, Heritage writer
In honor of National Physicians Week we are sharing profiles of 5 outstanding doctors who advanced the practice of medical care with their service at Kaiser Permanente.
Sidney R. Garfield, MD (1906–1984)
Dr. Garfield is Kaiser Permanente’s founding physician. As a surgeon, he first applied the principles of prepaid group medical practice while providing health care for construction workers on the Colorado River Aqueduct in California’s Mojave Desert in 1933. In 1938, Henry J. Kaiser and his son Edgar invited him to organize a similar program for construction workers and their families at Grand Coulee Dam in Washington. During World War II, Dr. Garfield developed a medical care program for hundreds of thousands of workers and family members at Kaiser shipyards in the San Francisco Bay Area and the Portland/Vancouver area, as well as at the Kaiser Steel Mill in Fontana, California. Historians have noted that one of the century’s major social contributions was the role of Dr. Garfield and Henry Kaiser in co-founding Kaiser Permanente and launching employer-sponsored health care in the United States.
Eugene Hickman, MD (1921–2013)
Dr. Hickman was the first African-American physician to join The Permanente Medical Group in Northern California. Dr. Hickman graduated from Nashville’s Meharry Medical School (the second-oldest medical school for African-Americans in the nation) in 1949, then practiced as a radiologist at several Los Angeles facilities — the City Health Department, Cedars-Sinai Medical Center, and the Veterans Administration hospital — before coming to Kaiser Permanente. He had a long career at the Oakland Kaiser Permanente Hospital, becoming president of the hospital staff and later chief of the department of radiology. He ended his 30-year tenure in 1989.
Beatrice Lei, MD (1910–2002)
Dr. Lei, a Chinese immigrant, was one of the 16 physicians recruited by Dr. Garfield in 1944–45 to serve the health care needs of the World War II Kaiser Richmond shipyard workers. 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 in 1948. 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 during her tenure, said, “Dr. Lei has always been one of the most popular pediatricians here. She has a wonderful rapport with children and their parents.”
Morris Collen, MD (1913–2014)
Dr. Garfield recruited Dr. Collen to be chief of medicine for the industrial health care program for workers in the Kaiser Richmond shipyards in July 1942. Over the course of his career at Kaiser Permanente, Dr. Collen saved lives by pioneering the treatment of pneumonia with penicillin, by applying efficient medical diagnostic processes to hard-working longshoremen, and by using then-new mainframe computers to automate the analysis of the “multiphasic examinations” he’d helped develop for incoming health plan members. He is considered one of the founders of the field of medical informatics.
Philip Tong Chu, MD (1918–1970)
Hawaii-born Dr. Chu was the first Hawaii Permanente Medical Group director from 1960 to 1970. He was a respected surgeon and visionary leader who was praised for his abiding respect for Hawaii’s cultural diversity. He earned his medical degree from Pennsylvania Medical School of St. John’s University in Shanghai, China, in 1944. As part of the World War II reconstruction, Dr. Chu was regional medical officer for the United Nations Relief and Rehabilitation Administration, China Division. After surgical residency at several U.S. hospitals, he served at the U.S. Public Health Service Indian Hospital at Sacaton, Arizona, and later served in Detroit. He spent the remainder of his life in Hawaii, working as a doctor and administrator.
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, Heritage writer
The clinking of glasses and din of conversation halted when the white-gloved archivists entered the room at the Smithsonian’s National Museum of American History.
Securely bedded on their cart was that evening’s crown jewel, a small, open-faced wooden box. Stuffed with the distinctive punch cards used in mainframe computers, this artifact represented the essence of Permanente Medicine – the sweat of laborers getting their first health examination, the fusion of physician practices with modern electronic systems, and the efficiencies of a medical plan that proudly served a nation in crisis during World War II.
This box and questionnaire cards were key elements of the Kaiser Permanente Automated Multiphasic Examinations.
Diane Wendt, Deputy Chair and Associate Curator of the Division of Medicine and Science, described the donation as “A humble but important object” in the history of American medicine when it was officially turned over at a Permanente Executive Leadership Summit event on Oct. 9, 2017.
The questionnaire cards represented an evolution of a battery of tests originally developed to handle the large influx of longshore workers that came into the health plan in the 1950s. 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 already 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.
Those records helped create fundamental medical information. A major medical news story splashed across the world in 2016: “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.” Yes, that deep data was compiled as part of the Automated Multiphasic examinations, showing the persistent value of that program.
