A framed set of caricatures hangs in the lobby of the Kaiser Permanente Division of Research in Oakland, described with this caption: “Drawn in 1943 by Mr. Machado, a Richmond, California, Kaiser shipyard employee treated for a hernia repair.”
The beautifully drawn and painted figures depict three key physicians who provided care for Henry J. Kaiser’s World War II shipyard workforce in Richmond, Calif. – Dr. Sidney Garfield (1906-1984), Dr. Morris Collen (1914-2014), and Dr. Cecil Cutting (1911-2008).
Dr. Collen’s oral history explains how he discovered these pictures while he was in the company of Dorothea Daniels, the first female hospital administrator at the Los Angeles Permanente Foundation Hospital in 1953 and first director of the Permanente Foundation Hospital School of Nursing in Oakland:
One day on rounds [probably in 1952, at the Oakland Hospital], Miss Daniels and I went through the basement storage area. In a dusty corner I saw a stack of pictures. It turned out that they were about fifteen framed caricatures drawn by the cartoonist for the shipyard paper while he was a hospital patient in Oakland. He sketched all the physicians he had met, and they all hung in the Oakland doctors’ dining room for several years. One day, they painted the dining room and must have put all the pictures down in the basement, where we found them. Most of them were now broken or stained with dirt. I took them, of Dr. Garfield, Dr. Cutting, and myself, and had them restored. They have been hanging in my office since that time.
The Kaiser Richmond shipyard newspaper Fore ‘n’ Aft reveals more about the artist, Reginald “Reg” Machado (1911-2004). He designed silk screened posters and launch programs, and was an artist for the newspaper. A biography on him published February 5, 1946, explains further:
Reg Machado probably has advanced in his own line of work as far as anyone in the shipyards. He has always been an artist. Reg came to the yards in December of 1941 with an idea … and in order to get his idea across, went to work in Yard Two as a sign painter. But it wasn’t long before he had developed what is known as the large and valuable Graphic Arts Department of which he is the Director. Born in the San Joaquin Valley, Reg swears he has never been farther north than Sausalito, nor farther south than Carmel. “However,” he said, “I hope to make a long trip soon.” We checked on the possibilities of this and learned he is slated to leave for the Kaiser-Frazer automobile plant at Willow Run. He will be in charge of a bigger and better Graphic Arts Department there.
Mr. Machado later returned to the San Francisco Bay Area and operated the Reg Machado Advertising Art studio for 20 years before retiring. He returned to the Monterey Bay Peninsula with his then-wife Betty, built his own home and others, and took up landscape painting. He eventually moved to the Sierra foothills.
Further research in the Kaiser Permanente archives revealed no support for the hernia operation part of the framed images caption, and a physicians group photo with Machado’s caricatures on the wall of the doctor’s dining room is dated 1942. But at least we now know more about Reginald.
Just like noted California artist Emmy Lou Packard, Reg Machado used his artistic skills in the service of winning World War II while working in the Kaiser Richmond shipyards. His contribution will not be forgotten.
Short link for this article: http://k-p.li/2nkjWgN
It’s official. Kaiser Permanente has acquired Group Health Cooperative, making Kaiser Permanente Washington our newest region, the first in over 30 years.
Although this merger is brand new, the two organizations began collaborating more than 65 years ago. Group Health Cooperative of Puget Sound (they dropped the “of Puget Sound” in 1995), like Kaiser Permanente, was always a mission-driven organization that approached health care in a very different way from traditional fee-for-service medicine.
In fact, few know that our common roots go as far back as 1950, just three years after Group Health Cooperative’s founding.
The relationship began in 1949 when the International Longshore and Warehouse Union [ILWU] approached Kaiser Permanente (then called the Permanente Health Plan) about taking on their membership. Initially it was the 20,000 members in the San Francisco Bay Area, with the understanding that it would soon be all of their members on the rest of the coast, from Seattle down to San Diego. Permanente and the ILWU had been in discussion since 1945. Among the many advantages raised was “The hospital’s facilities are open to all groups with no segregation of patients because of creed or color.” Imagine that.
