Voices From The Permanente Journal: Examining the Past While Embracing the Future



 

Cuong Le, MA, MAT1; Paul Bernstein, MD, FACS2; Kirk Fernandes, MS3

Perm J 2022;26:21.998 • E-pub: 04/05/2022 • https://doi.org/10.7812/TPP/22.998

Volume 26, Issue 1

Corresponding Author
Cuong H. Le
Cuong.H.Le@kp.org

Author Affiliations
1Kaiser Permanente, Atlanta, GA, USA

2The Permanente Federation, San Diego, CA, USA

3Hawaii Permanente Medical Group, Honolulu, HI, USA

Author Contributions:
Cuong Le, MA, MAT, Kaiser Permanente, Atlanta, GA, USA
Paul Bernstein, MD, FACS, The Permanente Federation, San Diego, CA, USA
Kirk Fernandes, MS, Hawaii Permanente Medical Group, Honolulu, HI, USA

Disclosures
Conflicts of Interest: None declared
Funding: None declared

Copyright Information
© 2022 The Permanente Federation. All rights reserved.

Background

This history of The Permanente Journal (TPJ) chronicles how preceding newsletters, bulletins, oral histories, and dedicated staff paved the way for the journal’s sustained, decades-long growth.

Introduction

Since 1997, TPJ has published quarterly issues about innovative developments of America’s health care delivery systems, evidence-based research, and best practices in medicine. Additionally, the journal has emphasized human experiences by touching on the sociological and psychological aspects of medicine and delved into covering pioneering therapies and treatments. The journal began as a space for physicians and leaders to share their experiences, practices, and clinical research and is now transforming into a leading destination for content, focusing on value-based and high-value care and health systems research. To recognize TPJ’s 2022 relaunch, this review of past newsletters, bulletins, and newly conducted oral histories reveal how people and events have led to the journal’s development and how they act as a foundation for its future.

THE BEGINNING, 1943–1950

Kaiser Permanente began with the partnership of industrialist Henry J. Kaiser and a young surgeon, Sidney Garfield, MD. Six Companies, Inc, a group of industrialists, including Kaiser, led the construction of California’s Colorado River Aqueduct project near Desert Center, California, in 1933. The project connected the Colorado River to the Los Angeles Basin. To care for the project’s workers, Dr Garfield’s Contractors General Hospital, implemented a prepaid health plan for a nickel per day per worker. Dr Garfield and Kaiser expanded the prepaid program to care for 15,000 workers and their families at Kaiser’s Grand Coulee Dam worksite in Washington.1p18 When the United States entered World War II in 1941, approximately 200,000 workers became employed at Kaiser’s shipyards in California, Oregon, and Washington until the end of the war.1p48 Kaiser and Dr Garfield joined together and implemented an integrated, prepaid health plan to care for thousands of diverse shipyard workers and their dependents.

TPJ inherited the legacy of the Permanente Foundation Medical Bulletin, which was first published by physicians treating thousands of workers at the busy Kaiser shipyards. During World War II, a concerning increase of pneumonia cases at the Kaiser Richmond shipyards led Dr Garfield’s friend and colleague, Morris Collen, MD, to publish articles about his pneumonia treatments using penicillin in July 1943, thus establishing the Permanente Foundation Medical Bulletin.2p7 The first issue “carried an account of medical research based on case histories from Kaiser’s shipbuilding industry.”3p5 The publication served as a medical journal and annual report for the Permanente Medical Care Plan at the Kaiser shipyards.

In the second annual report, Dr Garfield declared that “a medical care system worthy of perpetuation, in addition to being economically sound, must provide teaching, training, and research, all so necessary for the maintenance of high-quality care.”1p42 Between 1943 and 1945, the Permanente Foundation Medical Bulletin produced 67 articles, and an additional 30 were published in other medical journals, earning praise from the New England Journal of Medicine on August 24, 1944, for maintaining the “high standards and dignity of the medical profession” (Figure 1).1p42

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Figure 1: PFMB Cover 1943 vol 1, 1

Toward the end of the war, Hannah Peters, MD, and Wilson Footer, MD, published one of the first extensive cohort articles on gynecology in the industrial workplace, established cancer detection clinics, and provided educational programs for women about venereal diseases.4p141 Together, they made evidence-based recommendations for treating menorrhagia with vitamin B complex after following 23,000 women at the Kaiser shipyards.4p138

After World War II ended, Dr Garfield and Kaiser joined together to open the health plan on July 21, 1945, making it available to the public. As the shipyards slowly closed, the Permanente Foundation Medical Bulletin continued publishing research articles. The increasing demand for continuing medical education and best practices in 1949 led to the publication of the Educational Proceedings of the Permanente Hospitals.

