Pearls from a Clinician-Researcher in an Integrated Health Care Delivery System



 

Kate Michi Ettinger, JD1; Vivian M Ettinger, RN1; Marc G Jaffe, MD2,3; David A Schroeder, MDFACC4; Joan C Lo, MDFACP3,5,6

Perm J 2021;25:20.305

https://doi.org/10.7812/TPP/20.305
E-pub: 06/02/2021

Today, we face novel uncertainties, physical isolation, and increased vulnerability in the trenches. We must keep pace with technology-mediated care and increased systematization of health care delivery. The art of medicine and core values that once animated our professional aspirations may feel remote. This commentary profiles the career of Bruce Ettinger, MD (1938–2020),1,2 a physician in The Permanente Medical Group (TPMG) who grew professionally as Kaiser Permanente Northern California (KPNC) expanded around him. Described as “the quintessential physician researcher,” Ettinger was a clinician, scientist, educator, and founding TPMG Chair of Endocrinology. During his career, Ettinger found avenues to remain humane, foster community, stimulate curiosity, and improve the quality of care for patients in his practice, throughout KPNC, and for larger patient populations.

Ettinger’s first-year cadaver mates recalled that he prepared diligently for lab and executed dissections enthusiastically and efficiently. During residency on the Harvard Medical Unit at Boston City Hospital, Ettinger’s clinical competence and efficiency earned him the nickname “The Flash.” He and fellow house staff bonded in their commitment to provide excellent care for indigent patients in an underresourced setting. At Boston City Hospital, Ettinger learned to master procedures by “see one, do it a few times, teach it”—a motto that shaped his approach to learning and teaching. With residency cut short by the draft, Ettinger reported to Zama Army Hospital (Japan) in 1966. His commanding officer bemoaned, “What am I supposed to do with an internist? I need surgeons for MASH [Mobile Army Surgical Hospital] units and a pediatrician on base.” Ettinger quickly volunteered. “I can be a pediatrician. Kids are basically little people.” This ability to leverage an opportunity became a signature talent. A “Renaissance Man,” Ettinger studied Japanese, learned ceramics, and developed a lifelong appreciation for Japanese craftsmanship. A carpe diem approach to learn, create, and find the joy in any situation characterized his life.

Ettinger moved to the Bay Area in 1968 where he completed a fellowship in endocrinology and metabolism at the University of California San Francisco Metabolic Research Unit. In 1970, he joined TPMG as a senior physician in internal medicine/endocrinology at Kaiser Permanente San Francisco Medical Center (KP San Francisco). Known for “stones and bones,” Ettinger practiced for more than 30 years at KP San Francisco, served as Clinical Professor of Medicine and Radiology at the University of California San Francisco, and worked with KPNC for 50 years. As we forge ahead in these uncertain times, these pearls from Ettinger may inspire ways for others to realize their aspirations within an integrated health care delivery system.

HOW DO YOU AVOID BURNOUT?

Early in his career, Ettinger experienced a common struggle that some physicians encounter as they adjust to the change of pace from academic training to the steady demands of clinical practice. He overcame this weariness by forging a practice as a clinician and a researcher—a dual career track that supported his love of learning. Listening to his patients’ experiences, Ettinger discovered new questions to research. He crafted studies that challenged assumptions, underscored clinician concerns, and addressed patients’ needs. His clinical practice afforded a forum to apply evidence-based findings.

As a metabolic endocrinologist, Ettinger developed the role of the medical liaison to KPNC’s Regional Laboratory, a position that allowed him to delve into the science of laboratory testing, quality control, and emerging diagnostic technology. He also participated in a high-risk obstetric specialty clinic at KP San Francisco. By creating a professional niche rich with learning through diversity of practice, Ettinger stimulated his curiosity and avoided burnout.

Takeaway: Find ways to keep learning.

HOW DO YOU KNOW WHAT TO FOCUS ON?

Ettinger reflected at retirement that his body of research emerged from “watching what the tide brought in.” As a TPMG physician, he was free from financial pressures associated with large research operations and could focus on meaningful research to improve KP member care. He thrived on designing scientific studies that addressed discrete questions on key issues in clinical practice. His research included simple, focused studies completed in months rather than years.

Ettinger’s research at KP began with kidney stones, including clinical trials of medical therapies for nephrolithiasis prevention.3 He was the first to discover triamterene nephrolithiasis,4 and in 1979 collaborated with the nation’s kidney stone analysis laboratory to examine incidence, characteristics, and risk factors for this new disorder.5 Leveraging KP’s integrated health care delivery system, these research findings were translated immediately into evidence-based care implemented across the region. Shepherding the translation of research into clinical practice allowed his research to be highly impactful, which was gratifying and motivating.

