Dr Garfield's Enduring Legacy—Challenges and Opportunities

Abstract

It's about time. For too long, Sidney Garfield, MD, has stood in the giant shadow cast by his more celebrated partner and friend, Henry J Kaiser, the great entrepreneur and industrialist. Mr Kaiser's name and fame live on, mainly in association with the only nonprofit organization ever incorporated by the builder of more than 100 for-profit companies—Kaiser Permanente (KP). But the physician whose extraordinary vision and daring innovations in health care delivery that gave birth to that same organization remains largely unrecognized beyond the select circle of medical historians and the heritage-minded physicians and staff of KP. One needn't minimize the vital role of Mr Kaiser in KP's story to assert the seminal role played by Dr Garfield. They were genuine partners, each bringing to the enterprise critical elements lacking in the other: money and organizational genius from Mr Kaiser; a visionary mind and an unrelenting drive for innovation and quality improvement from Dr Garfield; and from both a genuine belief in and commitment to human dignity and progress. … he spelled out the essential elements of what we have come to call Permanente Medicine … This centennial of Dr Garfield's birth is a timely occasion not only to recall and celebrate his role in creating and evolving the unique model of health care delivery that would become KP, but to examine as well some of his key insights and innovations with regard to the current and future state of American health care. Fortunately, Dr Garfield himself articulated his ideas in a number of influential documents. These included, most importantly, his 1945 address to the Multnomah County Medical Association in Oregon,1 in which he spelled out the essential elements of what we have come to call Permanente Medicine, and a forward-looking article in the April 1970 issue of Scientific American2 (see page 46). In that article, he reiterated those foundational qualities and went on to anticipate a radical transformation of the health care system via the incipient power of information technology. In addition, the evolution of his ideas was expertly traced and recorded by his physician colleague John Smillie, MD, in his excellent 1991 history of KP, Can Physicians Manage the Quality and Cost of Health Care?3 Sidney R Garfield, MD, 1977 Anyone who has examined Dr Garfield's long career will appreciate the difficulty of assessing the historical and/or current relevance of his ideas and innovations. As his diminishing number of surviving colleagues will attest, he was a fount of ideas—virtual intellectual fireworks—admittedly igniting a few duds among the brilliant rockets. The ideas ranged across the entire spectrum of health care, from delivery models to financing to hospital design. In the end, it may fairly be said that he achieved his childhood dream of becoming an engineer (he is said to have broken down and cried when his parents insisted he attend medical school) by engineering our unique model of health care. But among all his many lasting contributions, which ones constitute the essential core of his life's work? And what relevance do they have for today and tomorrow? I believe Dr Garfield's lasting reputation will rest on four big ideas that, individually and in combination, powered fundamental transformations in health care. They are: the change from fee-for-service to prepayment the promotion of multispecialty group practice in combination with prepayment the emphasis on prevention and early detection to accomplish what he termed “the new economy of medicine,” in which providers would be rewarded for keeping people healthy; and, finally—and most presciently—the centrality of information technology in the future of health care. Significantly, each one of these 20th century innovations, three of which are deeply embedded in KP's own genetic code, is at or near a critical crossroads in this first decade of the 21st century, either still struggling for broad acceptance or under fresh assault as failed assumptions. Let us briefly examine each in turn.