In Lessons Blog

Since stepping down as CEO of The Permanente Medical Group (TPMG) this summer, I have returned to nearly half of the Kaiser Permanente medical centers in Northern California and met with more than 4,000 physicians.

I was invited each time to speak about the lessons covered in my book “Mistreated: Why We Think We’re Getting Good Healthcare—And Why We’re Usually Wrong,” and it has been a privilege doing so.

As I look ahead to future scheduled visits, I am struck by an important lesson I took away from each of my recent talks.

My first set of talks took place in the heart of the Silicon Valley, at the Santa Clara and San Jose facilities, where many of the patients work in the tech industry, earning six-figures or more a year. From there, I visited the Hayward and Fremont medical centers on the east side of the Bay, which serve a more “blue collar” population, comprising a broad array of nationalities and more than 100 languages spoken among the patients. Last week, I visited the Central Valley, stretching from Stockton to Modesto. There, a high percentage of individuals in the community work in seasonal agriculture, producing the grapes, lettuce and tomatoes we eat –and many obtain their health coverage through Medicaid.

Each of these geographies has its own set of needs and challenges when it comes to delivering high-quality and convenient medical care. Those in the more affluent urban areas demand healthcare powered by the latest mobile and digital technologies. Patients in the East Bay area value medical care that’s not only high quality but also culturally competent. The needs in rural geographies are different still, where the large distances between patients and doctors can make access to care difficult.

Furthermore, the leaders in each of these medical centers are as different from one another as the patients they serve: Dr. Susan Smarr, an OB-GYN physician from North Carolina leads Santa Clara. Dr. Raj Bhandari, a neurologist and chairman of the TPMG Compensation committee, heads up San Jose. Dr. Rob Greenberg, an emergency medicine physician and information technology guru, runs Hayward. And Dr. Sanjay Marwaha, an otolaryngologist and active community leader, is responsible for the Central Valley.

One might be inclined to think all these variables – the different patient populations, geographies and leadership styles – would result in equally diverse approaches to medical care and clinical outcomes. And yet, this was not the case. No matter their backgrounds, incomes or education levels, patients in all of these facilities received equally excellent care, obtained rapid access to medical treatment and experienced superior results. It is why, according to the most recent National Committee for Quality Assurance data, the overall quality outcomes for KP in Northern California ranked in the nation’s top 1%.

Early in my tenure as CEO, a physician I worked with described how she once treated a Nobel Prize winner in one exam room and a homeless man in another. She was proud to have been able to provide exactly the same level of care for both. This expectation and value system – to deliver superior care to all, regardless of socioeconomic status – permeates the entire medical group.

During my talks, I stressed how context in healthcare – the structure of the delivery system, how physicians are paid and the availability of modern information technology – shapes perception and behavior. The physicians working in these medical centers are excellent, but so are many doctors in the communities around them. The difference in outcomes reflects the integrated nature of a single multi-specialty medical group that is paid on a capitated basis and uses a comprehensive electronic health record. And unlike the 90% of U.S. doctors, nearly all of the physicians in The Permanente Medical Group offer their patients more convenient forms of care, including video visits and secure emailing, which has saved thousands of patients from having to miss work to travel to the doctor’s office unnecessarily.


Kaiser Permanente members in Northern California can access a number of apps that make access to improved health easier and more affordable.

Physicians in all practice settings work hard, and the ones at Kaiser Permanente are no different. But unlike most doctors across the country, they go home most nights feeling fulfilled. Like their colleagues in community practice, they wish their electronic health record system was more user-friendly, but because they share a single computer system with their colleagues and because their patients benefit tremendously from it, no physician would want to give it up. Their consistently high performance reflects the mission-driven spirit of the entire medical group, which can be traced back 80 years to its founder, Dr. Sidney Garfield.

When Dr. Garfield finished his training prior to World War II, he moved to the Mojave Desert to care for workers building the California aqueduct rather than staying in Los Angeles. It certainly wasn’t the scenery or the money that attracted him, but simply the patients who were in need of excellent medical care and could not obtain it. As is so often true in families, the things we value are passed down through generations. And it’s no coincidence that many of the leading programs in the United States, including the Mayo Clinic, Ochsner Health System and the Billings Clinic, can trace their commitment to high-quality care back through the decades to their founders.

If we as a nation want to improve healthcare-system outcomes for all Americans, we will need to shift how we as a country organize care delivery, reimburse physicians, and support doctors with modern technology. But we also will need to alter the culture of medicine. And I predict that this stumbling block may be the hardest to overcome.

I look forward to my next set of medical center visits. I am confident they will be equally positive and educational, not just for the audience, but for me as well. I know that if all Americans received the same excellence in care that these physicians provide in California, that our nation’s health – both our medical and economic health – would be world class.

Dr. Robert Pearl is the bestselling author of “Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong” and a Stanford University professor. Follow him on Twitter @RobertPearlMD.

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Showing 4 comments
  • Seth Ackuayi, MD, MMM

    So true!

  • Norma Lynn Roles

    Thank you, Dr. Pearl. It’s because of leaders such as yourself that the legacy of Dr. Garfield lives on. I am personally proud to have been part of the design team for the Santa Clara campus.

  • Ernesto S. Rivera

    Looking forward to your visit in the North Valley!

  • Ejaz Naqvi

    Thanks Robbie for your leadership that was so instrumental in turning TPMG around! Hope to see you in the DSA sometimes soon.
    Ejaz Naqvi
    Chronic Pain program

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