PermInNWCvrFinal.pdf 1 10/4/10 12:20 PM PERMANENTE IN THE NORTHWEST THE IN PERMANENTE “The history of this Northwest physician group parallels that of Garfield’s physicians in California; two groups with separate beginnings shared a template and later became affiliated as geographic Regions in a national Kaiser Permanente. The author of this account, Ian MacMillan, for many years confined his writing to notes in medical charts as an internist and rheumatologist with Kaiser Permanente. For 14 of those years he was the well-regarded Chief of the Department of Medicine at Kaiser Sunnyside Medical Center. … In his narrative covering six decades of Kaiser Permanente Northwest history, MacMillan exploits the opportunity to tell the stories of physicians and others in both major and minor roles. Testament to his broad curiosity, he enriches his archive with historical detail and context. Permanente in the Northwest relates through small stories how a change in financing medical care, implemented 60 years ago, created a rationale, and drove physicians to collaborate to deliver care to a population that included both the sick and the well. In telling this story, MacMillan has made the book relevant not only to past and present physicians who will find their names in the text, but also to the current national discussion of health care reform.” C — From the Foreword by Arthur D. Hayward, MD M Successor to Ian C. MacMillan, MD, as Y Northwest Permanente Chief of Medicine CM MY CY CMY K Dr. MacMillan chronicles the growth and development of Northwest Permanente from the birth of the idea of prepaid MD MacMillan, C. Ian medical care to the large multispecialty medical group of today. He provides a thoughtful, well-researched account of the clinicians, leaders, and innovators, along with the challenges, triumphs, and near disasters along the way. — H. Raymond Blair, MD, Northwest Permanente Pediatrician for 43 years A superbly chronicled account of the Northwest Permanente Medical Care Program from its humble beginnings to its evolution into a nationally recognized model. This book captures the true spirit of dedication and commitment by many talented individuals, professional and administrative, who contributed to the growth and advancement of the PERMANENTEPERMANENTE organization, while dealing with various challenges and conflicts. The text is easy reading, captivating, and fascinating. — Bhawar Singh, MD, Northwest Permanente Anesthesiologist for 42 years IN THE Permanente in the Northwest is an accounting of a rich legacy of physician leadership, clinical excellence, and medical politics that serves as the foundation of Northwest Permanente, P.C. The early years through the turn of the 21st century demonstrate how Northwest Permanente has become the leader in the deployment of an electronic medical record, the application of evidenced-based principles, and in the delivery of integrated care in the Northwest market. I have confidence that we are well equipped to lead our community in health care reform. — Sharon M. Higgins, MD, Northwest Permanente Executive Medical Director NORTHWESTNORTHWEST The Permanente Press Oakland, California • Portland, Oregon US $24.95 Ian C. MacMillan, MD Cover image © Sharon O’Keefe Cover tree image © TL Max McMillen Cover design by Lynette Leisure PERMANENTE IN THE NORTHWEST Ian C. MacMillan, MD with contributions from Kitty Evers, MD & Allan J. Weiland, MD Edited by Judy Hayward The Permanente Press Oakland, California • Portland, Oregon About the Author: Ian C. MacMillan, MD has never authored anything before. He was born and raised in Regina, Saskatchewan where he was influenced by his physician father to become a doctor. He received his MDCM from Queen’s University, Kingston, Ontario and interned at University of Alberta Hospital where he met his future wife Shirley on the pediatric ward. A Fellowship in Internal Medicine at the Mayo Clinic convinced him of the desirability of group practice and, after a pathology residency in Victoria B.C. where he was impressed with the beauty of the Pacific Northwest, he joined The Permanente Clinic in 1961. © 2010 by The Permanente Press Published 2010 by The Permanente Press Oakland, California • Portland, Oregon The Permanente Press is owned by The Permanente Federation, LLC Oakland, California PERMANENTE IN THE NORTHWEST 14 13 12 11 10 1 2 3 4 5 ISBN: 0-9770463-3-8 Library of Congress Control Number: 2009937531 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, without permission in writing from the publisher. Permissions may be sought directly from The Permanente Press Publishing Office, 500 NE Multnomah Street, Portland, Oregon, 97232 USA; phone 503-813-4387, fax 503-813-2348. Every effort has been made to trace the copyright holders of material reprinted in this book. The editors and publisher request that any copyright holder not listed here contact the publisher so that due acknowledgement may appear in subsequent editions. Book design by Lynette Leisure Printed in the United States of America k TO THE PHYSICIANS, NURSES, AND OTHER PERSONNEL WHO MET AND STILL MEET THE CHALLENGE OF PROVIDING HEALTH CARE CONSISTENT WITH THE CONCEPTS SET FORTH BY SIDNEY R. GARFIELD MANY YEARS AGO. k TABLE OF CONTENTS k FOREWORD. XIII PREFACE. .XV ACKNOWLEDGMENTS . .XVII INTRODUCTION . XIX NORTHWEST.PERMANENTE.CHRONOLOGY. XXI PART I: A LENGTHY PROLOGUE Chapter.1:.The.Roots. 