In a 1974 interview, Kaiser Permanente founding physician Sidney Garfield, MD, reflected on this earliest relation between Kaiser Permanente and Group Health Cooperative:
We were rather anxious to get the membership of course, but we couldn’t spread our service that far. We did have a service up in Portland, so that was fine. We got the doctors up there to accept those members, they wanted to do it too. In Los Angeles we had no service. We had it in Fontana, which is quite a distance away, maybe 70 miles from San Pedro. In San Diego we had no service.
[In the Northwest] what we did was arrange with… a prepaid plan up in Seattle, Group Health Association [Cooperative] I think they call it, so we talked them into taking on Longshoremen up there and there was a prepaid plan down in San Diego, a small one, and we talked them into taking on the Longshoremen, and we tackled the Los Angeles, San Francisco, Bay Area and the San Pedro area…
The Pacific Maritime Association began making a 3 cents per man hour contribution to the Welfare Fund on December 26, 1949.
Hospital plans go into effect as of February 1, 1950. Permanente Foundation’s Health plan will cover the San Francisco, Los Angeles and Portland – Vancouver areas. There is already a setup in Portland similar to the one in the San Francisco Bay Area. Permanente will open a clinic in Wilmington, Calif., immediately upon the ratification of the Welfare Plan by all locals.
In Seattle, Wash., the Group Health Cooperative of Puget Sound made the offer of medical care on the same basis and at the same price as Permanente.
By year’s end, 90 percent of eligible ILWU member had signed up for the plan. It was voluntary; the Permanente Foundation Health Plan was committed to offering “dual choice” to groups, so that no member would feel resentful at having something forced on them.
Group Health Cooperative communicator Pat Bailey adds this point:
This contract for 2,200 ILWU enrollees for Group Health came at a time when the Cooperative was cash-starved. But as already noted, with the new enrollees came pent-up health needs. Before long, the waiting list for hernia operations numbered as many as 50.
It’s hard to overstate the deep impact that this contractually-negotiated benefit made in the lives of the ILWU members.
When the plan began, there was a big rush for treatment of such illnesses as hernias and hemorrhoids, conditions the men had suffered with and lived with for many years. They hadn’t been able to pay for medical care on their own. A 1951 brochure produced by the ILWU about the Multiphasic testing examination noted that “…many of our members have not been to the doctor until they practically collapsed on the job.”
A March 10, 1950, article in The Dispatcher put it this way:
“The Welfare Plan is the greatest thing since the hiring hall.” That’s the opinion of D.N. (Lefty) Vaughn, Local 13 longshoreman, hospitalized here under Permanente. Vaughn told Local 13 visitors last week that if it wasn’t for the Welfare Plan he would have had to sell his home in order to pay for the major operation he’s getting for nothing through the Plan.
An editorial three weeks later further explained:
Life can be beautiful if you’re healthy is the way the ad men put it. There’s no doubt they’ve got a point, though it’s oversimplified. Health is no fringe issue, not when you are required to make a choice between an operation which will allow you to go on working and living, and the home you must sell to pay for that operation. Longshoremen no longer have to make such choices. More than one home has been saved since the medical coverage section of the Welfare Plan became effective two months ago.
Kaiser Permanente and Group Health Cooperative– partnering to help working American families get good health care since 1950.
Short link to this article: http://k-p.li/2mUqseU
Thanks to Robin Walker, ILWU archivist, for help with this article.
The Automated Multiphasic Examination
Second part, follows “Screening for Better Health: Medical Care as a Right”
Last summer a major medical news story splashed across the world: “Historic Kaiser Permanente Data to Aid in Long-Term Study to Determine Extent of Ethnic Disparities in Brain Health and Dementia; new $13 million study funded by National Institute on Aging will revisit patients who were first screened as long as 50 years ago.”
Where did this remarkable trove of data come from?
