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As CEO and executive director of The Permanente Medical Group, Richard Isaacs, MD, is responsible for overseeing an operation that provides care for more than five million people. He is also an otolaryngologist and completed his residency in Manhattan Eye, Ear and Throat, and a fellowship in head-neck oncology and skull base surgery at the University of California, Davis.
Dr. Isaacs recently spoke with ENTtoday physician editor Alexander G. Chiu, MD, about his work, including how his background as an otolaryngologist has prepared him for the role.
Dr. Chiu: Could you tell us a little about yourself, your current role, and what a normal work week looks like for you?
Dr. Isaacs: For the past three years, I have been the CEO and executive director of The Permanente Medical Group (TPMG), which is the largest medical group in the nation, and president and CEO of the Mid-Atlantic Permanente Medical Group (MAPMG). Between these two medical groups, we have approximately 11,000 physicians and more than 40,000 staff who provide care for 5.2 million Kaiser Permanente members in Northern California, Maryland, Virginia, and Washington, D.C.
I’ve been with The Permanente Medical Group for 24 years. I came right out of fellowship in Northern California and joined TPMG. When I was on the East Coast, I didn’t know about Kaiser Permanente. But it’s a great model for care delivery because the medical groups are aligned and in partnership with the health plan and hospital system. And we all work together to provide care and coverage to all Kaiser Permanente members.
When I first joined TPMG, I was a skull base surgeon and a microvascular surgeon at Kaiser Permanente’s South Sacramento Medical Center. For 10 years, I did complex skull base and microvascular surgery, head and neck surgery. I created a center of excellence in South Sacramento and became the physician-in-chief for the medical center, which serves about 300,000 people. During my tenure as physician-in-chief, KP South Sacramento was the alpha site for the successful implementation of Kaiser Permanente’s electronic health record, which was adopted by KP throughout the country.
I’m extremely fortunate to have excellent teams in both Northern California and in the Mid-Atlantic regions, and our physicians and staff are doing tremendous work for their patients.
Dr. Chiu: How does your identity as a head-neck surgeon influence your current role?
Dr. Isaacs: Being a head and neck surgeon has positioned me for every opportunity I’ve had at Kaiser Permanente. Number one, as an otolaryngologist you’re basically involved in every department: You’re taking care of kids, you’re taking care of teenagers, all the way up to geriatric populations, emergencies, the operating room, labor and delivery, the ER.
On a medical level, otolaryngology helped me gain a thorough understanding of hospital operations and how to get things done. In my current role, I still am a practicing head-neck oncologic surgeon. I get called in for cases that need a particular expertise, and I really appreciate the opportunity to still be part of a surgical team that is having such a positive impact on the lives of our patients.
Dr. Chiu: Can you talk about Permanente Medicine?
Dr. Isaacs: Permanente Medicine began during the Great Depression, when our founder Dr. Sidney Garfield went to the Mojave Desert to deliver medical care to California Aqueduct workers at a modest 12-bed hospital, called Contractor’s General Hospital.
Dr. Garfield was a general surgeon who trained in California, but he couldn’t find a job during the Depression so he went to the desert to provide healthcare to the construction workers, and basically went bankrupt the first year. But he borrowed some money and created a new concept in care called pre-payment, where for five cents per employee per day, he took care of all their healthcare needs. And that’s where the focus on prevention was established.
Then, during World War II, Dr. Garfield joined forces with industrialist Henry J. Kaiser in Richmond, Calif., to oversee the medical care and treatment for the Kaiser Shipyard workers building cargo ships, aircraft carriers, and other vessels to support the war effort. And by 1943 Dr. Garfield was leading a team of physicians and staff that provided medical care for more than 90,000 workers. After the war, the Permanente care delivery program was offered to the public.
Being a head and neck surgeon has positioned me for every opportunity I’ve had at Kaiser Permanente. —Richard Isaacs, MD
I believe we do prevention better than anybody in the country because our physicians and staff have an almost relentless focus on it. We consider every interaction we have with our patients—in person, on the phone, via secure email, etc.—to be an opportunity to practice preventive medicine.
