An Interview With Eric Blau, MD

Thank you to UCSD’s The Human Condition — a student-run, annual publication of artwork, poetry, and prose contributed by members of the UCSD medical community — for allowing us to reprint this interview with Dr. Blau.

University of California San Diego School of Medicine alumnus (class of 1973), renowned local physician and head of Kaiser San Diego’s Preventive Medicine program, Eric Blau is also an accomplished professional photographer. He has shown his photographs locally, nationally, and internationally for many years, and some of his work has also been collected in book form, winning national awards. Common Heroes, a work combining his photographs and interviews of terminally ill patients, was published in 1989 to great acclaim. This work portrays dying patients in their homes, with accompanying text touching on their thoughts on the dying process. Another project combining photographs and interviews is Stories of Adoption, a book exploring the feelings of adoptees, adoptive parents, and the birthparents who gave up their newborns for adoption. For the past fifteen years, Dr. Blau has been working on a photographic series called “The New Religion,” combining sculpture and human models in polylith photographs. A few of his selections from this body of work have been included here. The Human Condition was fortunate to meet with Dr. Blau in February 2006 to discuss his history at UCSD, his accomplishments as an artist, and his experiences as a physician.

NELSON: What brought you to UCSD?

BLAU: I finished undergraduate work in the late 1960s, and although I knew I was interested in pursuing a career in the sciences, I didn’t know what I wanted to do. I had worked one summer in the lab of Dr. James Holland, an oncologist at Roswell Park Memorial Hospital in Buffalo, NY, and he was influential in steering me toward medical school. I was quite interested in ecology, too, and I had been accepted as a graduate student in the ecology department at U.C. Davis. It was the height of the Vietnam War, and I decided I had a better chance of finishing my studies as a medical student.

It was November and cold in northern California when I flew down to UCSD for my interview. I was taken to Surfside, the small café overlooking Scripps Beach, as part of my visit. It was 77 degrees Fahrenheit, and I watched students play Frisbee on the sand. During the interview, I also learned that there was a small medical ecology program. All the people I met were incredibly friendly and encouraging, something I had not experienced at my other interviews. I had been accepted at some schools back East, but, after my visit, I felt UCSD was the place for me. My naïve thinking included the weather plus the beach and medical ecology.

NELSON: Did your hopes for combining your interests in ecology and medicine work out as anticipated?

BLAU: Not at all. The medical ecologist left after a couple of years. I realized his idea of ecology had more to do with what happens in a Petri dish. But I was seduced by clinical medicine, and the rest is history.

NELSON: What was it like attending UCSD at that time?

BLAU: UCSD was just four years old. The Basic Science Building and the Biomed Library had just been built. The medical school professors all seemed young, enthusiastic about being in La Jolla, and there was a sense of camaraderie that pervaded the medical school. There were few faculty members then, and the school had guest lecturers come to teach coursework in areas where the faculty had limited expertise. Most of the medical students my first year (including some students from the class before mine) lived in Mesa Apartments. We would organize dinners on the weekends and invite faculty to join us. However, this sense of community seemed to be limited to the medical school.

I had come from U.C. Davis, where the surrounding town was an extension of the campus, like UCSD. La Jolla was a much smaller, quieter place then. It closed down at about 8:30 every night and seemed very provincial. I rented a three-bedroom house on Eads Avenue with two other medical students for $150 per month.

NELSON: You hinted at your motivations for going into medicine. Have the kinds of people going into medicine changed over the years? Did people believe that going into medicine was a way to be an activist?

BLAU: Yes. Many of my classmates and I were involved as undergraduates in off-campus activities that would be considered student activism. We came of age in the ’60s, when there was a great deal of social upheaval. President Kennedy inspired people to get involved in improving the lives of Americans as well as people around the world. One could have been involved in the Civil Rights movement, the War on Poverty, Peace Corps, Job Corps, a nascent environmental movement, and many other causes. I believe that the admissions people at UCSD purposely looked for students who had been activists. I would guess it was no surprise when in my sophomore year, my class decided to go on strike and boycott class for six months in protest of the United States for broadening the Vietnam War into Cambodia.

