Editors' Comments

To Reach a High Level | to pdf >>
Tom Janisse, MD, Editor-in-Chief
In September, at The Permanente Journal (TPJ) editorial team's second strategic retreat, our invited guest was Dr. Morris Collen, a retired Permanente physician, in his mid-80's, who worked with Dr. Sydney Garfield. Still very active, he is a member of a National Library of Medicine committee that approves new journals for inclusion in the library and MEDLINE.

In the early 1940's, Dr. Garfield approached Dr. Collen and said, "Morrie, I want you to create a bulletin so that the physicians outside Permanente know what we do." Dr. Collen became the first Editor-in-Chief of The Permanente Bulletin and authored a number of clinical articles. After several issues, an influential medical school dean said to Dr. Collen, "I used to think you Permanente physicians were a bunch of Communists, but since I have read about the work you are doing in The Permanente Bulletin, I am very impressed with the quality of medicine that you practice in Kaiser Permanente."

As Dr. Collen addressed our editorial team, he expressed the same sentiment as had Sydney Garfield. "You need to publish The Permanente Journal so that physicians outside of Kaiser Permanente know what you do and how good you are. The Permanente Journal is a great vehicle for you to achieve that."

Physicians outside Kaiser Permanente (KP) now read TPJ and are equally impressed. However, to achieve full national and international recognition, and for our articles to be cited in MEDLINE, TPJ needs approval by the National Library of Medicine. The primary criterion is the publication of scientific articles. Although we do that now, we must increase the number of articles in each issue that are clinical studies using research methodology to develop statistically significant data resulting in original findings.

The "Catch 22" for any new journal is that physician-researchers and authors routinely select a journal listed in MEDLINE--which defines the national medical literature. However, to gain approval for MEDLINE, a journal must attract those same authors. When MEDLINE approval is granted, articles published in that journal for the previous year are retrospectively listed, which means that Permanente physician authors who publish in TPJ in 1999 would be cited in MEDLINE upon approval in 2000, which is our goal.

Permanente has no shortage of highly productive publishing physicians, who place hundreds of clinical and research articles in major national journals each year. Several of those article abstracts are reprinted in each issue of TPJ. Other important Permanente sources for scientific articles include our Regions' quality assurance and improvement studies, as well as Innovation Fund studies, and the Garfield Fund.

Although achieving MEDLINE status is certainly a worthy goal, TPJ publishes many important articles of high value for Permanente physicians, many of which define Permanente Medicine, such as: successful or best practices and health systems process innovations; crucial information on the external environment impacting Permanente; and articles demonstrating our social and humanitarian work.

TPJ already exhibits a unique format; raising this to the next level to achieve the stature of a major scientific journal aids the aspiration of Permanente to be the world leader in improving health.

Clinical Contributions and Original Research
Arthur L. Klatsky, MD, Associate Editor

The Clinical Contributions and Original Research sections are combined in this issue in order to feature a special research symposium. "The Gary Friedman Symposium" is devoted to papers derived from talks presented on May 11, 1998 at a celebration of a transition in the career of one of Kaiser Permanente's most distinguished physicians. Gary Friedman has been with KP since 1968 and is an internationally known, outstanding physician-epidemiologist who is substantially responsible for developing one of the first and largest epidemiologic research programs in an HMO. More details about his impressive career are to be found in the biographical sketch in the Symposium. The program included six scientific presentations, each of which emphasized Gary's role as an initiator of scientific research and as a mentor of developing researchers. Five of the presenters have written articles for the Journal. In their totality, they present a varied, but only partial picture of the accomplishments of the KP Northern California Division of Research (DOR). These articles should not be considered comprehensive reviews of the topics since they are based upon relatively brief talks. Relevant anecdotal material was left in the manuscripts by several of the presenters. Dr. Stephen Sidney's article, "The CARDIA study and the Development of Clinical Research at the Division of Research," provides an account of some of the results of a major multicenter study of cardiovascular risk factors in young persons. KP was one of four field centers for this longitudinal clinical study. Already very productive, the CARDIA study promises to become a key effort in this area of research. The scholarly paper by Dr. Noel Weiss, "'Sensitive' and 'specific' epidemiologic studies: The Division of Research of the KP Medical Care Program," provides information of considerable scientific interest to all physicians. Dr. Weiss, another distinguished and productive physician-epidemiologist, is not a KP physician and thus provides an outside perspective of the value and quality of DOR research and of Dr. Friedman's contribution. Dr. Joe Selby, who has succeeded Gary Friedman as Director of the DOR, has written "Screening for Colorectal Cancer: Research Contributions of The Permanente Medical Group." This is an excellent summary of one of KP's most shining series of research contributions, concerning the very practical and obviously important subject of how best to screen for colorectal cancer. Many persons have contributed to this effort, including Drs. Friedman and Selby. My contribution, "Illegal, Immoral, or Bad for the Heart?" is a personal account of development, under Gary Friedman's mentorship, of a second career as a physician-epidemiologist, and the article presents some of the findings of this work. Dr. Friedman's "Reflections" is also, in part, appropriately personal. The article includes some valuable reminders of the importance of preserving our records"a national treasure." Dr. Friedman also discusses some pitfalls of interpreting data, problems in accepting abstracted information, and the importance of investigator-initiated research in our type of medical system.