The published proceedings consisted of records of staff lectures, educational seminars, and proceedings of weekly grand rounds to provide “reviews and new developments in the field of medicine which may prove useful in the care of patients.”5p10 The Staff Education Committee published the Permanente Foundation Medical Bulletin 10 times per year. Ruth Straus became one of the longest-serving editors on the committee after joining Kaiser Permanente in 1949. The committee’s first project reported and abstracted staff education meetings for publication in the Permanente Foundation Medical Bulletin. Straus spent the next 25 years editing for the Permanente Foundation Medical Bulletin and later became the executive editor for the Kaiser Foundation Medical Bulletin, the successor to the Permanente Foundation Medical Bulletin. On the bulletin’s 10th anniversary, Dr Garfield conveyed that the medical bulletin is “[d]edicated to the advancement of medical care” using “new contributions from the Permanente Hospitals and the Permanente Foundation.”5p1–11

TOWARD A NATIONAL MEDICAL JOURNAL, 1951–1976

In 1951, Alfred Bolomey, MD, a physician with The Permanente Medical Group at Kaiser Permanente’s Oakland Hospital, known as Kaiser Oakland Medical Center today, proposed the distribution of “abstracts from staff education proceedings to staff doctors, residents, and interns”6p1 (Figure 2). Dr Bolomey served as the editor in chief, and Straus became the editorial assistant. His proposal brought Irving Lomhoff, MD, Carl Fisher, MD, and Paul Levatin, MD, from the Staff Education Committee as editors for the new publication. Together they produced a modest gray pamphlet known as the Kaiser Foundation Medical Bulletin. Unlike the previous periodicals and bulletins, the Kaiser Foundation Medical Bulletin became more comprehensive in 1951 by including content from Kaiser Permanente’s 4 hospitals, serving approximately 50,000 members in 3 states. Eventually, doctors worldwide requested to be on the bulletin’s mailing list. By 1954, the bulletin replaced its humble gray color for a “Kaiser-green jacket, with text set in clean ‘hot type’ on glossy paper that permitted illustrations of textbook caliber.”6p1

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Figure 2: KFMB staff 1959

Photo by Earl McMullen

Some of the Medical Bulletin’s editorial staff put their heads together over a problem. (L to R) Aileen Simpson, secretary to the staff; Ruth Straus, executive editor; Doctors Carl W. Fisher, editor-in-chief; A. J. Sender, Martin A. Shearn and Edgar J. Schoen. Inset: Dr. Alfred A. Bolomey, founder the Kaiser Foundation Medical Bulletin.

During the Kaiser Foundation Medical Bulletin’s first decade, editors and staff attended lectures and conferenceshosted by each hospital’s staff education program. Straus, now an experienced medical writer, helped publish the Annual Abstract Issue of the Kaiser Foundation Medical Bulletin in January 1961. The first issue included “57 articles, 2 books, a chapter in a third book, and 2 sections in scientific encyclopedias” published by Permanente physicians in national journals from the previous year.7p1 Around this same time, a newly established Department of Scientific Publication supported the bulletin and related publications.

Clifford H. Keene, MD, an ironworker turned surgeon from New York, served as the general manager of the Kaiser Permanente Medical Care Program and chair of the Kaiser Foundation Medical Bulletin’s editorial board in 1961. Dr Keene’s foreword in the first Annual Abstract Issue conveyed his hope that the bulletin would cultivate “the young and expanding hospital staffs’ interest and skill in scientific writing” and a desire that such “curiosity enhanced the professional climate of our hospitals and [could not] help but benefit the community at large.”7p1 The more than 60 published abstracts reflected Dr Keene’s hope that “success on the pages of a house organ goes on to achieve the broader readership of national publications.”7p1 He continued to support the publications as Kaiser Permanente’s chief executive officer and president in 1967.

After Ruth Straus retired in 1976, references to either the Kaiser Foundation Medical Bulletin or the Annual Abstract Issue stopped appearing in newsletters, hinting at the end of their respective publications (Figure 3). Another internal periodical would not emerge for 18 years, this time in the Kaiser Permanente Northwest region. The book Permanente in the Northwest, by Ian McMillan, MD, mentions a periodical known as the Permanente Practice, but its origins and further details remain missing from other archival sources.8p30 When the Permanente Practice stopped publishing, a new journal emerged in its place, originating with the staff of the Northwest Permanente Medical Group’s Department of Continuing Medical Education.9p1

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Figure 3: Ruth Straus from KP Reporter 1960.

