Letters to the Editor

Fall 2006 - Volume 10 Number 3


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



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



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



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


    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.

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


    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."



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


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



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




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
Iasi, Romania
E-mail: rcovali@yahoo.com



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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