Representing The Permanente Federation at the formal signing of the deed of gift were Geoffrey S. Sewell, MD, FACP (President and Executive Medical Director, Hawaii Permanente Medical Group, Inc.; Chairman, National Permanente Executive Committee, The Permanente Federation, LLC), Richard S. Isaacs, MD (Executive Director and CEO, The Permanente Medical Group; President and CEO, Mid-Atlantic Permanente Medical Group; Co-CEO, The Permanente Federation, LLC), and Edward M. Ellison, MD (Executive Medical Director/Chairman of the Board, Southern California Permanente Medical Group; Chairman of the Board and CEO, The Southeast Permanente Medical Group; Co-CEO, The Permanente Federation, LLC).
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By Steve Gilford
Senior consulting historian
As an independent historian with a long-standing interest in Kaiser Permanente, I was fortunate to be invited to the daylong 60th anniversary celebration of the Southern California Permanente Medical Group, held recently in Anaheim, Calif.
The event was to mark the medical group’s formal start in 1953 when 13 Permanente physicians, including Ray Kay, the first medical director, signed a partnership agreement that officially formed SCPMG.
The group’s origin actually goes back to 1943 when Henry J. Kaiser asked Permanente co-founder Sidney Garfield, MD, to establish a health care plan for workers of the Kaiser Steel mill in Fontana.
Today, SCPMG has more than 6,000 physicians practicing in 14 accredited Kaiser Foundation Hospitals and more than 190 medical office buildings.
Pride a theme of celebration
As I observed the events of the day (Sept. 28, 2013), I heard Permanente physicians express pride in the organization and its legacy. But at first I wasn’t entirely sure the expressions were genuine, or if it was similar to the type of pride shown for a football team or one’s alma mater.
As the day unfolded, it became increasingly clear that this was an authentic professional pride rooted in SCPMG’s 60-year history of trials and triumphs.
Pride in the organization can be traced back even further, to the tiny 12-bed hospital Sidney Garfield built in 1933 on a parched and lonely piece of desert land in one of the most physically inhospitable places in the United States.
The organization that sprang from that little frame building in the Mojave Desert, with its one doctor and one nurse, was being celebrated by thousands gathered together in one of the most populous and powerful metropolises of the nation.
Roll call gets vociferous response
Edward Ellison, MD, the SCPMG executive medical director, began the day by calling the roll of Southern California’s medical centers represented at the gathering. Each medical center team responded to the call with a spontaneous cheer that resonated across the large hall.
There was no question that these physicians were enthusiastic, but it was not yet clear to me just why they were responding with such vigor. Was it like the way people in a talk-show studio audience react when someone mentions their hometown?
Was it just because they had found a comfortable place to practice medicine outside the increasingly stormy arena of fee-for-service medicine, relieved to be insulated from some of the stresses their professional colleagues were facing?
Or was it truly because they were recognizing that they were a part of an organization that was truly special, with a leadership that encouraged them to practice preventive care and to take great care of their healthy members, as well as their sick patients?
Celebrities tout Permanente’s national role
As a part of the proceedings, there were dramatizations featuring Henry Kaiser, Sidney Garfield and even Rosie the Riveter – all well done and entertaining. They set the stage for Kevin Starr, noted California historian and author, and Nancy Snyderman, MD, chief medical editor, NBC News, and award-winning journalist.
The celebrities’ presentations put the achievements of Kaiser Permanente into perspective, each emphasizing the contribution of the organization to the nation’s health care.
Starr and Snyderman were the stars of the day, but for me the day’s high point was an onstage discussion by the four surviving SCPMG executive medical directors – Frank Murray, MD, 1982-1993, Oliver Goldsmith, MD, 1994- 2004, Jeffrey Weisz, MD, 2004-2011, and Edward Ellison, MD, current executive director.
They presented the organizational challenges that they had faced in their time and told how they had overcome them.
Through all their recollections flowed a strong streak of natural idealism that had helped them shape their responses to the challenges of their time at the helm. Their remarks – more than any other presentation – made it clear that SCPMG leaders created and passed on a strong legacy that was to be treasured, defended and enhanced.
As the day drew to a close, Dr. Ellison summed up what he felt was special about Permanente Medicine and SCPMG. “We are building infrastructure for the future . . . I am confident that our approach to achieving the total health of our patients in mind, body and spirit is the successful path to that future.
“Our conquering, enduring spirit, combined with our passion for medicine and our caring from the heart, will sustain us for the next 60 years,” he told the group.
Often, when you hear such presentations made by leaders in front of their staffs, if you listen carefully you can hear quiet undertones of mildly cynical scoffing or snickering from the rank and file who may have a quite different perspective on the relation between idealism and reality.
That afternoon I was listening closely for that tell-tale buzz from among the 3,000 people in the hall. I didn’t hear it.
What I did hear was enthusiastic agreement with what Dr. Ellison was saying. I understood then that the pride I had sensed in the responses to his morning roll call of the medical centers had been genuine and had only been enhanced by the day’s focus on the achievements and potential of Permanente Medicine.
