About the Journal

Journal Overview

The Permanente Journal (ISSN 1552-5767) is a peer-reviewed journal of medical science, social science in medicine, and medical humanities published quarterly by The Permanente Press. Journal subscriptions are entered for the calendar year. Advance payment in US dollars is required. The Permanente Journal welcomes requests for reprints and reproduction.


Use of any and all material published in The Permanente Journal is copyrighted and protected. The Permanente Journal offers free full-text access for all online content. The Permanente Journal is available online (ISSN 1552-5775) at www.thepermanentejournal.org.


Instructions for Authors and Manuscript Submssion Instructions are available along with a link to our manuscript submission center at www.thepermanentejournal.org/authors.html. Instructions for Artists and Artwork Submission Instructions are available along with a link to our submission center at www.thepermanentejournal.org/authors/artwork.html.


Physicians may earn up to 1 AMA PRA Category 1 Credit per article for reading and analyzing the designated CME articles published in each edition of TPJ. Each edition has four articles available for review. The Permanente Journal is happy to offer Continuing Medical Education credits for completing manuscript reviews for The Permanente Journal. Physicians are eligible to receive up to 15 AMA PRA Category 1 Credits per year (3 AMA PRA Category 1 Credits per manuscript).

Editorial Board

Tom Janisse, MD, MBA

Lee Jacobs, MD


Vincent Felitti, MD

Arthur Klatsky, MD

Scott Rasgon, MD

Gus M Garmel, MD,


Eric Macy, MD



James J Annesi, PhD,


Lisa Herrinton, PhD

John Stull, MD, MPH

Ricky Chen, MD

Robert Hogan, MD
Gretchen Summer, PhD, RN

Gary W Chien, MD

Tom Judd, MS

KM Tan, MD

Carrie Davino-Ramaya, MD

Ashok Krishnaswami, MD, MAS

Calvin Weisberger, MD

Charles Elder, MD

David Riley, MD

Winston F Wong, MD, MS

Philip I Haigh, MD,


Ruth Shaber, MD

Scott S Young, MD


Maher A Abbas, MD, FACS, FASCRS
Chief, Digestive Disease Institute, Cleveland Clinic, Abu Dhabi, UAE; Professor of Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio



Richard Abrohams, MD
Internal Medicine and Geriatrics, The Southeast Permanente Medical Group, Atlanta, Georgia



Fábio Ferreira Amorim, MD, PhD
Professor of Medicine, Escola Superior de Ciências da Saúde in the Department of Postgraduate and Extension Activities, Brasilia, Brazil



Stanley W Ashley, MD
Chief Medical Officer, Brigham and Women’s Hospital; Frank Sawyer Professor of Surgery, Harvard Medical School; Attending Surgeon, Gastrointestinal Cancer Center, Dana Farber Cancer Institute, Boston, Massachusetts



Thomas Bodenheimer, MD
Professor, Dept of Family and
Community Medicine, University
of California, San Francisco



Brian Budenholzer, MD
Associate Clinical Professor in the Department of Family Medicine at the Brody School of Medicine at East Carolina University, Greenville, North Carolina



Irene Carvalho, PhD
Clinical Neurosciences and Mental Health Department, School of Medicine, Oporto University, Porto-Portugal, Oporto, Portugal



Shamir O Cawich, MBBS, DM
Department of Surgery, St Augustine Campus, University of the West Indies, Trinidad and Tobago



Rita Charon, MD, PhD
Professor of Medicine, Founder and Executive Director of the Program in Narrative Medicine at the College of Physicians and Surgeons of Columbia University Medical Center, New York, New York



Pranab Chatterjee, MBBS, MD
Scientist, Indian Council of MedicalResearch, National Institute of Choleraand Enteric Diseases, Infectious DiseasesHospital, Beliaghata, Kolkata, India



Dan Cherkin, PhD
Senior Scientific Investigator, Group Health Cooperative, and Affiliate Professor, Dept of Family Medicine and School of Public Health—Health Services, University of Washington, Seattle



Mitsuro Chiba, MD, PhD
Department of Gastroenterology, Akita City Hospital, Kawamoto, Akita, Japan



