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In Memoriam John Graham Smillie, MD April 17, 1917-September 6, 2000

Kaiser Permanente Milestone:
John Graham Smillie, MD
By Steve Gilford

On September 6, 2000, John Smillie, TPMG pioneer, pediatrician, and author of "Can Physicians Manage the Quality and Costs of Health Care? The Story of The Permanente Medical Group" passed away. Born in 1917, in Eaton, Colorado, Jack couldn't remember a time when he didn't want to be a doctor. After earning a Bachelor of Science degree at UCLA, he entered the University of Southern California (USC) medical school in 1938. His choice of medical schools affected his entire career, because this was a time when many of the future leaders of the Permanente Medical Groups were in training or on the hospital staff. These included Ray Kay, who would lead the Southern Permanente Medical Group for several decades, and Morrie Collen, a founder and long-time leader of The Permanente Medical Group. At that time, Dr Kay was in private practice, but the young doctor noticed that he seemed to get much more professional satisfaction from his practice at USC/LA County in what amounted to a non-fee-based group practice. Instead of focusing on building up his practice, he saw that Dr Kay was spending more than half of his time at the USC Hospital.

In 1943, Jack Smillie had been married to Ruth Bliss Smillie for three years when his internship was cut short by World War II and he was inducted into the US Army Medical Corps. Dr Smillie enjoyed telling how years later, after his retirement while going through his personal papers, he had come across his old Army physical examination. When he looked at the signature of the examining medical officer, he discovered that it had been Lt Sidney R Garfield. Jack would joke that he was probably the only TPMG doctor who had met the Permanente founding physician while in his underwear.

At this time, the military was still segregated, and the medical units were no exception. African-American physicians and corpsmen treated African-American servicemen, and the white servicemen were treated by an all-white medical staff. Dr Smillie, now stationed in the Philippines, convinced his commanding officer to let him integrate their medical unit. To the surprise of many, the change went smoothly. His group became one of the first integrated medical units in the US Armed Forces.

After spending nearly two years in the Pacific, Dr Smillie returned home to his wife and to an extended residency in Pediatrics at USC/LA County Hospital. Soon, his interest in solving administrative problems was getting him noticed. According to hospital policy, any child with a temperature of over 103 degrees was automatically admitted to the Pediatrics Ward. This policy had been in effect since before the war, and Dr Smillie remembered how, by the next morning, the children's temperatures would most often have returned to normal. They could be released without any treatment. Several years later, that same policy was still in effect, but now interns and residents were routinely prescribing penicillin for these children on admission. Not surprisingly, these children were well the next day and could be released. To the new crop of physicians, it seemed as though this was yet another example of the power of the new "miracle drug," but Dr Smillie, remembering the prewar experience, was sure that the policy of admitting these young patients, taking them away from their homes and families, and treating them with penicillin, was purposeless. At his urging, the hospital administration set up a small examination room on the Pedi Ward, where a pediatrician saw every child the Emergency Room physician thought might need admission. Most could be sent home immediately, thus avoiding needless hospitalization and treatment. Admissions fell off and the hospital was able to close down a 35-bed ward. He said later, "This was an eye-opener to me--that I could save money in the cost of care and improve the quality of care at the same time."

Toward the end of his residency at USC/LA County, Dr Smillie began working part-time for two pediatricians in Hollywood, whose offices were on the corner of Hollywood and Vine. They had a very successful practice and took care of some of the movies' most famous families, including the children of Bing Crosby and Frank Sinatra. When the partners invited him to join this very successful and lucrative practice, Dr Smillie was tempted. Before accepting, though, he decided to discuss the offer with his friend and mentor, Ray Kay, who was now the Director of Postgraduate Education for USC at LA County. Dr Kay suggested that before he made up his mind, he should go up to the Bay Area and talk to the people at Permanente. They were looking for physicians. The physician doing the recruiting was Paul Fitzgibbon, one of the founders of TPMG and a physician from USC. Dr Fitzgibbon offered him a job, $700/month, with one half-day off for education out of eleven half-days a week, but it was for San Francisco, not Oakland. Dr Smillie became the first, and until Irving Klitsner's arrival from USC/LA County, the only San Francisco pediatrician serving both the 515 Market Street clinic and the 35-bed Permanente Harbor Hospital across town on Potrero Hill.

The physician in charge of the clinic and the hospital was Wallace Neighbor. Dr Neighbor had been involved with the Medical Group since the earliest days. He had run the hospital at Grand Coulee Dam and had later been selected by Sidney Garfield to run the Medical Program for the shipyard workers on the Columbia River. During their trips between Market Street and Potrero Hill, Wally Neighbor would tell the new Permanente physician about the history of the Medical Group, its ideals, values, and goals. Dr Smillie became sure that he had made the right decision in coming to Permanente.