Following a series of collaborative research studies that showed supplemental estrogen minimized postmenopausal bone loss,6 Ettinger focused on osteoporosis prevention and menopause management in women’s health.7,8 His research studies evaluated the skeletal effects of hormone therapy (HT),9 and the challenges and consequences of HT.10,11 Concerned about cancer risks from prolonged HT exposure,12 Ettinger led the Multiple Outcomes of Raloxifene Evaluation Trial to evaluate the efficacy of selective estrogen receptive modulators for postmenopausal osteoporosis.13

Ettinger relentlessly pursued the lowest dose needed to treat. He led several randomized trials that demonstrated lower than standard dosages of HT could maintain bone density adequately after menopause.6,14 This pursuit culminated in a patent for ultralow-dose transdermal estrogen—the ultimate lowest effective dose.15 In retirement, Ettinger became aware of concerning side effects arising from uninterrupted long-term bisphosphonate use.16 He delved into this issue from mechanistic pathways17 to disease incidence18 to clarify the risk and benefit considerations for this therapy. With more than 200 publications on menopause, osteoporosis, and fracture risk assessment,19,20 Ettinger’s dedication to women’s health research contributed evidence to support access to safe and effective choices for osteoporosis prevention after menopause.

Ettinger joined KPNC’s Division of Research in 1990. As a senior investigator at the Division of Research, his research collaborations expanded while he maintained his specialty practice at KP San Francisco. His robust body of highly impactful research in women’s health2 and osteoporosis1 continues to influence care delivery today.

Takeaway: Watch what the tide brings in. Leverage the opportunities that come to you.

HOW DO YOU STAY HUMAN?

Ettinger understood the African proverb: “If you want to go fast, go alone. If you want to go far, go together.” Ettinger nurtured the nascent TPMG endocrinology group. In the 1970s, he initiated a voluntary after-hours monthly dinner meeting for TPMG’s endocrinologists to build a collaborative community. Over 25 years, Ettinger organized, hosted, and facilitated this forum to discuss complex case management, design research to improve member outcomes, develop practice guidelines, and review the latest science from publications and conferences. Robust discussions of differing views resulted in consensus decisions and continuous peer learning that raised the region’s quality of care. New endocrinologists shared insights from training and benefited from the expertise of established colleagues. The benefit of this regular meeting was that it not only increased the skills and knowledge of the TPMG endocrinologists across Northern California, but also, and perhaps more importantly, these gatherings provided a forum where strong friendships, professional relationships, and a sense of a greater TPMG endocrinology community flourished. Other TPMG medicine specialty groups followed the model. For Ettinger, nurturing this community of peer learning was a vital part of staying human; he was proud of the endocrine group’s unity and accomplishments. As TPMG grew during the early 1980s, Ettinger became Chief of Endocrinology at KP San Francisco. He served as Regional Chair of the Chiefs of Endocrinology for TPMG Northern California until his retirement in 2003.

Takeaway: Create the community you seek.

HOW DO YOU STAY MOTIVATED?

Although Ettinger recognized the 3 qualities of intrinsic motivation (autonomy, mastery, and purpose) in his work, his well-lived life arose from staying tuned into himself and making choices that nourished him.

Do Work That Energizes You

Expressions of autonomy, such as a strong commitment to social justice, creativity, and innovation, permeated Ettinger’s career. After returning from Army service, Ettinger joined the White Coats to protest the war in Vietnam. Committed to the idea that working people should have access to high-quality health care, Ettinger joined TPMG in 1970. He believed in the KP mission, valued the KP patient population, and sought in his clinical research to improve KP members’ care and outcomes. In 1973, Ettinger chaired the Patient Services Committee at KP San Francisco, which set out to draft a Patient Bill of Rights. Ettinger initiated an inclusive, egalitarian process to hear from every employee. Over 3 years, he fostered consensus from the ground up around a Patient Bill of Rights. Adopted by KP San Francisco, it subsequently served as the template for KP’s Northern and Southern California region hospitals. A natural leader, Ettinger’s good humor, integrity, tenacity, competence, and openness inspired people to join his efforts.

Practicing within an integrated health care delivery system shaped how Ettinger approached innovations to improve patient care. When bone densitometry emerged as a new technology for osteoporosis screening, he advocated for KPNC to develop imaging expertise and capacity for its members. Harnessing the region’s integrated care environment, Ettinger initiated a bone density surveillance program for postmenopausal women. He provided operational leadership, technician training, and quality monitoring, and oversaw the program’s expansion to more than 15 densitometers across KPNC. More than a decade before osteoporosis screening became a national metric for quality care, Ettinger established the infrastructure that allowed KPNC to become a national leader in high-quality osteoporosis care and fracture prevention.

