.
I am fortunate to have been well trained to take care of people and help them get better. But having people come to me and tell me that they were able to take better care of themselves, that’s far more satisfying. That’s what I really enjoy doing.
Q: Have you had any experiences in medicine that were particularly important to you?
A: They happen all the time. When I was a rehabilitation resident, I was rehabbing a very elderly rheumatoid patient who had multiple joint replacements. These patients really have a hard time coming back from joint replacement. I was the resident for this woman, and we were on resident rounds with our attending physician. At the end of the resident rounds, the attending physician asked the patient, “Is there anything you want to tell us?”
The woman looked at all of us and said, “One day you will all be disabled. Right now you are temporarily able. Please don’t forget that.”
These things that patients teach us, they happen all the time. They constantly teach me lessons around how to be thankful for what I have, how to be positive. We need to be better role models. I am hoping physicians will take that on.
The patients need us to be positive. They need us to exude a healing aura, a healing image, a healing attitude, for them to continue to keep going. Our patients need us to be strong. We can’t afford to have them see us act like victims, act negatively, sweat, any of those things, because they count on us to exude this positive behavior. We don’t have to like it but, frankly, when we took the Hippocratic Oath, I really believe that exuding this positive attitude was part of it.
If you really are burnt out, you can’t do it anymore, I understand that. But if you are coming to the ball field every day to play ball, play this game of medicine, you gotta come to play. Because the people—not just on the field, but in the stands—are our patients, they’re watching us. They’re watching everything we do. Just like our children watch us, our spouse or significant other, our parents. The public’s perception of our attitudes is the public’s reality.
E-Mail: kirk.pappas@kp.org
Mr. Osborn is the managing editor of Sonoma Medicine
Sonoma Medicine, Volume 59, Number 3 (Summer 2008).
