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Faculty Focus

Michael Zubkoff, Ph.D.: Taking the long view

By Jennifer Durgin

Peter, let me tell you right up front. There is no way that we're going to bring a health-care economist in as chair of the Department of Community Medicine," James Strickler, M.D., then dean of DMS, remembers saying in 1975. Peter Whybrow, M.D., was heading a search committee charged with finding a new chair for the Department of Community Medicine (now called Community and Family Medicine); he'd just told Strickler about the committee's top choice—Michael Zubkoff, Ph.D., a Columbia University-trained economist. But hiring a health-care economist to chair a clinical department was out of the question, felt Strickler. It would be too volatile given the circumstances.

The circumstances were that four years earlier, in 1971, when DMS was being converted from a two-year basic-science feeder school to an M.D.-granting institution, the School needed more capacity for students' primary-care clerkships than was available at the Hitchcock Clinic. So Strickler and Carlton Chapman, M.D., DMS's dean at the time, created the Department of Community Medicine and charged it with finding primary- care clerkship locations throughout the region. In addition, Strickler and Chapman envisioned the department filling the role of a school of public health by addressing broader issues in medicine, such as the ethics and economics of health care.

Yet this dual mission was upsetting to many at DMS. One prominent faculty member called the department's work "fuzzy social science" that didn't belong at a medical school. So in this climate, the last thing Strickler wanted to do was rouse further opposition by bringing in an economist to head a department peopled mostly by M.D.'s. Nevertheless, Strickler agreed to meet Zubkoff and to his surprise liked him immediately. "I thought he made a lot of sense," Strickler recalls. "I thought he had good ideas. I was impressed with the way he interacted with faculty and students. I liked his values."

At the time, Zubkoff was vice chair of community and family medicine at Meharry Medical College, a historically black school in Nashville, Tenn. He had begun teaching at Meharry—and at Fisk University, another black school—in 1966, through a program of the Woodrow Wilson Foundation. Despite being one of only a few white faculty members at Meharry, Zubkoff fit in well. Not long after arriving there, he became responsible for organizing medical coverage at the civil rights marches led by Dr. Martin Luther King, Jr.

Being an activist came naturally to Zubkoff. His father, a colonel in the Air Force, had earned a reputation for being "a firebrand on behalf of Jews and blacks in the military," Mike Zubkoff explains. Whenever he could, Colonel Harry Zubkoff, himself a Jew, steered military work contracts toward minority-owned businesses. He also got involved with buying houses and then reselling them to minorities who weren't able to get a foothold in certain neighborhoods.

Time and again, Mike Zubkoff has been reminded of the impact of his father's activism. The first time was in the mid-1960s, when Zubkoff went to Atlanta to meet Dr. King. Upon being introduced, King asked, "Are you one of Colonel Zubkoff's kids?" Zubkoff stood there gaping, he recalls. "Reverend King put his hand on my shoulder and went on to tell me how proud I should be of all that the colonel had done, fighting throughout his career against prejudice and discrimination within the military, particularly towards blacks and Jews . . . knowing that he was seriously jeopardizing his career aspirations in the military."

Another "unexpected testimonial," as Zubkoff calls these events, occurred in 1974 at a federal conference on inflation. As a rapporteur for the conference, Zubkoff briefed President Gerald Ford, his economic advisors, and House and Senate leaders. "That evening, at the White House," Zubkoff recalls, "I was approached by a feisty little old-timer who asked, 'Are you one of the colonel's kids?' Upon learning that I was, he took me over to President Ford and began telling of how my dad . . . was developing innovative health programs for elderly and less fortunate residents of Miami Beach, and how these programs should be looked at as models for the nation." Only when Ford finally got a word in did Zubkoff learn the old-timer was former U.S. Senator Claude Pepper, who had helped establish the National Cancer Institute.

Though Zubkoff didn't join the Air Force, as his father had hoped he would, he still drew inspiration from the colonel's work. By 1975, when DMS was considering hiring him, Zubkoff was already making his own mark on the world. In addition to his governmental and civil rights work, Zubkoff had helped Meharry set up community- based health clinics in poor, southern towns with little access to health care. In turn, Meharry used the clinics as places for medical students and residents to do their clerkships.