Takeaway: Instigate creative change in areas that matter to you.

Mentor to Master

As a clinician-researcher, Ettinger brought the ethos of physician training to his research mentoring and cared about the learning of people who trained with him. He understood the challenges, constraints, and work environments of both academic researchers and physicians in the trenches. He deftly translated information to be relevant for each audience. He shared knowledge generously, empowered self-sufficiency, and opened doors for the next generation. Although accomplished, Ettinger remained humble and accessible.

Inculcated at Boston City Hospital, Ettinger valued teaching as part of his learning process; he was empathetic to new learners. Whether responding to a patient with a new diagnosis or to questions from a colleague, he relished sharing information. Attentive to each audience, he exuded an enthusiasm and ease that engaged others. This ethos continued into retirement; he reveled in sharing his passion for model yacht sailing by mentoring youth and novice sailors at Spreckels Lake in San Francisco’s Golden Gate Park.

Takeaway: Mentor as a path to mastery: teach, and by your students you will be taught.

Choose Your Corner

Curiosity, an earnest commitment to improving patient care, and the pursuit of excellence motivated his work as a clinician-researcher. Frequently consulted on challenging cases, his unrelenting curiosity ensured that his patients received the best care. Beloved for his ability to explain complex clinical issues with reassuring clarity, Ettinger partnered with his patients.

Ettinger fostered consensus by uniting colleagues around their shared commitment to scientific integrity and patient care. Disciplined when he had a differing perspective, he would craft a study to test his ideas. His unbiased, practical, and understandable approach to presenting science provided valuable insights. As a peer reviewer, a contribution that he enjoyed up to the end, his often extensive feedback focused on enhancing the scientific merit of prepublication work. A master at simplifying the scientific message, he approached the reviewer’s role as he gardened, pruning excess and nurturing buds.

Takeaway: “Choose your corner, pick away at it carefully, intensely and to the best of your ability and that way you might change the world.”—quoted by Charles Eames and attributed to Richard Feynman*

IN CLOSING

This commentary profiles the impact one individual practicing within an integrated care environment had on medicine, clinicians, and patients. We highlighted what made Ettinger’s efforts effective and contributed to a fulfilling, impactful professional life. We hope these pearls gleaned from our time working with Bruce Ettinger inspire your practice and professional lives.

      

*Richard Feynman is used with permission of Michelle Feynman & Carl Feynman; reviewed by the Eames Office.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Financial Support

No financial support was required for this work.

Author Affiliations

1San Francisco, CA

2Department of Endocrinology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA

3The Permanente Medical Group, Oakland, CA

4Providence Heart and Vascular Institute, Portland, OR

5Department of Endocrinology, Kaiser Permanente Oakland Medical Center, Oakland, CA

6Division of Research, Kaiser Permanente Northern California, Oakland, CA

Corresponding Author

Joan C Lo, MD, FACP (Joan.C.Lo@kp.org)

Author Contributions

Kate Michi Ettinger, JD, Vivian M Ettinger, RN, and Joan C Lo, MD, FACP, conceived the themes for this commentary and wrote the first draft of the manuscript. David A Schroeder, MD, FACC, and Marc G Jaffe, MD, revised subsequent drafts for important intellectual content. All authors reviewed the final draft and approved the manuscript for publication.

References

1. Marcus R, Cummings S, Lo J, Genant H. Bruce Ettinger, MD. J Bone Miner Res 2020 Sep;35(9):1621–2. DOI: https://doi.org/10.1002/jbmr.4131

2. Utian WH, Schiff I. Bruce Ettinger, MD (November 1938–June 2020). Menopause 2020 Sep;27(9):967–8. DOI: https://doi.org/10.1097/gme.0000000000001637

3. Ettinger B, Tang A, Citron JT, Livermore B, Williams T. Randomized trial of allopurinol in the prevention of calcium oxalate calculi. N Engl J Med 1986 Nov;315(22):1386–9. DOI: https://doi.org/10.1056/NEJM198611273152204, PMID:3534570.

4. Ettinger B, Weil E, Mandel NS, Darling S. Triamterene-induced nephrolithiasis. Ann Intern Med 1979 Nov;91(5):745–6. DOI: https://doi.org/10.7326/0003-4819-91-5-745, PMID:496113.

5. Ettinger B, Oldroyd NO, Sörgel F. Triamterene nephrolithiasis. J Am Med Assoc 1980 Nov;244(21):2443–5. DOI: https://doi.org/10.1001/jama.244.21.2443, PMID:7431573.

