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Dear
Sirs,
I
don't usually enjoy going to the Emergency Room to get stitches
for my son, but my recent trip to the San Rafael, CA KP ER turned
out to be a most rewarding experience.
Lying
on the table in the waiting room was the Summer
2006 issue of The Permanente Journal featuring the
articles commemorating the Garfield Centennial. I worked for Sidney
Garfield, MD, as Mental Health Coordinator of the Total Health
Care Program after I graduated from the Doctor of Mental Health
Program at UCSF in 1980. I always felt that I was privileged to
work with one of the true giants of American health care. I, too,
believe that Dr Garfield has never received his due recognition
in the field, so many thanks for highlighting his groundbreaking
contributions.
Dr
Garfield was truly prescient. Over three decades ago, he anticipated,
wrote about, and implemented all of today's buzzwords, such as
disease management and demand management and primary
care reengineering. He also pioneered population management
(the authors of "Total Panel Ownership..." in the same
issue would be behooved to read about his design of Total Health
Care and acknowledge that Dr Garfield thought of it all the way
back in the 70s), automated medical records, consumer empowerment,
integrating health education and behavioral health care into the
primary care setting to meet the needs of the "well"
and the "worried well," and approaching the primary
care delivery system with the productions, operations, and management
vision atypical to medical settings. Robert Feldman, MD's comments
about Dr Garfield's gracious, generous, and unassuming demeanor
definitely rang true, too. Working with Dr Garfield as a 28-year-old
definitely gave me the feeling that I was developing in the shadow
of greatness.
My
career has taken me on a meandering path since the Total Health
Care Program. After a decade working at for-profit managed care
organizations--I left my clinical role at Total Health Care in
1984 to attend Harvard Business School--I ended up with the conviction
that something was seriously amiss in our health care delivery
system, as it focused primarily on cost control, rather than enhancing
the experience of health care consumers. So, in 1997, I founded
a company called CareCounsel that contracts with employers to
act as advocates for their employees and retirees as they navigate
the complex health care landscape. I want your readers to know
that our firm would be out of business if everyone was a KP member.
But, alas, that is not the case, so CareCounsel has thrived.
In
closing, Dr Garfield was a true innovator and a real inspiration
in my professional life. Thank you, thank you and thank you for
honoring him so well.
Lawrence
N Gelb, MBA, PhD
President and CEO, CareCounsel
San Rafael, CA
Editor,
As
a physician retired from SCPMG, I receive The Permanente Journal
regularly and wished to share my own personal memory of Sidney
R Garfield, MD.
When
I was in residency in New York City, in 1970 or 1971, I had the
privilege of helping to provide care to Mrs Garfield who came
to be treated by the Chairman of our department at the hospital
where I trained. It was an honor for us to realize that persons
came to our medical center for care from far and wide.
Sylvain
Fribourg, MD
Retired--Panorama City Medical Center
Editor,
The
Summer 2006 edition of The
Permanente Journal is outstanding! I am reading the articles
by and about Dr Garfield which is of such interest to me that
I am reading it between seeing patients. Dr
Garfield's Scientific American address could have been
written today--sort of a sad commentary.
Michael
S Alberts, MD, General Surgeon
Mill Plain Medical Offices
Vancouver,
WA
Editor,
The
Summer 2006 issue blew me
away. Ignition came from the article "Otto
Loewi's Great Dream." I was rocketed back to NYU Medical
School, 1944, when, as a second-year medical student, Dr Otto
Loewi was our professor of pharmacology. He shared with the whole
class his dream experience that won him a Nobel Prize. Seeing
it "up in lights" in the journal "set me afire."
Perhaps
you are acquainted with Charles Grossman, MD, a ninety-year-old
practitioner in Portland, OR. He is a friend who went to NYU a
few years before I did and came to Oregon to work in the original
Portland Permanente group. He eventually left for solo practice
but I suggest that he would be a good subject for a journal article.
He was the first clinician to treat a patient with penicillin
and, in 1977, he led the first party of US doctors to visit the
People's Republic of China. I was one of that group along with
Vera Katz, former mayor of Portland. Dr Grossman's story is unusual
and interesting.
Thank
you for sending me the journal.