In 1961 the U.S. Public Health Service awarded the Kaiser Foundation Research Institute a grant to study the automation of the multiphasic health testing it had been conducting manually for 10 years. Members would now go through the screening stations with computer cards that got marked along the way. At the end of the session, which took a couple of hours, there would now be a computerized medical record of their current health status. The Automated Multiphasic Health Test was born.
The first AMHT center was at a new building on the Oakland Hospital campus at 3779 Piedmont Ave. By the end of 1966, Kaiser Permanente had enlarged and updated its testing facility and laboratories nearby at a state-of-the-art center at 3772 Howe Street, and expanded the computer center and offices in the Piedmont building. A second center in San Francisco was linked to the mainframe computer in Oakland.
Dr. Collen, in the Journal of the American Medical Association (1966), accurately predicted that “The advent of automation and computers may introduce a new era of preventive medicine … [The computer] will probably have the greatest technological impact on medical science since the invention of the microscope.”
The AMHT continued to be seen as a vital tool in the diagnosis and treatment of occupational and industrial illnesses. A 1967 article in the Archives of Environmental Health discussed the employment data gathered, which included a list of 170 occupational titles and a battery of work-related health questions. “The computer storage of data on more than 40,000 adults annually permits extensive epidemiological research, especially directed toward the preventive aspects of chronic disease.”
It wasn’t just union members who benefitted. The Modern Hospital, May 1966 called the periodic health examinations to more than 4,000 patients monthly “… an impressive investment in the concept of ‘health medicine.’”
The test expanded to about 20 stations, measuring everything from hearing to heart function. It even went beyond mere testing – if recommended, a patient could get a tetanus booster via the new high-pressure injector system.
A 1970 article by Dr. Garfield in the prestigious New England Journal of Medicine with the provocative title “Multiphasic Health Testing and Medical Care as a Right” began with this abstract:
Although no long-term evidence exists that the course of disease is influenced by multiphasic health testing, this is largely irrelevant. Such programs are essential for other very important reasons. The existing and spreading concept of medical care as a right, with its elimination of personally paid fees, is creating a demand for periodic health checkups and health appraisals. This demand cannot be met by traditional methods totally involving the physician without great waste of doctor time.
Multiphasic health testing can help separate the entry mix of patients into the well, the asymptomatic sick and the sick. This separation makes possible optimum use of physicians’ services, which can be devoted to the area where they are most needed: the care of the sick.
The efficiencies of the AMHT were sufficient that these programs were sometimes adopted by private practice, large companies, and public health agencies. Dr. Collen remarked:
It is still of great interest to me and much personal satisfaction that the AMHT is still flourishing in Japan, Taiwan, and in China; and in the past when I visited them I found the AMHT centers in Japan to be primarily employer-sponsored for employees. I found the newest AMHT centers in Taiwan and China to be for-profit, marvels of efficiency and associated with health education centers open to the public, and with a high level of provider and patient satisfaction.
But despite the AMHT’s popularity, it was discontinued by Kaiser Permanente by the late 1970s when a federal grant supporting the work dried up and Kaiser Permanente declined to commit further resources.
Dr. Collen himself noted some of the challenges to quantifying the benefits of screening:
…Epidemiologists required us to report on gross mortality, and since the potentially postponable conditions comprised only about 15 percent of all the causes of death, most people died from other conditions … some of the criticism of urging checkups is based upon the fact that one does not decrease total gross mortality. That is, everyone eventually dies from something.
Gary Friedman, MD, former director of Kaiser Permanente’s Division of Research, recently explained additional medical limitations to the AMHT:
Initial enthusiasm for multiphasic health screening was tempered by experience in using it and by scientific studies that did not confirm benefits vs. costs of specific screening tests. For example, it was initially hoped that routine chest x-rays, included in AMHT, would lead to early detection and increased curability of lung cancer. Studies did not confirm this benefit. A yes/no question about chest pain provoked by exercise and relieved by rest was included in the AMHT symptom questionnaire. Although a yes answer seemed almost diagnostic of angina pectoris, this often did not prove to be the case in the follow-up examination by the physician, who could question the patient in greater detail, consuming valuable time.