6. Ettinger B, Genant HK, Cann CE. Postmenopausal bone loss is prevented by treatment with low-dosage estrogen with calcium. Ann Intern Med 1987 Jan;106(1):40–5. DOI: https://doi.org/10.7326/0003-4819-106-1-40, PMID:3789576.

7. Ettinger B, Selby J, Citron JT, Vangessel A, Ettinger VM, Hendrickson MR. Cyclic hormone replacement therapy using quarterly progestin. Obstet Gynecol 1994 May;83(5 Pt 1):693–700, PMID:8164927.

8. Ettinger B, Pressman A, Sklarin P, Bauer DC, Cauley JA, Cummings SR. Associations between low levels of serum estradiol, bone density, and fractures among elderly women: The study of osteoporotic fractures. J Clin Endocrinol Metab 1998 Jul;83(7):2239–43. DOI: https://doi.org/10.1210/jcem.83.7.4708, PMID:9661589.

9. Ettinger B, Genant HK, Steiger P, Madvig P. Low-dosage micronized 17 beta-estradiol prevents bone loss in postmenopausal women. Am J Obstet Gynecol 1992 Feb;166(2):479–88. DOI: https://doi.org/10.1016/0002-9378(92)91653-r, PMID:1536215.

10. Ettinger B, Friedman GD, Bush T, Quesenberry CP, Jr. Reduced mortality associated with long-term postmenopausal estrogen therapy. Obstet Gynecol 1996 Jan;87(1):6–12. DOI: https://doi.org/10.1016/0029-7844(95)00358-4, PMID:8532268.

11. Ettinger B, Grady D, Tosteson AN, Pressman A, Macer JL. Effect of the Women’s Health Initiative on women’s decisions to discontinue postmenopausal hormone therapy. Obstet Gynecol 2003 Dec;102(6):1225–32. DOI: https://doi.org/10.1016/j.obstetgynecol.2003.08.007, PMID:14662208.

12. Ettinger B, Quesenberry C, Schroeder DA, Friedman G. Long-term postmenopausal estrogen therapy may be associated with increased risk of breast cancer: A cohort study. Menopause 1997;4(3):125–9. DOI: https://doi.org/10.1097/00042192-199704030-00002

13. Ettinger B, Black DM, Mitlak BH, et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: Results from a 3-year randomized clinical trial: Multiple Outcomes of Raloxifene Evaluation (MORE) investigators. J Am Med Assoc 1999 Aug;282(7):637–45. DOI: https://doi.org/10.1001/jama.282.7.637, PMID:10517716.

14. Ettinger B, Ensrud KE, Wallace R, et al. Effects of ultralow-dose transdermal estradiol on bone mineral density: A randomized clinical trial. Obstet Gynecol 2004 Sep;104(3):443–51. DOI: https://doi.org/10.1097/01.AOG.0000137833.43248.79, PMID:15339752.

15. Cummings SR, Ettinger B, Ellman H, Inventors. Regents of the University of California, Kaiser Foundation Health Plan, The Permanente Medical Group, Berlex Laboratories, assignee. Methods for treating postmenopausal women using ultra-low doses of estrogen. US Patent 669763; February 17, 2004.

16. Ettinger B, Stuenkel CA, Schnatz PF. Menopause practitioner perspective on the American Society of Bone and Mineral Research Task Force report on atypical femoral fracture. Menopause 2013 Oct;20(10):1092–7. DOI: https://doi.org/10.1097/GME.0b013e3182a7c57b, PMID:24048261.

17. Ettinger B, Burr DB, Ritchie RO. Proposed pathogenesis for atypical femoral fractures: Lessons from materials research. Bone 2013 Aug;55(2):495–500. DOI: https://doi.org/10.1016/j.bone.2013.02.004, PMID:23419776.

18. Lo JC, Grimsrud CD, Ott SM, Chandra M, Hui RL, Ettinger B. Atypical femur fracture incidence in women increases with duration of bisphosphonate exposure. Osteoporos Int 2019 Dec;30(12):2515–20. DOI: https://doi.org/10.1007/s00198-019-05112-5, PMID:31555883.

19. Ettinger B. A personal perspective on fracture risk assessment tools. Menopause 2008 Sep–Oct;15(5):1023–6. DOI: https://doi.org/10.1097/gme.0b013e31817f3e4d, PMID:18703988.

20. Ettinger B, Black DM, Dawson-Hughes B, Pressman AR, Melton LJ, 3rd. Updated fracture incidence rates for the US version of FRAX. Osteoporos Int 2010 Jan;21(1):25–33. DOI: https://doi.org/10.1007/s00198-009-1032-9, PMID:19705048.

Keywords: career, clinician-researcher, leadership, mentoring, physician, research, endocrinology

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