Sidney Garfield—A Personal Recollection

It is a pleasure for me to write about Sidney R Garfield, MD, the co-founder of Kaiser Permanente (KP). For 15 years from 1969 until his death in 1984, I worked closely with him on studies in health care delivery during which time we developed a deep friendship.

I joined TPMG as an internist in Oakland in 1959. Within a few years I became involved in clinical diabetes research and was in charge of the Multiphasic Health Testing (MHT) programs in Oakland and San Francisco. These programs had been started by Morris Collen, MD, at the suggestion of Dr Garfield. They included a broad variety of medical history information and tests, with the data stored automatically on computers.

When I joined the medical group, I heard of a mythic taskmaster named Sidney Garfield, a surgeon who had started a medical group—Sidney Garfield and Associates—back in the 1930s and 1940s. In the early years he hired physicians and ran the medical group as an entrepreneur. Prepaid medical care was thus furnished for the Kaiser Organization and Health Plan. In 1953, he voluntarily relinquished control to the physicians in the group—without compensation or a continued official position in the medical group. This new physician organization was established first as a partnership and in 1981 as a corporation—The Permanente Medical Group, Inc.

He treated construction workers as he would important administrators or physicians. He was generous and unpretentious.

Following his departure from the medical group leadership, Dr Garfield served on the Board of Directors of the Health Plan and the Kaiser Health Plan Foundation. His primary role was in building new clinics and hospitals. He was always very interested in medical building needs. For example, he designed the rather revolutionary Kaiser Hospital floor plan at Walnut Creek in the early 1950s in which visitors' access to patients utilized corridors on the outside of the wards rather than traversing through the working area for doctors and nurses.

When I met him in 1969, he had been officially retired from these Boards and had the title of Consultant. However, he was anything but retired. He was completely preoccupied with and dedicated to improving the KP Medical Care Program. His goals were to make it more accessible, efficient, and cost effective while providing quality medical care. He always had new ideas—one of them was the creation of the MHT program.

Dr Garfield had developed a plan to use MHT to facilitate access to our medical care system and provide baseline health evaluation data. The ultimate objective was institution of a rational and cost-effective treatment and preventive program. A new key element was to utilize nurse practitioners to conserve physician time for care of the sick. Dr Garfield was able to get research funds from the Kaiser Family Foundation to support a study and a rigorous evaluation of the proposed new system.¹ He and I worked to develop the MHT program to accomplish these goals.

We needed 12 nurse practitioners. None were trained and available. We, therefore, developed an intensive six-month training program at Oakland. This was the first use of nurse practitioners in KP. We were also one of the first medical services to use multi-analyzers for blood chemistries and hematology with online, real time computer reporting of results while the patient was still on the MHT unit. This allowed same day completion of the evaluation.

Over the 15 years of our collaboration, I spent a great deal of time with Dr Garfield working on research regarding health care delivery. I saw him almost daily under many different circumstances. He was a remarkable man—patient, tolerant, always considerate, soft-spoken, almost shy, but strong—a complete gentleman. He treated construction workers as he would important administrators or physicians. He was generous and unpretentious. I never heard him gossip or criticize his medical colleagues. He said he sought out and tried to employ the strengths of the people he worked with. He readily acknowledged a good job, and if he didn't have anything positive to say he didn't say anything. He was dapper and dressed well in custom-made clothes. He didn't carry a wallet, just a credit card and a few large bills—he had class.

Dr Garfield was always open to new ideas. One day I saw him reading a book on cybernetics looking for information he could apply to medicine. He had a marvelous ability to visualize the future of medical care delivery and to see clearly the main issues that needed to be approached in solving a problem. His analyses were remarkably and deceptively simple. It frequently seemed that he was too far ahead of the field. He had a deep conviction that medical care was a universal right (a term Dr Garfield coined)—an idea now widely accepted as part of our values.

Total Health Care Project Final Report—Dedication to Sidney R Garfield, MD.

Dr Sidney R Garfield (1906–1984), founder of the Kaiser Permanente Medical Care Program and a pioneer in the Health Maintenance Organization movement, was one of the world's brilliant and pragmatic students of health services. During his very active career he created programs furnishing medical services for a series of major construction projects, for the workers and their families in wartime shipbuilding and then, as its founder, the Kaiser Permanente Medical Care Program. Dr Garfield was the recipient of numerous awards and recognitions including the Lyndon Baines Johnson Foundation Award for Significant Contributions in the Field of Health Care Delivery.

Through this experience he became convinced and consumed with the belief that the provision of medical care could be better organized than through the prevailing fee-for-service system. He was convinced that the prepayment for services could contribute to economic and viable incentives to provide high quality of care at affordable costs. It offered reasonable amenities for physicians and enhanced their role to be responsible for both the quality and cost effectiveness of medical care.

It was his belief that for the greatest benefit, health care should not be limited to care for the sick, but should include and emphasize the entire spectrum of prevention, health education and health maintenance. He envisioned an appropriately balanced consortium among physicians, nurse practitioners, mental health counselors and health educators that might bring together, effectively and economically, the entire spectrum of primary health care services.

It was with this concept in mind that Dr Garfield fashioned the Total Health Care Project as a study of what he envisioned as an ideal health service module. Those of us who have had the privilege of working with him on this project find the Total Health Care study a fitting epitaph to his lifelong commitment for better health and medical care for the country. This report is dedicated to his memory.

As a final note, Dr Garfield headed a comprehensive study in health care delivery called the Total Health Care Project. He passed away before the final report was completed. Below is the dedication to him that is included in the report.

Dr Garfield, (right) with a Kaiser Company official viewing the building site of the Permanente Foundation Hospital in Oakland, CA, 1942.