In 1952, Dr Garfield asked Dr Smillie to run a new hospital which he was opening in Dragerton, a remote town in Northeastern Utah's Carbon County. Utah Permanente was to serve coal miners in that area, some of whom worked for Kaiser. It was important to open the hospital as soon as possible, because the miners were at that time without medical care and there was an epidemic of measles and of streptococcal tonsillopharyngitis underway. Dr Smillie and his staff must have set a record getting the local hospital back into operation.

Although Utah Permanente later closed, a victim of a downturn in the coal market, Dr Smillie took pride in the work done there and pointed out that the relationship of respect and trust established with the United Mine Workers of America that developed there, helped to make possible the later development of the Colorado Region. Over the past 15 years, I have made three trips to Dragerton, and it is clear that the miners and their families remember Utah Permanente with much affection.

While at Dragerton, Dr Smillie began recording the history of the Medical Group. His movies of Dragerton are the only ones of which I am aware. When the Medical Care Program began building the Geary Street Hospital in San Francisco, Dr Smillie was there, too, with his movie camera. He edited his footage of the construction of the hospital and medical office building into a short documentary he called, "The Building of a Medical Center."

One of the innovations that set Kaiser Hospitals apart from others was their early introduction of the rooming-in concept. During the time that Dr Garfield was designing the hospitals in Walnut Creek and in San Francisco, Dr Smillie had read about a rooming-in concept introduced at Yale University's hospital. When the topic of a nursery design for the new hospital came up in conversation, Dr Smillie told Dr Garfield about the Yale idea. As a result, Dr Garfield designed the baby-in-a-drawer concept, a system that allowed the newborn to be moved between a small hospital nursery and the mother, at the mother's convenience, by using a drawer that slid back and forth through the wall near the mother's bed. The baby-in-a-drawer caught the public imagination for patient-based innovation, and for a while, it was a kind of trademark of the Kaiser Hospitals.

When Dr Smillie came to San Francisco and the Permanente Harbor Hospital, he'd set as lifetime goals building up a pediatrics staff to about ten physicians and starting a residency program in his specialty. By 1960, he had accomplished both. His administrative abilities and his gentle but effective form of leadership were soon recognized, and he was selected as Assistant Physician-in-Chief in San Francisco under Dr Collen.

Then, from 1961 to 1971, Dr Smillie was PIC in San Francisco, one of the longest terms in the history of the Medical Groups. Today, Dr Collen recalled that "[Dr Smillie] was fond of saying that his greatest reward from his many years as a practicing pediatrician was seeing the children he had taken care of later bringing their children to him for care. John Smillie was a great physician who always practiced good quality and compassionate medicine; and he was an excellent medical executive who was admired and respected by all of his associates for his dedication and commitment to providing good quality medical care to Kaiser Foundation Health Plan members."

In 1971, Dr Smillie retired from medical practice to become assistant to TPMG Executive Director, Cecil Cutting. One of Dr Smillie's major responsibilities was to coordinate a physician-recruiting service for the entire KP Northern California Region. During this period, with Dr Cutting, he also helped develop a system to monitor accessibility and worked on plans to comply with equal employment opportunity requirements as well as an affirmative action program for physicians. In 1977, the six Regional Medical Directors decided that although the Health Plan had government relations people in Washington, DC, the physicians did not have effective access to that office. As a result, they were being saddled with legislative ideas that did not encompass their points of view. They wanted their own person in Washington. Dr Smillie who had already served as Chairman of the Board of the Group Health Association of America, who had testified before Congressional committees, and whose standards for GHAA membership had been incorporated into the HMO Act, seemed to be a natural for the position. He proved to have been an excellent choice and served as a representative of the Permanente Medical Groups in Washington until 1980--in effect as the first interregional Permanente physician. In 1980, until his retirement in 1981, he represented the Medical Directors in what was then called the Central Office, today's Program Office.

Remembering the effect that learning about the history had on him when he joined the KP Medical Care Program, Dr Smillie had decided to write a history of The Permanente Medical Group and to grapple with the central problem raised by the KP Program: Can physicians manage the quality and costs of health care? Drawing on not only his considerable firsthand experience, Dr Smillie also went through decades of minutes of the TPMG Executive Committee, interviewed all of the surviving "Old Guard," and dedicated himself to preserving as much of the history of the Program as he could. In 1991, with the support of TPMG, the book was published by McGraw Hill. Dr Smillie lived to hear that nearly a decade later, his book is still so appreciated that it is going to be republished by The Permanente Federation and will soon be available to a new generation of physicians, probably before the first of the year. Eagerly awaited by many, Can Physicians Manage the Quality and Costs of Health Care? The Story of The Permanente Medical Group may well be Dr Smillie's most lasting contribution, among many, to the Kaiser Permanente Medical Care Program.

In an interview conducted by the Regional Oral History Office of the University of California's Bancroft Library, Dr Smillie looked back on his career: "I had an enormous satisfaction in dealing with the patients because I could do anything I wanted without worrying about how much it cost them, because it didn't cost them anything. They had already paid me and our group for their care, and for their hospitalization. And I was free to practice the kind of medicine I had learned to practice as a resident at Los Angeles County Hospital. It was a source of enormous satisfaction."