The strike began after a UCSD graduate student lit himself on fire on Revelle Plaza and then died during the lunch hour. After that incident, the medical students in my class had a meeting and we felt we could not continue with our class work while the war widened. We had a rancorous meeting with the faculty and eventually agreed to go to class for two hours a day, during which our professors told us what they thought we should study to become doctors. On the one hand, we wanted to be prepared to take care of people; on the other hand, we were engaged in the world. For the first few weeks I worked intensely on anti-war activities. Then I realized there were a limited number of things I could do, and I resumed my studies and prepared for the first part of the Boards. Most of my classmates did the same. The class before us had scored in the 50th percentile, which pleased the school. My class, which didn’t attend formal lectures from January until the exam, finished number one in the country, which may say something about the teaching of preclinical medicine.

NELSON: Over the years, that spirit of activism in medicine at UCSD seems to have waned.

BLAU: I think that students today view society with the same jaundiced eye that we did. The difference is we were naïve enough to feel we could change the world. So we tried. I think that students now are more cynical about their abilities to effect change. They look inward and attempt to improve their own situations — affect their microcosm instead of making wild attempts to change their macrocosm. Individual lifestyles matter more now. The practice of medicine is much different now too, both in terms of the remuneration and organization of medicine.

Back in the ’60s and early ’70s, when I made career decisions, being a primary care physician was a reasonable thing to do, and we didn’t even think about money. Many of us were not sophisticated enough to know different physicians’ incomes, and we made decisions based on role models. Twenty-seven out of the forty students who graduated in my class went into an internal medicine internship. In internal medicine, we felt we would be able to work in a less developed country or be Marcus Welby — be the icons of general practice. Today, students are much more sophisticated, and they recognize that the life of a primary care physician is much tougher than it used to be. They also look at the hassles of practice and the amount of money people make, and make career decisions based on lifestyle. We didn’t consider lifestyle as much because doctors seemed to enjoy their work in those days. I’m not sure that’s true now.

NELSON: Do you think the shrinking number of students who want to go into family practice or general internal medicine these days might spell disaster?

BLAU: Over the years, it seems that there have been dire predictions of shortages in various specialties in medicine. It may require a dearth of primary care physicians in America to change the incentives to bring more physicians into these areas. These inducements may take the form of better working conditions, improved remuneration for primary care doctors, or more respect from within the medical community.

NELSON: Do you have recommendations for those of us who are just starting out in our medical careers, given the economics and politics of medicine, particularly in primary care?

BLAU: Go where your heart is. You’ll make a fine living. Don’t worry about money. Do what you enjoy. I think that should be anyone’s goal.

NELSON: How have you kept your practice fulfilling despite the pressure on primary care doctors?

BLAU: I am a primary care physician and I love what I do, but I have a unique job. Some people think I have the best job in San Diego. The nice thing about medicine is that there is a place for everyone. If you don’t ever want to see a patient, you can still find a meaningful, fulfilling career in medicine. If you love to see patients, there is a place for you, in big groups, little groups, HMOs, by yourself. That’s the wonderful thing about medicine. There are so many opportunities. I’ve picked one I like, so I’m happy.

NELSON: How do you spend your time?

BLAU: I’m the head of Preventive Medicine for Kaiser San Diego. The bulk of my time is spent mentoring nurse practitioners and physician assistants. As they provide preventive medicine visits, I do things like recheck physical findings, discuss histories and treatment plans for complicated patients, and I see patients with the mid-levels. I also have a very small practice consisting of people who work in the Kaiser system. For about fifteen years, I was an outpatient internal medicine attending at the Ambulatory Care Center before it moved to 4th and Lewis. I still do a little teaching, and occasionally I have a medical student working with me for an independent study project. I currently have four pharmacy students doing projects. I also find time to spend with my family and make photographs.

NELSON: How is working at Kaiser?

BLAU: I joined Kaiser because I didn’t want to hire staff, I didn’t want to fire people, and I wanted to have a stable salary. I didn’t want to charge patients according to how much work I did. I wanted patients to get what they needed, and not have any conflict between helping patients get what they needed and my making a living. I love that aspect of Kaiser. There is a loss of individual control as a physician working at Kaiser. It can be a problem and a blessing. It’s wonderful to work in a setting with support systems in place to help you deliver high quality healthcare. But you must be willing to relinquish some personal autonomy.