Clearly however, the value of some screening tests has been amply confirmed. Finding and treating high blood pressure in asymptomatic individuals prevents strokes. And screening for colorectal cancer by the various tests available can lead to early detection and cure, or the removal of polyps that could later progress to cancer.
Despite these issues, Dr. Collen defended the value of the AMHT in a 1986 UC Berkeley oral history by Sally Smith Hughes:
…The study [on AMHT] did clearly demonstrate that for those conditions that are potentially postponable, there is a significant decrease in mortality.
He went on to note larger policy and commercial impediments to the AMHT:
Blue Cross/Blue Shield and other indemnity insurers to this day still do not pay for checkups. They take the position that periodic health checkups are schedulable and elective, so are not insurable events. Medicare to this day does not pay for checkups. The contrast, in other countries, like in Japan and in France, their social security and governmental supportive systems pay for periodic health checkups for well people, but do not pay for sick care. Just the opposite from the U.S. So if our Public Health Service is so interested in
preventive medicine, why do they fail to support the financing of checkups? A very key reason that multiphasic testing has not proliferated in the United States is because it is not reimbursed by any of the insuring agents. That has been reported by vendors who try to sell the systems.
I should point out that the Public Health Service had asked us to patent the system because it was an invention. Whether I was right or wrong, I refused to do so. I felt that it should be in the public domain, and it is. It’s never been patented.
Dr. Collen concluded with deep pride in the accomplishments:
We actually developed the most comprehensive inpatient and outpatient medical information system in the world. And this book, Hospital Computer Systems, describes that. There were only a half-a dozen others in the world that were doing that.
As the 2016 medical news story about the persistent value of the AMHT data shows, this was a significant accomplishment in medical practice. Thank you, Dr. Collen.
Short link to this article: http://k-p.li/2n00mcW
Alix Sabin, guest writer
“An inspiration to . . . women physicians.”
That was the shout-out to Beatrice Lei, MD, in 2002, as she was posthumously inducted into the Kaiser Permanente Diversity Hall of Fame.
“Through her quiet demeanor, excellence and dedication to quality care delivery and clear focus on what was required to be successful, she served as a role model and inspiration to the women physicians and Asian American physicians and employees who would follow.”
Dr. Lei arrived in San Francisco in the late 1930s from her native Shantou, China, determined to learn effective treatments for tuberculosis. She had intended to return to China, where the disease had become prevalent, but she was unable to go home after Japan seized Shantou during World War II.
Dr. Lei stayed in the United States, passed the California Medical Boards, and went on to work for Sidney Garfield, MD, at the Kaiser Richmond shipyards as one of 16 young physicians recruited in 1944 and 1945. She helped transition the health care program into the postwar era and became the first female and first Asian physician accepted as a partner in The Permanente Medical Group after it formed in 1948.
Early members of The Permanente Medical Group have been well chronicled over the years, including Dr. Garfield, who created Permanente medicine; Cecil Cutting, MD, TPMG’s first executive director; and Morris Collen, MD, known for his pioneering work in applying computer technology to modern medicine. Dr Lei’s story is lesser known.
Born in Shantou, China in 1910, Pooi Tuen (Beatrice) Lei was one of 11 children. While it was highly unusual at that time for girls to attend school, Lei’s father wanted all of his children to get an education.
In 1928 she entered the Hackett Medical College for Women — the first (and at the time, the only) medical school in China for women — determined to help her family and her community of Shantou, which had no physicians. She received her medical degree in 1932, completed her residency in Shanghai in 1935, and returned to Shantou to practice medicine.
Once in the United States, Dr. Lei was recruited in 1944 to work for Dr. Garfield who was caring for the employees at the Kaiser Richmond shipyards.