Robert R Cima, MD, FACS, FASCRS
Associate Professor of Surgery, Division of Colon and Rectal Surgery; Vice Chairman, Department of Surgery, Mayo Clinic, Rochester, Minnesota

Ellen Cosgrove, MD
Vice Dean, Academic Affairs and Education, University of Nevada, Las Vegas School of Medicine, Las Vegas, Nevada



Quentin Eichbaum, MD, PhD, MPH, MFA, MMCH, FCAP
Associate Director of Transfusion Medicine; Associate Professor of Pathology; Associate Professor of Medical Education and Administration; Director, Fellowship Program in Transfusion Medicine; Member, Vanderbilt Institute for Global Health; Vanderbilt University School of Medicine, Nashville, Tennessee



Richard Frankel, PhD
Professor of Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis



James T Hardee, MD
Internal Medicine, Colorado Permanente Medical Group; Associate Clinical Professor of Medicine, University of Colorado School of Medicine, Westminster



Carol Havens, MD
Family Practice and Addiction Medicine, Director of Clinical Education, The Permanente Medical Group, Oakland, California



Arthur Hayward, MD
Assistant Clinical Professor, Division of General Medicine, Dept of Internal Medicine, Oregon Health Sciences University, Portland



Catherine Hickie, MBBS
Director of Clinical Training, Bloomfield Hospital, Greater Western Area Health Service; Conjoint Senior Lecturer in Psychiatry, University of New
South Wales, Australia



Gunver Sophia Kienle, Dr Med
Senior Researcher, University of Witten/Herdecke, Institute for Applied Epistemology and Medical Methodology, Freiburg im Breisgau, Germany



Anna Luise Kirkengen, MD, PhD
Department of General Practice Research, Institute of Community Medicine, Norwegian University of Science and Technology, Trondheim, Norway



Thomas E Kottke, MD
Medical Director for Well-Being, HealthPartners; Consulting Cardiologist, HealthPartners Medical Group; Senior Clinical Investigator, HealthPartners Institute for Education and Research; Professor of Medicine, University of Minnesota, Minneapolis



Tieraona Low Dog, MD
Fellowship Director, Academy of Integrative Health and Medicine, LaJolla, California; Director, Integrative Medicine Concepts, Pecos, New Mexico; President, My Own Health; Director, Scientific and Regulatory Affairs, Healthy Lifestyle Brands; Tempe, Arizona

Lewis Mehl-Madrona, MD, PhD, MPhil
Director of Geriatric Education, Maine Dartmouth Family Medicine Residency; Director of Education and Training, Coyote Institute, Augusta, Maine



Colin G Murphy, MCh, FRCSI
Department of Trauma and Orthopaedics, Galway University Hospitals, Newcastle, Galway, Ireland



Michel M Murr, MD, FACS
Director of Bariatric Surgery, Chief of Surgery, Tampa General Hospital, Florida



Sylvestre Quevedo, MD
Department of Medicine and Global Health Sciences, University of California, San Francisco



Ilan Rubinfeld, MD, MBA, FACS, FCCP
Director, Surgical Intensive Care; Associate Program Director, General Surgery Residency; Henry Ford Hospital, Detroit, Michigan; Assistant Professor of Surgery, Wayne State University School of Medicine, Detroit, Michigan



Marilyn Schlitz, PhD
Chief Executive Officer of Worldview Enterprises, LLC, and Senior Fellow and President Emeritus at the Institute of Noetic Sciences in Petaluma, CA; Professor in and the Chair of the Doctor of Philosophy in Transpersonal Psychology program at Sofia University in Palo Alto, CA



Tido von Schoen-Angerer, MD, MPH
Researcher, ARCIM Institute, Filderstadt, Germany, Attending Physician, Department of Pediatrics, Fribourg Hospital, Switzerland



Audrey Shafer, MD
Associate Professor, Dept of Anesthesia, Co-Director, Biomedical Ethics & Medical Humanities Scholarly Concentration, Stanford University School of Medicine, Palo Alto, California