NELSON: Given that we don’t yet have a single-payer system in the United States, but you are working in a system in which all your patients are insured, how do you think we can take care of the great number who are uninsured in our community?

BLAU: I’m not an expert in healthcare funding, but I believe there are a great many possibilities. First, the government can get more involved. If I ruled the world, the first thing I would do is eliminate insurance companies and limit the profits of pharmaceutical companies and other large-profit-margin segments of the healthcare industry. Medicare has 3–5 percent administrative costs, as does Kaiser. Private health insurance has closer to 30 percent overhead. If you took that 30 percent that insured people are paying and made the system not-for-profit, more people could receive care.

I don’t think we should pay shareholders to have our municipal water provided or to have our streets swept. Why should we pay them to provide our healthcare? Why should there be large corporate profits for healthcare delivery? Should CEOs of insurance plans make tens of millions of dollars annually? Drug companies that do research should be able to reap profits, but healthcare delivery itself could be not-for-profit. You could take the money currently in those profits, redistribute it, and be much better off. There is enough money currently being spent in America on healthcare to provide healthcare for all. It’s just not being spent wisely.

NELSON: How did you get involved with photography?

BLAU: I grew up the son of a professional photographer, and we had a darkroom as big as the living room in our house. My dad was a traditional, professional photographer. He did weddings, architectural photography, advertisements, and newspaper photographs, eventually finishing his career as a photo engraver. I learned at his knee.

NELSON: Were you able to make photographs while you were in medical school?

BLAU: I didn’t start professionally until after medical school.

NELSON: Did you wait until after your training was finished?

BLAU: I always made photographs, at the beginning just for myself. Whether or not I got paid, I would still be making photographs. After residency, I took time to get back to photography. A close friend who was a very good photographer said, “Let’s go to Maine. There is a workshop there.” The idea of learning from well-known photographers at a workshop intrigued me.

NELSON: What were your inspirations early on?

BLAU: Originally, I was trying to do imitation Ansel Adams photographs with a 35 mm camera, which technically was not the proper tool for making landscape photographs. I made those and brought them to the workshop. The workshop had a show of all the students’ work, and the show was juried by one of the instructors. I was the only student who didn’t have a photograph juried into the show. My work wasn’t very good, and I recognized that. I realized that you shouldn’t try to pretend you’re someone else and imitate their photographs. You need to find your own voice.

Around that time I was going to travel around Ireland by bicycle, so I brought along a camera and made photographs. Susan Barron, an instructor at this workshop, made 3 x 4 inch photographs. Although I said I didn’t want to imitate others, I found these photographs marvelously intimate and seductive. Susan was making these at a time when other photographers were making photographs bigger and bigger, which was very popular in the early ’80s. So I went around Ireland making 3 x 5 inch photographs. When I came back I had a show at the Athenaeum in La Jolla. It was my first show, which thrilled me. From that time, I started to exhibit my work.

NELSON: Did your colleagues know you were doing photography?

BLAU: No. I found out something from the workshops. When you are a physician and an artist, even though art and medicine are common enough interests, fellow artists (if they find out you’re a physician) think you’re a dilettante. During much of the 1980s, I spent more time doing photography than medicine, so I tried to keep these spheres very separate. I didn’t want artists to know I was in medicine, and I didn’t want physicians to know about my photography. When you’re a doctor you want your fellow physicians to take you seriously as well — you don’t want them to know you spend so much time doing photography.

NELSON: From your books it appears you eventually did find inspiration from medicine.