When World War II ended, the shipyard workforce diminished significantly and many doctors left. But a core set, committed to the concept of prepaid group practice, remained. One was Dr. Lei.
“When the shipyards closed after the war, so many people moved out of the area that we thought we might have to close the facility,” Dr. Lei recalled during an interview in 1974. “Many of our doctors left the program and started private practice. Some of them asked me to join them, but I refused. There was still a need here. Besides that, I wanted to continue practicing in Richmond. It has always been like home to me.”
In 1945, Henry J. Kaiser and Dr. Garfield made the Permanente Health Plan available to the general public.
Dr. Lei served as chief of Pediatrics at the Kaiser Permanente Richmond Field Hospital from 1946 to 1966, and continued practicing there until she retired in 1975. Frederic Geier, MD, who was physician-in-chief at Richmond Medical Center from 1955 to 1974, said, “Dr. Lei has always been one of the most popular pediatricians here. She has a wonderful rapport with children and their parents.”
During her tenure with TPMG, Dr. Lei also distinguished herself for her commitment to helping others. For instance, she hired and mentored many residents, provided free health care for people in need of assistance, and regularly helped and counseled Chinese students studying in the United States.
After Dr. Lei retired, she continued to dedicate herself to improving the health of her community by providing free medical treatment to family, friends and others who needed care but could not afford it. She died in 2002, at the age of 92.
At Dr. Lei’s induction into the Kaiser Permanente Hall of Fame, she was quoted as having offered this perspective on her immigrant story: “It is hard for Chinese to come to this country… nothing comes easy. We have to work very hard and appreciate what we have. It is critical that we study hard, work hard, contribute to the community, and make all Chinese people look good and feel proud.”
We honor Dr. Lei’s contributions on March 8, International Women’s Day.
Alix Sabin is a Senior Communications Consultant for TPMG – The Technology Group. A version of this article appeared in the Winter, 2017, issue of Permanente Excellence, a new quarterly magazine published by The Permanente Medical Group and distributed to TPMG Physicians. Research materials for this article were provided by Kaiser Permanente Heritage Resources.
Short link to this article: http://k-p.li/2lZhqN1
[Part one of two]
For many years a hallmark of Kaiser Permanente’s preventive health care program was a battery of tests, designed to alert doctors to trends and red flags in a patient’s health. And it started with service to industrial workers.
Lester Breslow, MD, published a seminal article in the March 1950 American Journal of Public Health titled “Multiphasic Screening Examinations: An Extension of the Mass Screening Technique.” Dr. Breslow, who worked for the California State Department of Public Health in Berkeley, challenged the limitations of periodic health examinations, and proposed the value of an integrated battery of preliminary examinations – a “multiphasic examination.” The advantages included a single combined medical record, cost savings, and improved diagnoses. One passage in Dr. Breslow’s article stood out:
“This survey can be conducted in a time not much greater than would be required for screening for a single disease. Where such screening procedures are carried out among industrial populations the time element is especially important.”
At that time, the Permanente Health Plan was expanding to the public after having only served Henry J. Kaiser’s World War II employees, and much of that growth was from unions. Dr. Breslow had been a college classmate of Kaiser Permanente’s Dr. Morris Collen, and the AJPH article offered a solution to the challenges of bringing in large numbers of industrial members with physically demanding jobs and poor health care.
Since the main medical competitors, Blue Cross/Blue Shield, did not provide health checkups unless one had a medical complaint, the Permanente facilities saw a surge in well-patient testing that began to drain the system. Searching for solutions, Dr. Collen spoke with Dr. Breslow, who suggested setting up a multiphasic screening for a large new member organization – the International Longshore and Warehouse Union. Although the screening was coordinated under Permanente’s leadership, it included the cooperation of the United States Public Health Service, the California State Department of Health, the San Francisco Public Health Department, the Bureau of Vocational Rehabilitation, and the San Francisco Tuberculosis Association.