Ralph
Crawshaw, MD
Chair of Collegium for the Study of the Spirit of Medicine,
The Foundation for Medical Excellence, Portland, OR
To the Editor,
I
was very pleased to read about the advances in genetic services
in the KP Southern California Region.1 The diagnosis
and possible treatment of rare genetic disorders such as Fabry's
disease is laudatory. However, I must sadly note the absence of
a much more common and treatable genetic disorder affecting mainly
our adult patients, ie hemochromatosis. There must be a large
group of undiagnosed but treatable patients with this disorder
within our general patient population.
Hemochromatosis
was the subject of a review article in your Journal a number
of years ago (Winter 1999; Update: Winter 2004). The author of
that article was able to establish (about 35 years ago), a screening
program for the disorder in the general KP population in the San
Diego Region. Screening required only one or two relatively inexpensive
blood tests for most cases. These tests may be ordered with the
first routine labs in newly enrolled patients. Unfortunately,
the state of California doesn't yet require the testing of patients
for hemochromatosis.
Hemochromatosis
was also a topic at one of our annual Southern California Pediatric
Symposia in the 1990s. A case report of one affected patient was
included in the lecture syllabus. The report was of a KP physician
who served in the Southern California Region for more than 25
years. He is also one of my closest friends. His disease went
undiagnosed while he was under the care of 14 KP physicians. He
estimates that, in the 15 years since retirement, his medical
care has cost KP and government systems about two million dollars.
It can be argued that most, if not all, of his medical problems
can be traced back to his hemochromatosis. I include in that statement
the very real threat of suicide.
Since
we do care for the aging population, more and more of our patients
may live to become symptomatic from their diseases. Can we afford
to wait until they do? Would any of the authors care to discuss
the factors within our organization that have acted to restrict
the spread of screening programs for hemochromatosis to all the
regions of the KP patient care organizations?
Glenn
C Szalay, MD (Retired)
Formerly, Harbor City Service Region
Southern
California Permanente Medical Group
Reference
-
Alvarado M, Shinno N, Monroe CD, et al. Genetic services in
the Southern California Region: Delivering the promises of tomorrow
today. Perm J 2006 Spr;10(1):29-37.
--Reply
In
response to Dr Szalay's letter, we would like to address the impact
of population screening for hemochromatosis. Although we agree
with Dr Szalay that we all need to support the development of
sound genetic screening programs within KP, the main purpose of
our article was to illustrate the history of genetic services
at SCPMG. We are sorry if our article gave Dr Szalay the impression
that Regional Genetics at SCPMG are not advocates for genetic
screening programs. Our department has been involved in the coordination
and implementation of a number of screening programs in Southern
California, including the California Expanded AFP program for
fetal anomalies, the California Newborn Screening program, and
our own internal prenatal program for cystic fibrosis carrier
testing.
Although
a number of experts support the idea of a population screening
program for hemochromatosis, there are many issues to evaluate
and resolve before any such program can be adopted. An assessment
might include the following: disease incidence/prevalence; the
nature and implications of the screening test options; genotype/phenotype
correlation; treatment options; and other factors. The CDC1
does not recommend population screening for hemochromatosis.
Genetic evaluation and testing is appropriate for those with a
family history and for patients who are symptomatic.
As
resolutions evolve for the issues surrounding population screening
for hemochromatosis, our organization should continuously re-evaluate
such screening. The topic was recently referred to our technology
assessment group for an evaluation of evidence and assessment
of the current expert consensus. Thank you for raising an important
question.
Mònica
Alvarado, MS
Regional Genetics, SCPMG
Reference
-
1. Centers for Disease Control and Prevention. Hemochromatosis
for health care professionals [monograph on the Internet]. Atlanta
(GA): Centers for Disease Control and Prevention; 2005 Jul 25
[cited 2006 May 22]. Available from: www.cdc.gov/search.do?action=search&queryText=hemochromatosis.
Click on: "Hemochromatosis for Health Care Professionals."
Editor,
I
read the article on stereotactic
radiosurgery with great interest (Spring 2006, p 9-15). To
be honest it is the first article that has interest for me since
I started receiving the Journal a few years ago.
Please
note a typographical error on page 12, figure 4: the correct wording
is "automated perimetry." I looked up periphimetry in
Taber's and could not find, nor do we use that term in eye care.