A NEW BEGINNING

The Northwest Permanente Journal of Clinical Practice came together when Tom Janisse, MD, a Northwest Permanente anesthesiologist, became the interim director of Continuing Medical Education while Phillip Brenes, MD, a Northwest Permanente pediatrician, took a sabbatical year in the early 1990s. As interim director, Dr Janisse took note of widely read department newsletters, such as the Department of Pharmacy, NWP Continuing Medical Education, Medical Legal, and Dermatology Update.10p2 He proposed that they gather all these newsletters to start a journal with their respective editors.11p3 The first several issues were printed in their respective formats to maintain each department’s uniqueness.11p3–4

The quarterly publication was “directed to the clinicians of Northwest Permanente and intended to be a major forum for the exchange of clinical information relevant to the practice of medicine in Kaiser Permanente’s Northwest region.”10p2 Dr Brenes became the editor in chief, and Dr Janisse became the associate editor in chief. Although the periodical served the physicians of a specific geographic region of Kaiser Permanente, its publication picked up the historical baton left by Ruth Straus’ retirement.

Like the Kaiser Foundation Medical Bulletin, the Northwest Permanente Journal of Clinical Practice included an “Abstracts” section like the Annual Abstracts Issues by Straus. This section contained reviews by Northwest Permanente physicians of medical and surgical journal articles across multiple disciplines and specialties to provide a forum where current practitioners could connect and exchange new ideas or practices.

The Northwest Permanente Journal of Clinical Practice distinctly included literature beyond scientific research and clinical practice common in medical journals and previous bulletins. Physicians published their “rich talent and clinical skills” while showcasing their “wide range of experiences from a variety of sources that influence clinical practice.”10p2 The new journal’s organic expansion beyond clinical research and practice literature reflected the multifaceted characteristics in the practice of medicine.

A new section, “Soul of the Healer,” located toward the end of each issue’s table of contents, provided an opportunity for practitioners to share creative pieces on the social and psychological aspects of medicine, a genre that later came to be called narrative medicine. Other sections in the journal “flavored by the humanities” included the “Practice Highlights” and “Letters” sections.10p2 When the Northwest Permanente Journal of Clinical Practice suspended publication at the beginning of 1997, the “Soul of the Healer” section transitioned to TPJ.

A VOICE OF PERMANENTE, 1997

Although the Northwest Permanente Medical Group’s compendium of newsletters and distinctive formatting had merged into a more standardized style, it was still not an organization-wide journal like the Kaiser Foundation Medical Bulletin. The Permanente Federation’s 1997 formation created the national leadership organization for the independently practicing Permanente Medical Groups to optimize care delivery following the philosophy and practice of Permanente Medicine. The organization’s relationships and networks provided the opportunity for a programwide journal.

Dr Janisse, then acting as Northwest Permanente’s associate medical director in 1997, discussed the creation of TPJ with Francis J. Crosson, MD, The Permanente Federation’s executive director at the time.11p10 Dr Crosson welcomed the idea and understood the goal for a journal to have a broader readership. Similarly, Dr Janisse recognized The Permanente Federation’s need to establish a national voice for the Permanente Medical Groups.

Dr Crosson’s support, combined with the continued successful partnership with the Kaiser Foundation Health Plan and Hospitals, served as the foundation for a new medical journal.12p6 Dr Janisse became TPJ’s founding editor in chief. The new journal helped the Permanente Medical Groups come together and provide physicians with a space to discuss best practices and learn about programs in their departments.11p17

The first issue of TPJ opened with “The Voice of Permanente,” where Dr Janisse outlined the journal’s goals, creating its identity and purpose for the next decade. First, it was decided that the journal must “promote and support Kaiser Permanente’s goal of bringing increased value to our members and communities.” Furthermore, TPJ set out to inspire “critical thinking in day-to-day clinical practice and encourage the description of clinical experience in a managed care setting.”13p2 Dr Janisse described Kaiser Permanente and TPJ as having “an obligation to promote research into clinical practices and set the standards and communicate” them to improve quality and patient outcomes.13p2 Such goals included the well-being of physicians and clinicians who expressed aspects of their work through artistic media, such as drawings, poetry, and even comic strips.