I left Anaheim with a renewed sense of pride in my association with Kaiser Permanente, for my modest part in searching out, saving and communicating its history to new generations of physicians who will preserve and expand the legacy begun by its founders.
By Ginny McPartland
Affordable health care was an elusive commodity in 1930s America. Medical practice was becoming more sophisticated, and qualified doctors were in great demand. Consequently, private professional care was out of reach for many Americans. Employer-sponsored health plans started to spring up in the late 1930s and early 1940s, but even those progressive prepaid plans were slow to add workers’ families to the coverage.
Permanente medicine, developed by industrialist Henry J. Kaiser and enterprising physician Sidney Garfield, was launched to take care of workers in Kaiser’s West Coast shipyards. The two had done this before: Garfield had set up a prepaid plan for workers on the Los Angeles Aqueduct project in 1933, and he and Kaiser had teamed up to care for workers at the Grand Coulee Dam in Washington state in the late 1930s.
The Kaiser-Garfield prepaid, group practice plan for shipard workers was progressive and exemplary by all accounts. Unlimited medical care for the individual workers was provided for 50 cents per week. But Garfield and his doctors had their hands full, so initially only the worker – not the family members – was covered by the health plan.
Stuart Lester of “Medical Economics,” writes in the February 1944 issue: “The principal threat to the permanence of the Permanente Foundation – which provides virtually unlimited medical care for 130,000 Kaiser shipyard workers in two states* is the workers’ complaint that it makes no provision for their families.”
The article continues: “The family problem is especially acute in the shipyard town of Richmond, Calif., where the ratio of physicians to population is something like 1 to 4,000 and where the only hospital facilities of any consequence are those provided by Kaiser’s Richmond Field Hospital.”
In Richmond, Portland (Oregon) and Vancouver (Wash.), nonsubscriber family members were treated for a fee. Office visits were $2.25. For maternity, $200 covered prenatal care, delivery, hospitalization, C-section if required, postnatal care, and care for the newborn. Employees at the Kaiser Fontana steel plant in Southern California were the exception. In 1944, Fontana workers could purchase complete coverage for a family of four for $1.80 a week.
Physicians debate how to cover families
“Medical Economics” writer Lester refers to three possible solutions proposed at the time: an expansion of the Permanente plan to include family members; an expansion into the Richmond area by the California Physicians’ Services (CPS) prepaid plan as operating in other war industry communities; or the development of a prepaid arrangement for families through a private physician network.
The California Medical Association (CMA) launched the CPS in 1939 to offer prepaid care to low-income families in California. Initially, the physicians association’s plan offered a “full coverage contract” that included all outpatient physician services. In 1942, CPS excluded the first two doctor visits from coverage to make the plan financially viable, according to the April 1943 issue of the CMA’s “California and Western Medicine.” In 1943, CPS, the precursor to Blue Shield, had 39,000 commercial members, 5,100 government rural health program subscribers and a total of 32,000 war housing resident members in Vallejo, Marin, Los Angeles and San Diego.
“Dr. Sidney R. Garfield, Kaiser’s medical director, sees two obstacles to an extension of his program to include families: One is opposition by the local medical societies. The other is lack of facilities – particularly in the hospital at Richmond,” Lester wrote in “Medical Economics.” The article noted that expansions of the Richmond Field Hospital and the Permanente Foundation Hospital in Oakland were under way.
The second proposal – having CPS provide family coverage for Richmond area workers – had been tried previously and failed. In 1942, CPS had offered a family plan in nearby El Cerrito and was not able to attract enough members. The coverage for non-Kaiser workers was enticing: a $5 flat fee no matter how many family members. It wasn’t practical for Kaiser employees, however. To take advantage of the CPS plan, a worker would have to buy his or her own coverage for $2.16 a month and then pay $5 for the rest of the family.
According to the “Medical Economics” article, solving of the family care issue by fee-for-service doctors was doomed from the beginning. A shortage of private doctors and inadequacy of medical facilities made any such plan unfeasible. Also, California private practice physicians were admittedly just tolerating the Permanente model of prepaid, group practice with salaried physicians. One private doctor told the magazine: “The Kaiser-Garfield groups are doing a job right now that is aiding the war effort, and are doing it well. But we don’t like their system.”
Kaiser extends coverage to shipyard families
In the spring of 1945, the Permanente medical plan, now with expanded facilities to accommodate more members, was extended to the families of all Kaiser shipyard workers. “Medical Economics” reported the details of the Permanente family care plan: for $117 a year ($2.25 per week) for a family of four, coverage was extensive. It included 111 days of hospitalization, complete diagnostic services, necessary drugs, physician services at home or medical office, major and minor surgery, and ambulance service within a 30-mile radius. Members paid an extra charge of $60 for comprehensive maternity care, $15 for a tonsillectomy and $2 for a house call.