Mark Snyder, MD
Specialist Leader, Electronic Medical Record Implementation and Physician Adoption; Deloitte Consulting, LLP, McLean, Virginia



Swee Yaw Tan, MBchB (Edin), MRCP (UK), ACSM, FAMS
Senior Consultant Cardiologist, National Heart Centre, Adjunct Assistant Professor Duke National University of Singapore Graduate Medical School, Singapore



William L Toffler, MD
Professor Emeritas of Family Medicine, Oregon Health and Sciences University, Portland


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By Barry Abrams, MD


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2016 TPJ Reviewers

Thank you to our 2016 reviewers: Authors, editors, and readers all benefit from your thoughtful and experienced comments.

Antoine Abcar, MD; Akin Abisogun, MD; Armen Aboulian, MD; Richard Abrohams, MD; Chalapathi Rao Achanta, MD; Jay Agarwal, MD; Sourabh Aggarwal, MD; Vanita Ahuja, MD; Mikel Aickin, PhD; Michael Alberts, MD; Fabio Amorim, MD, PhD; James Annesi, PhD; Diana Antoniskis, MD; Christopher Aquino, MD; Sharisse Arnold Rehring, MD; Stanley Ashley, MD; Andrew Avins, MD; Marthie Baker, MS, MA, RN; Nandini Bakshi, MD; Dustin Ballard, MD; Rowena Bartolome, RN, BSN, PHN, MHA; Joshua Barzilay, MD; Arne Beck, PhD; Kathy Benjamin, RN; John Benson, MD; Jane Benton, MD; Paul Bernstein, MD; Ruth Bertsch, MD, PhD; Balkys Bivins, ARNP; Joyce Black, PhD, RN, FAAN; Shelley Bobb, MDiv, MDR; John Boltri, MD; Kimon Bonadie, DM; Gabriel Bosslet, MD, MA; Robert Bota, MD, MSG; Nathan Boucher, DrPH, PA-C, MS, MPA; Erin Bowles, MPH; Brent Bowman, MBA; Derick Brinkerhoff, EdD; Yuri Bronstein, MD; Sherry-Ann Brown, MD, PhD; Susan Brown, MSW; Diane Brown, PhD, RN; Delilah Bruskas, PhD, RN; Kenneth Burns, MD; Heather Burton, MD; Nathan Carlson, MD; Tony Carnevale, MD; Kiersten Carter, MD; Maurice Cates, MD; David Cawthorpe, PhD; David Chadwick, MD; Joseph Chan, MD; Pranab Chatterjee, MBBS; Faisal Cheema, MD; Ricky Chen, MD; Puneet Chhabra, MD, MBBS, DM; Deborah Chiarucci, MD; Gary Chien, MD; Reema Chugh, MD; Colleen Chun, MD; David D Clarke, MD; David E Clarke, MD, FCCP; Charles Clemons, MD; Felicia Cohn, PhD; Douglas Corley, MD; Alan Cortez, MD; David Corwin, MD; Ellen Cosgrove, MD; Cecelia Crawford, DNP, RN; Barbara Crawford, RN; Thomas Cunningham, MD; Peter Cvietusa, MD; John Damrose, MD, FACS; Bich Dang, MD; John Davenport, MD; Carrie Davino-Ramaya, MD; Nancy Davis, PhD; Richard Dell, MD; Richard Della Penna, MD; Jonathan Doris, MD; R James Dudl, MD; Ashley Duggan, PhD; Alex Dummett, MD; John Dunn, MD; Andrew Dutka, MD; Quentin Eichbaum, MD, PhD, MPH, MFA; Charles Elder, MD; Roland Estrella; Donna Ettel, PhD; Ted Eytan, MD; Adriano Facioli, PhD; Abimbola Farinde, PharmD; Shireen Fatemi, MD; Vincent Felitti, MD; Carol Forgash, LCSW; Carol Forster, MD; Carlos