Another major portion of this issue's Clinical Contributions, "Operating Room Benchmarking: The Kaiser Permanente Experience," reports the experience of a National KP group of experts who comprehensively examined operating room practices, culture, and problems. Not surprisingly, the results have been controversial, and for this reason, several commentaries representing diverse views have been included. As there is also an editorial comment about this article, it is not necessary to say more here, except that the article, which was evaluated by the Juran Institute as an "exemplary" benchmarking project in scope and depth, should be of interest to physicians in all specialties since we are all caught up in examination of our methods. Change--or the prospect of change--is always initially difficult and painful.

Finally, we include in this issue a brief report by Drs. Jeffrey Pollen and Daniel Smiley entitled, "Antibiotic Prophylaxis and Needle Biopsy." It is a nice example of the type of clinical study which Permanente physicians could and, I think, should do in substantial numbers. There must be many such data bases in the records of hundreds of physicians in all specialties. We would be more than happy to receive some of these as brief articles for consideration of publication.

Please write with comments, additions, corrections, disagreements, or personal observations about any Clinical Contributions article.

Health Systems Management
Lee Jacobs, MD, Associate Editor

Performance! New Standards for the Permanente Medical Groups
As Kaiser Permanente has transitioned from a community service organization of the 60s and 70s to a business operating in competitive marketplaces in the 90s, instilling new performance expectations has been the focus for all the Permanente Medical Groups. Standards for a Permanente physician now go far beyond simply showing up with a stethoscope; most groups are establishing expectations around minimum patient care hours, contributions to population-based quality initiatives, and the provision of highly satisfying care as basic requirements.

To successfully compete, there is no doubt that the Permanente Medical Groups need the discipline of establishing clear performance expectations, providing frequent and clear feedback to clinicians, and holding every person accountable for accomplishing these standards if they are to remain with Permanente. Specifically, to compete successfully now means that, no matter how unpopular, each medical group must maximize the number of hours spent providing direct patient care, set clear performance expectations around HEDIS and other quality measures, and require a high level of patient satisfaction. Clinicians unable to attain the high level of performance that defines the Permanente physician of the 90s would have to improve or would have to leave the medical group regardless of tenure. Along with this advent of such rigorous performance-based determinations comes an accountability of Permanente leaders to support clinicians in their quest to improve performance, especially individuals with long-standing deficiencies.

In this edition, I co-author a paper with Drs. Terry Stein and Vivian Nagy on the importance of the work of the Interregional Clinician-Patient Communication Leadership Group. The article is an overview on the subject of patient communication interventions for clinicians, which is especially important as we seek new educational opportunities to support individual performance in patient satisfaction. Why such an emphasis on patient service? If, over the years, the premium costs and the level of demonstrable quality are at parity across all competitors in our markets, it will be how far Permanente outdistances our competitors in service that will best determine the extent of our competitive advantage in each market. I believe that you will find this article to be informative as we all deal with this very important area of patient communication.

Do you have any thoughts on Permanente performance expectations in the 90s? Let us hear from you!

External Affairs
Scott Rasgon, MD, Associate Editor

The External Affairs section has a variety of articles with different perspectives on the state of affairs inside and outside our health care organization. Susan Ayres' article, "The New, 1998 Brand Advertising Campaign," speaks about us as a health care organization "in the hands of doctors." This is an advertising campaign to differentiate us from our competition. The message is that we are not a medical business with medical decisions made by business personnel. In "Coming Clean," Cynthia Lopez and Nancy Buell highlight the community service project in California to help people remove tattoos. Dr. Joel Hyatt writes in "Purchasers' Demands for Care (Disease) Management" about our work on care management and how purchasers are looking for this type of care. Dr. Don Parsons comments on what might be happening on medical care legislation after the President's troubles are resolved. I hope you find this selection of articles to be enjoyable and informative reading.