Again,
thanks for the excellent article and art work.
Daniel
C Weber, OD
Rock Creek Medical Offices
Lafayette,
CO
--Reply
We
thank Dr Weber and others for his interest in our article. We
also thank him for correction on the term "perimetry."
Joseph
C T Chen, MD, PhD
RadiosurgeryNeurological
Surgery
KP
Los Angeles Medical Center
Editor,
For
years before I joined Permanente, I've used The Permanente
Journal as an example of how KP and Permanente practice provide
unique clinical leadership and value to a variety of audiences.
The clinical innovations and practical application of evidence-based
principles present in each issue serve us and our patients well.
Congratulations
and thanks for the work you do.
Stan
Kramer, MD
Area Medical Director
Washington,
DC, and suburban Maryland
Dear Sirs,
Your
article entitled "Total
Panel Ownership and the Panel Support Tool--Its All About the
Relationship" (Summer 2006) provides us with some very
much-needed encouragement.
Many
of us have lost touch with our professional roots and are having
difficulty remembering why we became doctors in the first place.
It is invigorating to see the vision at KP unfolding.
This
latest initiative demonstrates that your organization is serious
about supporting the doctor-patient relationship; something that
many health care leaders have told us is no longer sustainable
and will soon be "lost forever."
The
article also points to two other essential requirements for transforming
health care: First, we can no longer afford to allow "value"
to be defined for us by agencies that are external to our organizations.
The
evidence on which outside agencies have based the value of and
reimbursement for health care has been meager at best, and is
becoming increasingly irrelevant as we move towards more collaborative
models of health care delivery.
As
we come to know our patients more intimately, no one else is in
a better position to define what their needs are, and no one else
is better qualified to determine the value of the health care
that we bring to them.
The
other essential requirement for transforming health care is something
that leaders in other industries have known for well over a decade,
but only a handful of leaders in health care have been able to
recognize or incorporate into their organization's daily operations.
We
are now in a "knowledge economy" and the key to any
organization's success will be the implementation of an overarching
strategy for "knowledge management." Indeed, such strategies
may very well prove to be the basis for the integrated delivery
system's competitive advantage in the health care marketplace.
Organizations
that view their employees as "knowledge workers," treat
them with respect, and provide the environment for them to continuously
innovate and improve what they produce have nothing to fear from
those that continue to treat them like commodities.
It's
all about the relationship.
Leon
F Baltrucki, MD
Staff Pathologist
Department of Pathology & Laboratory Medicine
Veterans' Affairs Medical Center
West Palm Beach, Florida
Editor,
Will
you please explain to me what a private health insurance policy
commonly includes?
There
are a lot of discussions about this in Romania now, and I would
like to know the American model. During the awful communist years,
everybody had taken about 6% of his wages for the health system.
Then, when he felt ill, he went to the dispensary or to the hospital
and had blood tests and operations performed for free. If he wanted
to be operated on by a famous professor, then he had to pay a
big tip, directly in the pocket of the professor, but the hospital
or the health system got nothing out of this tip. This system
is still working now, but there is less and less money coming
into the health system, and the medicines, water, and electricity
are more and more expensive. That is why our health minister tries
to make a reform, and include only certain basic blood tests and
some basic medical interventions (we do not yet know exactly which
ones), while other tests or, for example, esthetic operations
must be paid to the hospital in cash by the patient who asks for
them, or by private health insurance. I find this quite fair.
I
read an article about these private health insurance policies
that have had no success with us so far, because everybody prefers
the cheaper way. If the health system reform will be started,
then the private insurance policies may be successful, and I would
like to know how they are in USA. Are there cheaper ones and more
expensive ones? What do some less expensive ones include? What
would the expensive ones include? This is a new field for me,
and I am very curious about it.
Roxana
Covali, MD, PhD
Radiologist
Iasi, Romania
E-mail:
rcovali@yahoo.com
--Reply
Readers,
I
have passed this request to sources in Kaiser Foundation Health
Plan but hope that individual physicians may wish to respond to
Dr Covali's question about what health insurance is like in America.
Her e-mail address is rcovali@yahoo.com
Vincent
J Felitti, MD
Book Review Editor
San
Diego Medical Center
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