Franco-Paredes, MD; Richard Frankel, PhD; Sandra Freiwald, MD; Pascal Fuchshuber, MD; Geoff Galbraith, MD; Sherwin Gallardo, MD; Gus Garmel, MD; Lynn Garofalo-Wright, DPPDc, MHA; Hernando Garzon, MD; Kamal Gera, MD; Nancy Gibbs, MD; Lana Gimber, MD, MPH; Louise Glaser, MD; Harry Glauber, MD; Paul Glen, MD; Ronald Glick, MD; Richard Godfrey, MD; Shel Gottlieb, MD; Adam Graycar, PhD; Sarah Greene, MPH; Jeffrey Grice, MD; Holly Groom, MPH; Casey Grover, MD; Kern Guppy, MD, PhD; Neeru Gupta, MD; Philip Haigh, MD; Patrick Hanaway, MD; Douglas Hanes, PhD; Ramy Hanna, MD; James T Hardee, MD; Carol Havens, MD; Arthur Hayward, MD; Lisa Heikoff, MD; Stephen Henry, MD; Lisa Herrinton, PhD; Trina Histon, PhD; George Ho, Jr, MD; Dieter Hoffmann, MD; Robert Hogan, MD; Marcus Hollander, PhD; Michael Horberg, MD, MAS, FACP, FIDSA; Sharon Hudson, PhD; Gary Huffaker, MD; Paul Hull, MD; Talha Imam, MD; Carlos Iribarren, MD, MPH, PhD; Steven Isenberg, MD; Mohamed Ismail, MD, MPH; Lee Jacobs, MD; Monica Jarrell, NP; Michelle Jesse, PhD; Samir Johna, MD; Steven Johnson, DO; Ping Johnson, PhD; Kermit Jones, MD, JD; Renate G Justin, MD; Joseph Kahwaji, MD; Jonathan Kei, MD, MPH; Laura Kerr, PhD, IMFT; M Kamal Khalid, MD; Afshin Khatibi, MD; Ian Kimmich, ELS; Anna Luise Kirkengen, MD, PhD; Daniel Klaristenfeld, MD; Arthur Klatsky, MD; Mina Kono, MD; John Koo, MD; Susan Korn, MSHSA; Mike Kositch, MD; Thomas Kottke, MD, MSPH; Michael Krall, MD; Ashok Krishnaswami, MD; Dean Kujubu, MD; Victoria Kumar, MD; David Kwon, MD, FACS; Myles Lampenfeld, MD; Mary Lane-Carlson, EdD, MPH, RD, CDE; Jens Langsjoen, MD; Mark Lassoff, MD; Lisa Law, MD; David Lee, MD; Kuo-Wei Lee, MD; Lonnie Lee, MD; Sok Lee, MD, MA; Pamela Lemke, CNM, MS; Eleanor Levin, MD; Martha Levine, MD; Joel Levis, MD, PhD; Gerald Levy, MD; Catherine Lewis, MD; Tracy Lieu, MD, MPH; Evelyn Lifsey, PhD; Daniel Linnen; Jorje Lipiz, MD; George Longstreth, MD; Eduardo Lopez, MD; Cindy Lopez, RN, BSN; Richard Lord; Robert Lundstrom, MD; William Lynes, MD; John Maa, MD; Eric M Macy, MD; Jared Lane Maeda, PhD, MPH; Iccha Maharjan; Jeffrey Maier, MD; Nicole Mareno, PhD; Peter J Martin, MD; Stephen Martin, MD, EdM; Michael McCulloch, LAc, MPH, PhD; Walt McDonald, MD; Michael McFarlane, MBBS, DM, FRCS, FACS; Max McMillen, ELS; Donald Mebust, MD; Lewis Mehl-Madrona MD, PhD; Susanne Mierendorf, MD; David Moiel, MD; Richard Moldawsky, MD; Lisa Morrise, MArts; Karen Mularski, MD; Kathleen Mullen, PhD; Craig Munroe, MD; Colin Murphy, FRCSI; Sean Murphy, MD; John Murphy, PhD; James Mykytenko, MD; Arian Nachat, MD; Ganesh Nagaraj, MD; Allison Naleway, PhD; Craig Nelson, PhD; Kimberly Newell Green, MD; Miki Nguyen, MPH; Bonnie Nicholas, RN, CNCC(C), CPTC; Marsha Novick, MD; Brian Nuyen; Julie Nyquist, PhD; Ahmed Obeidat, MD, PhD; Zachary Oliver, EdD; Chun