BLAU: In her 50s, my aunt developed pancreatic cancer and didn’t tell anybody, though my family is a very warm and close-knit family. Thanksgiving in Sacramento might mean thirty relatives around the house, yakking; however, in the setting of this family, my aunt didn’t tell anybody she had cancer until she was quite sick. I was a resident at the time, and she was living in La Mesa. One day I got a call from her. She was quite distraught, explained what was going on, but said, “You can’t tell anybody.” I immediately called my mother (her sister) and within a day or two everyone in the family knew. The family came down to get her, and brought her up to Sacramento to give her the support she had not had. One of the things that struck me about this whole experience, especially after having Elizabeth Kubler-Ross (one of our professors here at UCSD) lecture about death and dying, was how isolated my aunt must have felt. In my family, so talkative and open, she was not capable of talking to us. What goes on in the rest of the world? So I started trying to find people that had a terminal illness who would talk to me; that was the first book [Common Heroes]. Interestingly, I had a very difficult time finding patients. I thought it would be unethical to talk to my own patients. I was looking for a place where people who had terminal illnesses might be willing to talk with me. One place, of course, is an oncologist’s office. So I called up the oncologist that I worked with and asked, “Is there anyone I can talk to about their experiences with dying?” — the hospice movement was starting then, in 1982, 1983. He sent me a patient, and later the patient came back to him and apparently started to talk. The oncologist said to me, “I don’t know what you did in your interview, but I have a much better relationship with her now,” so he started sending me patients. I soon discovered that most of these people were not talking to their family members, not talking to their doctors, not talking to anybody. There was a fear of upsetting what they viewed as a fine balance; they were afraid of causing emotional upset of people close to them, and of course their family members were also frightened they might disturb the patient. I decided to interview and photograph these people. The first photographs I made were emotionally evocative. Patients were in bed, dying, looking ill, with a lot of medical paraphernalia surrounding them. I found that people didn’t want to look at the photographs, and they wouldn’t read the captions that I had written. So what I ended up doing was making people look as healthy as possible, just like you and me. I tried to make snapshots, as opposed to fine art. It seemed to work. People would take the time to read the captions that accompanied the photographs, and the show received a lot of critical acclaim, traveled around, and eventually was published in book form.

NELSON: How did you get started with your “New Religion” series?

BLAU: In the 1980s, I was a member of Spectrum Gallery, a cooperative gallery in downtown San Diego. Two other members were the painter Jeanne Branscomb and the sculptor Anne Mudge. Around 1990, I had left Spectrum and was represented by the Brad Lemery Gallery. The gallery showed mostly photography, but did have a show of Anne Mudge’s sculptures. One afternoon, while Anne’s show was still there, I volunteered to make some photographs of her sculptures for her. She and Jeanne were hanging around watching, and I convinced them that incorporating themselves into the photographs would enhance the images. We tried various clothed, draped, and unclothed poses. I eventually printed the version you’ve seen, using a print development process with which I’d been experimenting called polylith printing.

NELSON: Can you explain polylith photography to the uninitiated?

BLAU: A polylith print is a pinkish to walnut-colored photograph that looks somewhat like an albumin print from he 19th century. The tonal range is reproduced fairly uniformly, but the dark tones tend to be inhomogeneous. The photograph is made from a traditional black and white negative on a photographic paper containing chromium.

In the mid-1980s, I had received a grant from the Polaroid Corporation to make photographs using their materials and processes. Although there are many advantages to using Polaroid materials, one of the major drawbacks with most of their products was the inability to make multiple images. They did, however, have one film that produced a negative in addition to the positive image. This film was quite slow, meaning one needed a lot of light, or long exposure times, to properly expose it. This meant I could not use it to produce street photography, the type of images I had been making and for which I had received the grant. I began to use a studio to create sets for the new photographs I would be making with Polaroid materials.

There seemed to be a wonderful synchronicity between Anne’s sculptures, the use of the polylith print process, and my need to work in a controlled environment with the Polaroid materials. I began photographing Anne’s sculptures at her home studio. At first, I was just interested in how organic they seemed to me. I was not photographing them with any larger intellectual goal in mind. I would arrive at her studio and just react to the sculptures and raw materials she was using. When I began publicly exhibiting these photos, Arthur Ollman, the director of the Museum of Photographic Arts, commented that they reminded him of religious icons. For the lack of a better title, and because galleries and museums wanted to name this collection of photos, I used The New Religion. To this day, most of the individual images are titled by the people (models) that populate them along with the names of the sculptures.

NELSON: Whom did you use for models?

BLAU: For several years Anne Mudge and her artist friends and my artist friends [modeled for the project]. I started having shows of this work, and it became known that I would pay models with a print, which attracted some models. Later, people I worked with posed for me.