This work was one of the main reasons Strickler ended up offering Zubkoff the job in 1975 and, likewise, why he accepted it. (Dartmouth's Tuck School of Business also gave Zubkoff a faculty appointment, and he still teaches at Tuck as a professor of economics and management.) "What attracted me was that Dartmouth was talking about supporting the development of primary care in what I considered northern Appalachia," says Zubkoff. He recognized that although Maine, New Hampshire, and Vermont appear bucolic to the casual visitor, outside of a few oases of affluence there was then, and is still, a good deal of poverty in the region. Having "the opportunity to help communities recruit and retain primary-care providers, doctors, nurses, nurse practitioners, and to have them then be involved in training the next generation of doctors at our medical school, seemed to me to be just right."

From the beginning, Zubkoff pursued the vision that Strickler and Chapman had laid out for the department—a vision in which the department focused on both individual patient care and broader issues in medicine, reaching out to communities throughout northern New England. The department set up clerkship sites all over New Hampshire, Maine, and Vermont, plus—to increase students' exposure to culturally diverse populations—clerkships in Tuba City, Ariz.; Bethel, Alaska; and Miami, Fla. Zubkoff also looked for faculty who were interested in the big picture of health care. In his first year at DMS, he recruited John Wennberg, M.D., M.P.H., the founder and director of Dartmouth's world renowned Center for the Evaluative Clinical Sciences (CECS).

Wennberg "was well-known, up and coming," says Zubkoff. "He was a physician who was asking questions about the interface of economics and medicine." Wennberg—then an associate professor in the Department of Preventive and Social Medicine at Harvard—had been commuting to Boston from his home in Waterbury, Vt., for the previous two years. Zubkoff offered him a position closer to home, and Jack Wennberg accepted it.

"At the time, the school's resources to support Jack were very limited," says Strickler. "I'm surprised, in retrospect, we were able to get him and retain him." In fact, recruiting and retaining faculty has proved to be one of Zubkoff's greatest strengths. "He's very persuasive," says Strickler. "He convinces people that there are opportunities that are challenging . . . that [Dartmouth] is a good place to be." At the same time that Zubkoff was building the core faculty in the department, he was also helping DMS form stronger relationships with rural clinicians through the Primary Care Cooperative Project. The oldest such network in the U.S., it gives these clinicians—physicians, nurses, and nurse practitioners who practice in some of the most remote areas of northern New England, including several towns in Aroostook County, Maine, near the Canadian border—a chance to engage in practice-based research and continue their education. And for DMS, the COOP Project provides sites from which faculty are able to gather data about primary care.

"What was perceived as a disadvantage in some circles," says Strickler—that is, DMS's rural location—turned out to be "a tremendous advantage, because it gave the Medical School a linkage and interaction with community-based physicians." These contacts have helped the Department of Community and Family Medicine (CFM), and ultimately DMS, to become a national leader in medical outcomes research and community- based teaching.

Today, CFM enjoys the largest sponsored research budget of any such department in the nation—$33 million in grants and contracts either administered by the department or for which the principal investigator's primary appointment is CFM. Seven of the department's full- and parttime faculty have been elected to the prestigious Institute of Medicine (IOM). In 1983, Zubkoff became only the second Dartmouth faculty member elected to the IOM as well as the youngest member ever.

In addition to being the home of CECS, the department houses innovative research programs in primary care, medical education, epidemiology and biostatistics, mental-health services, and medical outcomes. On Zubkoff's watch, the department has also emerged as a national leader educationally, overseeing courses like Health, Society, and the Physician for fourth-year students; the nation's first graduate program in outcomes research; a new M.P.H. program; and, most recently, an M.D.-M.B.A. program (which Zubkoff himself oversees). "The department has been a holding company for a lot of people's dreams," says Zubkoff. "Why people stay is probably because they feel it's an environment that's been encouraging of them doing their thing. It's not been a controlling structure."

"Mike has created a tremendous, congenial atmosphere for people to work," says Wennberg. "There's very little academic backbiting and other unpleasantries that are sometimes associated with academia."

It hasn't always been easy for Zubkoff, however, especially in the beginning. "Strickler used to take me out to the Hanover Inn Tavern to tell me that he wasn't sure I was going to make it," says Zubkoff. There were "times when I felt less than appreciated or felt a little bruised," but, he adds, "if you believe that something's important, you just stick with it."

"Mike had a vision," says Strickler. Zubkoff believed that the department could be a leader on all fronts—in clinical care, education, and health-care research. "The fact of the matter," concludes Strickler, "is he was right."

"We're glad he stuck with it," says Wennberg, who's been at Dartmouth almost as long as Zubkoff, "and we stuck with him."

The department's dual mission was upsetting to many at DMS. One prominent faculty member called its work "fuzzy social science" that didn't belong at a medical school.

Jennifer Durgin is Dartmouth Medicine magazine's senior writer.

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