Ouyang, MD; Gurpreet Padam, MD; Anuradha Pai, MD; Kevin Patel, MD; Nilesh Patel, MD; Donna Patey, MSN; Mathew Pauley, JD, MA, MDR; Cathriya Penny, DNP, FNP-BC, GNP-BC, ACHPN, BC-ADM; Sandra Petronio, PhD; William Pfeiffer, MD; Walker Poston, PhD, MPH; Karlo Quadros, MD; Sylvestre Quevedo, MD; Stein Rafto, MD; Javier Rangel, MD; Barry Rasgon, MD; Scott Rasgon, MD; Albert Ray, MD; Carol Redding, MA; Kimberly Reece, MD; Julie Richards, MPH; Gail Richardson, DNP; Bradley Richie, MD; David Riley, MD; Craig Robbins, MD, MPH; David Roberson, MD, FACS; Melissa Rockefeller, MD; Jens Roehrich, PhD; Cecilia Runkle, PhD; Lynnice Ruona, RN; Gerald Saliman, MD; Michael Salinsky, MD; Danny Sam, MD; Hope Sasek, RN; Jerry Schilz, MD; Andrew Schreffler, MD; David C Schwebel, PhD; Theodore Scott, FNP; Elizabeth Scruth, RN, PhD; Ashok Shah, MD; Vishal Sharma, MD; Wen Shen, MD; Karen Sherman, PhD, MPH; Gregorio Sicard, MD, FACS; Kelly Sievers, CRNA; Matthew Silver, MD; John Sim, MD; Robert Skinner, MD; Kurt Smidt-Jernstrom, DMin; Norma Smith, PhD; Herbert Sorensen, MD; Stephen Soto de Mayor, PA; P Anando Stangl, MD; Bradley Steele, MD; Jill Steinbruegge, MD; John Steiner, MD, MPH; Nancy Stotts, RN, EdD, FAAN; Tom Sult, MD; Gretchen Summer, PhD, RN-BC; Clifford Swap, MD, MS; Jean-Luc Szpakowski, MD; Karen Tallman, PhD; Swee Yaw Tan, MD; Talar Tejirian, MD, FACS; Anil Thomas, MD; Gregory Thorkelson, MD; Ian Tofler, MD; Eric Tong, MD; Sandra Torrente, MD; H Nicole Tran, MD, PhD; Rob Unitan, MD; Sachin Vaid, MD, MS, MRCS; Sonja Van Laar, PhD; Jeffrey Velotta, MD; David Vinson, MD; Tido von Schoen-Angerer, MD, MPH; Susan Wagner-Debusman; Robert Weaver, PhD; Joshua Weil, MD; Allan Weiland, MD; Sheila Weinmann, PhD, MPH; Calvin Weisberger, MD; Constance Weisner, DrPH, MSW; Benjamin Wheatley, MPP; Roger Williams, MEd; Bradley J Winston, MD; David Witt, MD; Lucia Wocial, PhD; Winston Wong, MD; Louise Yeung, MD; Ed Yian, MD; Hyo-Chun Yoon, MD; Scott Young, MD


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Contact Us


Tom Janisse, MD, MBA

Merry Parker

Lynette Leisure

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Christopher Dauterman, MBA

Ian Kimmich, ELS



27,000 print readers per quarter, 9725 eTOC readers, and in 2017, 1.5 million page views on TPJ articles in PubMed from a broad international readership.

The Permanente Press

The Permanente Journal (ISSN 1552-5767) is a peer-reviewed journal of medical science, social science in medicine, and medical humanities published quarterly by The Permanente Press.


Physicians may earn up to 1 AMA PRA Category 1 Credit per article for reading and analyzing the designated CME articles published in each edition of TPJ.

ISSN 1552-5775 Copyright © 2018 thepermanentejournal.org.

The Permanente Press. All Rights Reserved.