NELSON: You are clearly comfortable with your subjects, including some who are nude. Did your experience as a physician complement your experience as a photographer?

BLAU: It was really tough at first. I was very nervous interviewing and photographing the dying people because I felt that I was invading their privacy. Stories of Adoption was not so difficult because people wanted to talk. I didn’t have to tease out their stories when I interviewed them. With The New Religion series, when someone volunteers to model, that doesn’t mean they are comfortable at all. Often, it might take a few sessions to get a photo that has any sense of emotion. When I first started making these photographs, I was somewhat uncomfortable because the models were my friends and I wasn’t used to them taking their clothes off in front of me. With time, it just seemed like the right way to make the photographs I wanted to create. And nudity can add a sense of tension to many of the photographs. I have no trouble [in the office with patients], and I trained during the ’60s when nudity in society was a little more acceptable than it is now.

NELSON: Does this tension sometimes interfere with your ability to get the photograph you want?

BLAU: It can. Sometimes I want a sense of calm like in Fertility Rites #3 [photograph of woman lying down]. Do you know the painting of Rousseau’s with the woman sleeping, the lion above her? I wanted that feeling. For me, the drapes, the human form, and props are added vocabulary that allows me to enhance my photos. The larger my vocabulary, the more tools I have at my disposal in creating an image.

NELSON: How do you feel your photography has had an impact upon your medical work?

BLAU: Being a physician requires being on time, being organized, being obsessive compulsive. You should be rigorous in what you’re doing, concentrate, pay attention, but that is one side of one’s life. Photography brings out the side of me that is open to the possibilities, that doesn’t necessarily have to be on time, and that works on whim. Art and photography balance my life. I enjoy the way people think in the arts — often nonlinearly — as opposed to the way we often think as physicians.

NELSON: For those of us who are going into medicine and have an artistic interest, perhaps not on the professional level, do you have any advice on how to incorporate art into our lives?

BLAU: You are already doing it. I probably don’t have any good advice, but I encourage being involved with art. I could just as easily be an artist without a professional reputation. It’s only because someone buys a photograph that I become a professional as opposed to a hobbyist. There obviously are many ways to express your artistic side. If your tool is a pencil, great; if it’s a camera, great; or you can express yourself as a doctor.

NELSON: How do you think your works and similar ones have had an impact upon patients? Common Heroes was published early in the growth of the hospice movement, and, since then, there have been many portrayals of terminally ill patients.

BLAU: I don’t know. I hope Common Heroes is read both by people who have serious illnesses as well as those who wish to learn about the experiences of those with serious illnesses.

NELSON: Given how successful Kaiser has been, both in managing the financial aspects of medicine and in terms of patient satisfaction and outcomes, do you think Kaiser will be the model if and when this country adopts a single-payer system?

BLAU: I don’t think so. I don’t think it should be. Americans aren’t ready for that. We [Kaiser] are one system, and I think having a pluralistic healthcare delivery system can be quite beneficial. There are people who want to go to their family doctor in their neighborhoods, who knows them socially, whose kids play with their kids. There are people who want the latest technology and research that only an academic center can provide. What I would like is a single-payer system, provided people can choose what type of healthcare delivery system they prefer. I worry that “one-size-fits-all” doesn’t work that well.

NELSON: Do you feel that the increasing focus on preventive care in the United States in recent years has changed the way patients approach their physicians?

BLAU: No. There has always been a group that wants preventive care services, and there has always been a group that does not want preventive care. In fact, we at Kaiser are doing outreach now, which is turning the paradigm of medicine on its head. The normal paradigm is patient-initiated healthcare, usually when patients are sick. When you reverse this, Big Brother Kaiser calls up and says, “You haven’t had a mammogram in two years. You should have one. Please call this number to schedule.” There are a lot of patients that don’t like this approach and view it as an intrusion. They say, “I’ll call you when I need care; otherwise, you stay out of my business!” So there is a mix of people. Americans are becoming more cognizant that there are options. We now recognize that there are a variety of evidence-based interventions that can help improve health both in the short and long run. There are a whole lot of people out there, though, who still smoke, drink, and do not exercise.

NELSON: Are patients taking better care of themselves?

BLAU: Yes, some are.