The screening was seen as a groundbreaking step public health. The ILWU Dispatcher article May 11, 1951 proclaimed:
The longshoremen’s program represents pioneer work in preventive medicine—the science of keeping people healthy. Multiple health tests for such a large group are a new procedure, in use only since 1948 and scientifically proved to be effective in detecting disease while there is still time for treatment.
Dr. Collen proceeded try his first group test at the ILWU’s Local 10 hall at pier 18 in San Francisco, and screened several thousand longshoremen. An article in The Dispatcher from August 17, 1951, was titled “ILWU Waterfront Health Tests ‘Complete Success’; 4,002 Go Through” boasted:
Follow-up tests and treatment are now being given to members whose test results showed any signs of disease by a special team of Permanente doctors assigned to the ILWU under the ILWU·PMA [Pacific Maritime Association] Welfare Plan.
At a dinner for all the people who worked on the project, Permanente Health Plan, Director Dr. E. Richard Weinerman said the health test program was a “complete success . . . The fact that this program was the first to be organized by a union, the first to provide so comprehensive an array of tests and the first to assure complete medical follow-up through the health plan made it an outstanding contribution to the field of preventive medicine.”
Dr. Weinerman also noted the role of what we now call “culturally competent care.” In a Dispatcher article July 6, 1951, he said “In order to condition [our physicians] to do the best possible analysis, the union is taking them on a tour of the waterfront to observe working conditions. Then they will be able, to understand clearly how longshoremen work, and they can interpret symptoms more accurately.”
Dr. Collen later recalled the next steps of expanding the screening to all Permanente members in his oral history:
We started our multiphasic program in the Oakland clinic [on November 29, 1951]… After the clinics closed at five-thirty, we used the existing office space in the surgery clinic. We developed a whole series of arrows and put colored tapes on the floors so that patients would go in through the various rooms and have their height, weight, blood pressure, and other physiological measures taken, and then fill out a history form. Then they would be directed to the laboratory for blood and urine tests, to the x-ray department for a chest x-ray, and to the electrocardiography department for an electrocardiogram. In that way, we didn’t require any extra equipment or any extra facility space. We developed a team of personnel that would work in the evenings from about five-thirty to eight, and we examined some twenty-five to thirty patients every evening that way at a very low cost.
In 1952, the Kaiser Permanente clinic at 515 Market Street in San Francisco also opened a Multiphasic Health Test facility in a space that had formerly been used as an orthopedic clinic.
The process consisted of about 15 procedures and only required the presence of a single physician, assisted by paramedics. Dr. Collen went on to explain the beautiful medical logic of the testing:
. . . Health is the only condition in life when you find people are medically similar. That is, healthy people have a relatively normal distribution of their tests and measurements so that you can develop routine repetitive procedures to do these tests. The health checkup, the evaluation of a normal well person, is the most routine, repetitive procedure in medicine.
As soon as one has a variation from normal, which is the basic definition of being ill or sick, then one becomes unique. Every diabetic is different; every hypertensive is different, and a diabetic with hypertension is even more complicated. So it is difficult to develop routine rules for sick people. But for normal people, and by definition 95 percent of healthy people are within normal limits, you can develop routine repetitive procedures. And that is the secret of the efficiency and economy of a programmed, systematized, multiphasic checkup.
An article in the Permanente newsletter Planning for Health touted the Multiphasic:
A broad stride in the practice of Permanente’s fundamental principle of preventive medicine was accomplished with the recent inauguration of the Multiphasic Health Check-up program at the Oakland and San Francisco medical centers. A new type of general medical examination, Multiphasic Check-up, is based on the premise that early diagnosis and adequate treatment can materially reduce the ill effects from significant diseases.
By the mid-1950s, 30 to 40 percent of all new members were choosing the multiphasic on their first visit.
However, in the early 1960s changes in technology would transform the examination. And the future was . . . computers.
Short link to this article: http://k-p.li/2mtLDb6
Special thanks to ILWU archivist Robin Walker for her help with this article.