In its past, art and photographs by talented physician contributors adorned the journal’s front cover (Figure 4). Dr Janisse connected with a community of artists, photographers, illustrators, writers, and sculptors when he lived in Volcano, a small town at the foothills of the Sierra Nevada.11p1 Together they founded The Volcano Review, a quarterly publication that preserved the town through the perspectives of local artists, inspiring Dr Janisse to include the “Soul of the Healer” section in TPJ.11p1–2 “Physicians even back then, or probably forever, have been artists,” said Dr Janisse.11p21 Drawings often conveyed how clinicians felt about current health crises, such as smoking, or included historical artifacts, as was the case in “Stamp: The Doctor” from 1947 in the journal’s Winter 2007 issue (Figure 5). Although discontinued, this rich content is still available in TPJ’s archives online.

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Figure 4: TPJ Cover from 1997 (Volume 1, Issue 2)

The cover note for the issue reads, “El Capitan” by Wuhao (Taki) Tu, MD. Dr. Tu is a retired nephrologist-internist. He worked for The Permanente Medical Group from 1962–1988. This watercolor entitled, “El Capitan,” is one of many of his creations. He states, “My paintings are simply my way of reacting to the beauties of the lights and the colors of nature.”

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Figure 5: Doctor Stamp, TPJ 2007 vol 11, 1

In TPJ’s first decade, it faced the need for more contributors from outside of Kaiser Permanente. To achieve this aim, Dr Janisse attended conferences where major health partners and organizations were also present. He spoke with the researchers presenting at the conferences and introduced them to TPJ as a space to publish their research.11p31–32 Unlike other national medical journals, TPJ was free to read and had no publication charges for authors, which helped increase contributions.

After a successful first decade, the journal started to look toward its future as a national medical journal, which meant becoming indexed in MEDLINE, an index of biomedical journals managed by the National Library of Medicine. Known as the second-decade strategy by the TPJ editorial team, Dr Collen, then in his late 80s, helped begin the process of obtaining this important indexing milestone in the early 2000s.

During the process, Dr Collen’s top advice included suggestions to 1) order original research or feature articles first, 2) place abstracts and editorials to the back, and 3) focus on medical articles. Although Dr Janisse continued to support the uniqueness and warmth of social science articles, there was a notable decline in contributions to the “Soul of the Healer” section. Dr Collen agreed that such pieces were acceptable, recognizing the importance of psychosocial research. Despite reductions in artistic and literary pieces, Dr Janisse remarked that physicians’ artistic expressions intersected with their clinical practices. The current senior editor, Gus Garmel, MD, FACEP, FAAEM, debuted his “Image Diagnosis” section in 2010 and balanced medicine and art by providing teaching moments for readers with X-rays or diagrams. As a physician, academic, writer, and teacher, Dr Garmel has described the section as a space where someone could grasp complex topics in a short amount of time.14p19

Since 2006, TPJ’s layout and contents has followed headings and sections from the National Library of Medicine. In 2012, the journal became officially indexed in MEDLINE, marking a significant milestone. Having achieved this important goal, the journal thrived throughout its second decade, increasing the number of authors inside and outside of Kaiser Permanente. Like the Kaiser Foundation Medical Bulletin’s international reach, the journal’s authors originated from many parts of the world, including Ireland, Italy, Germany, Japan, Turkey, and Singapore.

TPJ’s website, launched in 2007, expanded the journal to an even wider audience. Useful statistics became available for review by editors and historians. In 2016, the journal accumulated 1.5 million article page views in PubMed, and its website received about 250,000 views. International users visited from more than 180 countries and territories. Following the MEDLINE indexing milestone, the journal was also indexed in PubMed Central, EBSCO Academic Search Complete, and CrossRef. Southern California Permanente Medical Group allergist and senior editor for the journal, Eric Macy, MD, attributed the readership numbers and sources to TPJ’s uniqueness in its free access.15p8

In March 2020, Dr Janisse retired as the journal’s founding editor and Stephen Tarnoff, MD, former president and executive medical director of Washington Permanente Medical Group, accepted the call to become interim editor in chief.

THE FUTURE OF TPJ

Dr Tarnoff, an avid reader of TPJ for more than 20 years, became attracted to the journal “because it was an atypical source for clinical practice, innovations, and ideas.”16p6 Nicole Tran, MD, PhD, an internal medicine physician with The Permanente Medical Group, became senior editor during the transition. Dr Tran started reviewing articles for the journal in 2011 and became interested in including residents in the journal’s editorial process. She accepted an invitation to visit the journal’s editorial team in Portland to propose her new ideas.17p1 Like Dr Garmel, Dr Tran described the journal as a teaching space, leading her to propose the idea of “making physicians in training aware of the journal and learning the ins and outs of what happens to an article from the point it is submitted to the point it is reviewed” and published.17p1

One of Dr Tran’s memorable projects was TPJ’s special edition about women in medicine in 2020. “Together with the executive director of the American Medical Women’s Association and fellow physician at The Permanente Medical Group, Eliza Lo Chin, MD, MPH, we wanted to share a special collection of articles about and from women in medicine both within and outside of Kaiser Permanente,” said Dr Tran.17p2 She explained that this collaboration reflects the nature of TPJ to allow Permanente physicians and authors to build connections with people in the broader community of medicine and practice.