2 • Early Prepaid Medicine in the Northwest • For-Profit Health Care Corporations • A Prepaid Medical Plan in Clackamas County • Group Health Cooperative of Puget Sound • The Clackamas Plan • Sidney Garfield and Desert Center 1933-1938 • Henry Kaiser and Sidney Garfield at Grand Coulee 1938-1941 • Prepaid Health Plans at Manhattan Project Sites • Ernest Saward at Hanford Engineering Works 1943-1945 PART II: THE EARLY DECADES Chapter.2:.Wartimes.1941-1945. 18 • Northwest Shipyards • Shipyard Workers • Shipyard Housing • Shipyard Life • Artists in the Shipyards • Day Care for Workers’ Children • Garfield’s Health Care Program for Shipyard Workers • Wartime Physician Recruitment • Medical Societies and Discrimination • Northern Permanente Foundation Hospital • The Physicians • Clinical Achievements • The Permanente Medical Journals .Chapter.3:.Hard.Times.1945-1950 .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. 32 • Assault by the Washington State Medical Association and the American Medical Association vii • Carrying On • Hanging On • Wrong Side of the River and Failure to Thrive • The Vanport Flood • First Partnership Chapter.4:.The.Fifties:.Firm.Foundation . 44 • Conflict, Crisis, Compromise: The Permanente Medical Group • What’s in a Name? Kaiser and Permanente • Internal Conflicts • Garfield’s Dilemma • Reforms • The Tahoe Agreement: Template for Permanente Medical Groups • External Pressures: Resolution 16 and the Larson Report • Public Image and Physician Recruitment • Bess Kaiser Hospital PART III: PEOPLE, POLITICS, AND PARADISE Chapter.5:.Vienna,.Vladivostok,.and.Vancouver:.. The.Norbert.Fell.Story. 56 Chapter.6:.Pariahs.and.Presidents. 60 • Opposition to Permanente • Origins of the American Medical Association • Growing American Medical Association power • The Committee on the Cost of Medical Care • American Medical Association Code of Ethics • The Cold Shoulder • Medicare Battles • From Rejection to Acceptance and Respect • Presidents Chapter.7:.Island.Paradise. 69 • Kaiser Honolulu Medical Center and Pacific Medical Associates • Problems • Saward to the Rescue • Hard Times and Good Times • Changing Needs PART IV: SPECIALTIES Chapter.8:.The.ER.and.the.OR. 78 • Emergencies at the Northern Permanente Foundation Hospital • Emergencies at Bess Kaiser and Kaiser Sunnyside Hospitals • Scalpels and Sutures, Hammers and Saws • Orthopedics viii • Neurosurgery • “TURPs” and Stones • History of Anesthesia in Oregon • Anesthesia at Northwest Permanente Chapter.9:.Pediatricians,.Obstetricians.and.Quints . 92 • Pioneering Pediatricians • The New Pediatricians • Innovations • Early Obstetricians • And Then There Were Five: The Quints Chapter.10:.Ophthalmotorhinolaryngology. 102 • Ullman, Mossman, and Hilbourne • Ophthalmologists • The Early Otolaryngologists • The Optometrists Chapter.11:.Pathological.Needs. 108 • The Early Pathologists • The New Cadre • Turf Battles: Jones vs. Greenlick • Automation Chapter.12:.Radiology. 113 Chapter.13:.Internists.and.the.Early.. Medical.Subspecialists . 115 • History of Internal Medicine in the U.S. • Evolution of Medical Subspecialists at Northwest Permanente • Department of Medicine at Northwest Permanente • Cardiology • Hematology • Endocrinology • Rheumatology • Gastroenterology • Neurology • Infectious Disease • Nephrology • Intensivists • Pulmonology • Hospitalists • Geriatrics and Long-Term Care Chapter.14:.Specialties.Old.and.New. 130 • Syphilis, Skin and Surgery • Industrial Medicine ix • Oncology • Cancer Counseling and Education Chapter.15:.Psychiatry.and.Physiatry:.. Healing.the.Mind.and.Body. 139 • Post-War Psychiatry • Permanente Psychiatry and the First Therapists • Growing Pains: Conflict, New Leadership, Innovation • ATP, ADRS, KPRR, and ACHP • Early Physical Therapy • Physiatry PART V: ADDITIONAL PERMANENTE PERSUASIONS Chapter.16:.Social.Conscience.of.Permanente.. Health.Care . 154 by.Kitty.Evers,.MD • Physician Advocacy and Support • Healing Arts in the Workplace • Permanente Women • The Center for Health Research • Volunteering in the Community and in the World PART VI: THE RECENT DECADES Chapter.17:.The.Seventies.