One of my favorite courses in college was “The American Historical Novel” and I have been hooked on the genre ever since. Paul Bernstein, MD, of the Head and Neck Surgery Department at the San Diego Medical Center has taken a stab at historical fiction with a subject near and dear to the heart of every Permanente physician: the life of Sidney Garfield, MD, and the founding of the Kaiser Permanente (KP) Medical Care Program. Written in the first person from Dr Garfield’s point of view, The Courage to Heal takes us from his days as a surgery resident through the signing of the Medical Service Agreement between the Kaiser Foundation Health Plan and Hospitals and the Permanente Medical Groups, which gives KP its current structure.

Dr Garfield is portrayed as an idealistic hero who toils selflessly in the interests of his patients and of his vision of affordable medical care. Henry Kaiser is painted as a visionary industrialist and as a controlling, top-down manager. The love interest is a beautiful, dedicated nurse with a secret. Dr Bernstein casts the medical establishment as compassionless adherents to the fee-for-service model. It is classic good versus evil: the KP physicians save lives; the fee-for-service physicians smoke and drink.

The interactions of the characters make for some juicy reading. The first-person voice is a little off-putting at first but it lends an interesting immediacy to the story. We get Dr Garfield’s thoughts and motivations, but none of those from the other characters, thus maintaining a sense of mystery.

There are a few rough spots. For example, from time to time, Dr Bernstein parenthetically cites actual historical sources for quotes. Whereas in a journal article or scholarly historical piece accurate citation is a must, in a novel, I found it distracting. I overlooked this because reading historical fiction is less about the facts than about the themes. The themes Dr Bernstein tackles here work just as well in 2007 as they did in 1937. Too many people still do not have access to good health care. Those who do have access pay too much for it. Quality is often suboptimal. The fee-for-service system puts perverse incentives in front of physicians to do more than is necessary. These challenges were true for Dr Garfield and they are true for us.

To be sure, Dr Bernstein leaves unexplored some important issues surrounding the founding of KP. For instance, whereas fee-for-service may give physicians an incentive to do too much, some argue that prepaid health care might give physicians an incentive to do too little. However, because the book comes from Dr Garfield’s first-person perspective, we can forgive that. Dr Garfield was a man of integrity, and the thought of scrimping on services never entered his mind.

In the end, I think I like historical fiction most because I find it poignant. It is not the characters or the narrator who are omniscient, but we the readers. We not only already know the end, but we also know what happened between the end and the present. In college, a classmate told me not to bother reading Thucydides’ History of the Peloponnesian War because Sparta wins. But knowing that makes all of the debate and missteps by the Athenian assembly that much more tragic. The tragedy is compounded by the fact that we, unlike Thucydides, also know that the loss of the Peloponnesian War meant the end of the golden age of Athens, and that it would be many centuries before there was another such center of democracy and learning.

While reading Dr Bernstein’s book, I was struck by that same poignancy. Courage to Heal ends on a note of triumph. Dr Garfield started with a small desert hospital, and, despite adversity, managed to cofound a thriving medical enterprise, yet, he would have a hard time recognizing the KP of today. We have HealthConnect, ICD-9 coding, Medicare at risk, E&M coding, and DHMO products; self-insurance products are just around the corner. We have come a long way from our roots as a prepaid health plan with an emphasis on preventive care. Maybe in the end, fee for service does win.

Overall, I found this to be an engaging read and I would recommend it to everyone in our Program. Perhaps if we have an understanding of our roots, our future path will be a little clearer.