Looking to the future of TPJ, Dr Garmel imagines that the health care community will continuously discover more value in the journal to help with their practices and support their research, and Dr Tarnoff envisions a greater focus on articles about care delivery and care delivery science.

Dr Macy hopes that the next 5 years will move the journal closer to a first-tier journal.17p15 Dr Tran foresees that the journal will experience growth in the pillars of “quality improvement, medical education, health care delivery and improvement, and equity, inclusion, and diversity.”17p11 TPJ’s historical connections from a shipyard medical bulletin to the Kaiser Foundation Medical Bulletin reflect a rich medical education and research heritage. The journal will continue to publish peer-reviewed articles about clinical practice improvements, care delivery science, and value-based medicine for patients and communities for decades to come. The full archive of TPJ’s content, from 1997 onward, is available with no barriers to access at www.thepermanentejournal.org.

References
1.     Smillie JG. Can Physicians Manage the Quality and Costs of Health Care? The Story of the Permanente Medical Group. Oakland, CA: The Permanente Federation; 2000.
2.     Collen M. Kaiser Permanente Medical Care Oral History Project II, Year 1 Theme: Evidence-Based Medicine,” conducted by Martin Meeker in 2005. Regional Oral History Office, The Bancroft Library, University of California, Berkeley, 2007.
3.     Lester S. The men that Kaiser “waked”: An account of the physician’s role in a precedent-breaking medical project. Med Econ 1944;21(5):5,36–44.
4.     Peters H, Footer W. Gynecology in industry. Permanente Found Med Bull 1945;3(3):137–141.
5.     Garfield SR. A report on Permanente’s first ten years. Permanente Found Med Bull: Tenth Anniversary Issue. 1952 Aug;10(1–4):1–11.
6.     “Bulletin Goes ‘Round the World.” KaiPerm Kapsul 1959;2(4):1, 6.
7.     KF Authors Publish in Nat’l Journals.” KP Reporter 1961;3(2):1–2.
8.     MacMillan IC. Permanente in the Northwest. Oakland, CA: Permanente Press; 2010, 30.
9.     Weiland AJ. From the regional medical director. Northwest Permanente J Clin Pract. 1994;1(1):1.
10.   Brenes P. Editor’s comments. Northwest Permanente J Clin Pract. 1994;1(1):2.
11.   Janisse T, Le C. The Permanente Journal Oral History Project Transcript: Tom Janisse, M.D. The Permanente Journal Oral History Project. Oakland, CA: Kaiser Permanente Heritage Resources, 1,3–4,10,17,21,31–32.
12.   Crosson J, Le C. The Permanente Journal Oral History Project Transcript: Francis J. Crosson, M.D. The Permanente Journal Oral History Project. Oakland, CA: Kaiser Permanente Heritage Resources, 6.
13.   Janisse T. A voice of Permanente. Perm J. 1997;1(1):2–4.
14.   Garmel G, Le C. The Permanente Journal Oral History Project Transcript: Gus Garmel, M.D. The Permanente Journal Oral History Project. Oakland, CA: Kaiser Permanente Heritage Resources, 10,19.
15.   Macy E, Le C. The Permanente Journal Oral History Project Transcript: Eric Macy, M.D. The Permanente Journal Oral History Project. Oakland, CA: Kaiser Permanente Heritage Resources, 8.
16.   Tarnoff S, Le C. The Permanente Journal Oral History Project Transcript: Stephen Tarnoff, M.D. The Permanente Journal Oral History Project. Oakland, CA: Kaiser Permanente Heritage Resources, 6.
17.   Tran N, Le C. The Permanente Journal Oral History Project Transcript: Nicole Tran, M.D. The Permanente Journal Oral History Project. Oakland, CA: Kaiser Permanente Heritage Resources, 1,2,11,15.

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CIRCULATION

2 million page views of TPJ articles in PubMed from a broad international readership.

Indexing

Indexed in MEDLINE, PubMed Central, EMBASE, EBSCO Academic Search Complete, and CrossRef.


                                             

 

 

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