Where we came from – Sidney Garfield, MD, 1970

This post began as discussion of my reacquaintance with the work of theSidney R. Garfield Health Care Innovation Center, which happened when I was in California recently. I was happy to find that they have put up an Internet site for those who want to learn more. I especially recommend looking at the photos. It’s an impressive place – I was able to go on a tour in August, 2007, and I was especially interested in their “mock home.”

What I remembered, though, was that I had wanted to read a landmark publication written by the Center’s namesake, Sidney Garfield, MD, “The Delivery of Medical Care,” which was published in 1970. I believe that learning about where I/we came from as physicians and informaticists is important – the dreams of those who came before us inform our dreams. I was happy see that the article is now available online – see: The Delivery of Medical Care.

Sadly, the challenges that Dr. Garfield mentioned in 1970 health care ring true today: “In 1967, the National Advisory Commission on Health Manpower reported that medical care in the US is more a colletion of bits and pieces (with overlapping, duplication, great gaps, high costs and wasted effort) than an integrated system in which need and efforts are closely related.”

After reading the piece, I think that his vision is a compelling one today, and much of what he dreamed of has come true today, in certain health systems, such as the ability to administer a health risk appraisal and leverage it as a productive entrance into the health care system (even saying “the entire record is stored by the computer as a health profile for future reference” – this is the name that Group Health has given its health risk appraisal). He understood that poorly informed actors in health care resulted in people entering through the wrong door and

The entry of healthy people into the medical care system should not be considered undesirable. It opens the door to a great opportunity for American medicine: if these well people are guided away from sick car into a new, meaningful health care service, there is hope that we can develop an effective preventive-care program for the future.

There is a heavy reliance on computing power for this new vision, and I might argue perhaps too heavy a reliance; however, what’s remarkable about his models is that they place the patient at the top, with the medical system underneath in support. This is significant, even in 2007.

What’s especially influential for me is his idea that he was a proponent of the Kaiser Permanente model, but was not hoping to make this approach exclusive to Kaiser Permanente. He was open source before anyone knew what that was:

We believe any group of physicians, or a foundation working with physicians, can easily duplicate the Kaiser Permanente success….freedom of choice is important; we believe that the choice of alternate systems, including solo practice, is preferable for both the public and physicians.

I think this is great, and it’s a reason I cite for doing what I’m doing during this experience – helping the entire system succeed in guiding people “away from sick care into a new, meaningful health care service.”

There’s a cautionary note in what I read about over-reliance on technology, and I need to continually check in that I am not promoting technology at the cross purpose of leadership. There is also an energizing note for me about focusing on medical education in this journey – where Sidney talked about the need of medical school faculties to educate about different ways of practice so “these young men can choose wisely.”

The diversity advocate in me appreciates that Sidney Garfield did not predict in his writing in 1970 was that it would be “women and men of all ages and backgrounds” choosing wisely. At the same time, this is a welcome change in our profession that Kaiser Permanente the organization has actively fostered in its work.


[…] So now my energy regarding the gap is on a societal scale rather than an organizational one. Why? Because I can’t imagine ending my professional journey with the idea that a person’s ability to achieve their life goals through optimal health is dependent on the street they walk to to receive health care. I think the same is true for those who came before us, including Sidney Garfield, MD, one of the founders of Kaiser Permanente, as he wrote in a landmark publication in 1970. […]

Ted Eytan, MD