“Medical Economics” concluded the article with this statement: “Insurance men pointed out that the total annual cost for a family of four, $117 a year, is an amount which has generally proved to be too high for any wide participation on a voluntary basis.”
Workers who left the shipyards could maintain coverage for a “slightly higher” premium as long as they continued to live in the service area. This retention provision foreshadowed Kaiser and Garfield’s plans to keep the Permanente medical care plan alive after the war industries shut down.
*Kaiser shipyards health plan actually took care of workers in three states, California, Washington and Oregon, and enrolled up to 190,000 members at the peak of the war.
The following vignette comes from the desk of Samuel Sapin, MD, who writes on physician freedom and the bonds of mutual trust and affection that he found in nearly a half-century of practice in Permanente medicine.
Recent reports indicate that doctors are retiring early. Having wearied of administrative burdens and insurance company requirements, they are not experiencing the professional satisfaction they had hoped for when they chose to practice medicine.
On August 1, 1955, 54 years ago, I joined the Southern California Permanente Medical Group, leaving a potentially lucrative pediatric practice on Park Avenue in Manhattan mainly because I disliked the business aspect of practice and the inability of my uninsured patients to receive necessary care. With Permanente, I first practiced general pediatrics in Los Angeles for four years, and then pediatric cardiology from 1959 until I retired in 2000.
Becoming a Permanente physician was one of the most important decisions of my life. It gave me the opportunity to treat my patients in a manner consistent with my professional knowledge and training regardless of medical care costs, and the opportunity to build warm and trusting relationships that have endured these many years. This was brought home to me this summer after I received phone calls from three former patients.
The first call was from an 18-year-old girl who had been my patient from birth and found to have a severe cardiac abnormality, a single ventricle. With love from her devoted parents and family, and after early surgery and implantation of a pacemaker subsequently, she has been living the life of a healthy teenager. She called this summer to tell me, proudly, that she had just been accepted into the freshman class at UCLA. I felt honored that she wanted to share her good news with me.
The second call was from a 45-year-old woman, also my patient from birth. In her teens, although asymptomatic, my physical examination revealed evidence of an abnormal, prolapsed mitral valve. She then left Los Angeles to attend college and changed her health insurance plan. She subsequently had a career and a child of her own, and would occasionally call me as she got older to update me on her condition. On this latest call, she was now becoming fatigued and her cardiologist advised surgical correction of her valve, now leaking. I supported his decision. The valve was then repaired surgically and did not have to be to be replaced. Her husband and family helped care for her child, and I was kept informed about her progress during and after surgery. All went well.
The third call was also from a former patient, Denise Dalto, now 57 years old. She is a remarkable woman with a devoted husband, Bob Dalto, two loving elder parents, two children, and two grandchildren. I first saw her when she was five years old (52 years ago) and made a diagnosis, confirmed by cardiac catheterizations, of coarctation (narrowing) of her aorta with associated abnormalities of her aortic valve and blood vessels going to her head and arms. Surgery to correct the coarctation was performed at age 14, but repair of the blood vessels was deemed too difficult to repair safely in those years. Since then she has led a very active life, including hiking, traveling and teaching. For 34 years, she successfully taught school children in public schools from diverse racial and ethnic backgrounds, who had been unable to reach their academic potential and required teachers with special abilities.
Denise informed me on this call that recent imaging studies showed that one of the abnormal blood vessels in her neck was enlarging and in danger of rupture. After much deliberation by surgeons at the Kaiser Foundation Hospital in Los Angeles, surgery though somewhat risky, was advised. It would involve four different surgical and radiological specialties, and three operations within one month, a daunting prospect for even a brave patient. She phoned to ask my opinion about the proposed surgery. After investigation, I reassured her about the skills of the physicians involved, and she underwent the three procedures. All were carefully planned and all went well. A remarkable recovery followed, with a return to her normal, very active lifestyle. Before her surgery, she retired from her teaching position. One of her colleagues took the photo here of Denise, her pupils gathered around her to say good-bye and wish her well.
These phone calls within a space of weeks, from three former patients, made me realize more than ever, how fortunate I was to have joined the Permanente medical group. The Kaiser Permanente physician, over a lifetime of practice, has a wonderful opportunity to develop these personal bonds, which in retirement, gives one a great sense of professional fulfillment and the feeling of a life well spent.
– Sam Sapin, MD, SCPMG pediatric cardiologist (retired) and Clinical Professor of Pediatrics, Division of Cardiology, David Geffen School of Medicine, UCLA
Ms. Dalto gave her consent for the release of her story.