This focus on prevention has significantly improved individual and population health, created better patient care experiences, and controlled costs. As an example, Kaiser Permanente Northern California members are 52 percent less likely to die from colorectal cancer—and our total number of colorectal cancer cases has decreased by 26 percent—since TPMG successfully launched an integrated and comprehensive screening program.
At the same time, we have centers of excellence that rival the best in the world because our surgeons get really good at what they do, given the volume of patients we have. One great example is the work we’re doing with thoracic surgery. In Northern California, we shifted thoracic surgery cases from 16 hospitals to five designated specialty-care centers. And a study showed that by shifting lung cancer surgery to designated centers, we reduced the number of days patients spent in the hospital, decreased intensive care use, and reduced post-operative complications.
We also saw an increase in the use of minimally invasive, video-assisted thoracoscopic surgery, and the average operating time for these types of surgeries decreased. This is a model for the country.
Dr. Chiu: It’s also almost like the Shouldice Hernia Hospital model, where you get so good at what you’re doing that you’re going to do it cost-effectively as well as more safely for the patient, with better outcomes.
Dr. Isaacs: Exactly. We developed a center of excellence for cancer care, and every Thursday we have Sloan-Kettering-like grand rounds, where every surgical oncologist, every radiation oncologist, reviews every patient. And we do it within telemedicine: There’s a hub in Santa Clara, there’s a hub in Oakland, and there’s a hub in greater Sacramento. But when it comes time to make the clinical decisions and have a tumor board, patients have the benefit of a large group of experts evaluating their cases and making comprehensive and coordinated treatment plans.
Dr. Chiu: You clearly are a physician-run health system. What do you think the advantages are of that versus the non-physician-run health systems that seem to populate the country?
Dr. Isaacs: I believe it’s important to have physician leadership in healthcare organizations, because the focus will be on care delivery. At TPMG, for example, we don’t answer to a health plan; we work in conjunction with a health plan. The benefit of this arrangement is that the incentives are very much aligned. Our program is largely pre-paid, like it was in the Mojave Desert more than 80 years ago, so the focus is on population health and doing the right thing for patient care. If you lead with quality, you are creating a model that helps ensure patients are getting the care they need, as opposed to the fee-for-service model that provides incentives for providing more care, but not necessarily better care.
Dr. Chiu: How do you address burnout within your physician group?
Dr. Isaacs: When I assumed the role of CEO nearly three years ago, I created a strategy with The Permanente Medical Group’s board of directors that is focused on what I call total performance. There are three components to total performance: joy and meaning in medicine, exceptional care experience, and operational excellence.
Our Joy and Meaning in Medicine program, or JAMM as we call it, is about more than striving for the absence of clinician burnout. It’s about helping our physicians and staff reconnect to their purpose by optimizing workflows and tools that enable them to focus more of their time on work that is meaningful and makes a positive impact on the lives of others.
Our operational leaders have been closely engaged in the development and execution of JAMM, and they are gathering data directly from our physicians to better understand the factors that affect JAMM in their day-to-day work.
I believe it’s important to have physician leadership in healthcare organizations, because the focus will be on care delivery. —Richard Isaacs, MD
Operational excellence creates the capacity for you to have systems that help support the work that you’re doing. For the head and neck surgeon, for example, there’s nothing more frustrating than having a patient who has neck cancer and needs to get to the operating room—but not having the appropriate process in place to get him to the operating room.
It’s really about having systems that support the practice and having leadership that engages the surgeons and the people doing the work so they can help drive changes to make their practice better. And then ultimately there’s a culture of leadership that drives this work. We talk about the pebbles in your shoes: What are the issues you struggle with every single day, and how can we remove those and make it easier for you?
Dr. Chiu: We did an article on gender equity benefits and the lack of them as one of the causes of burnout, especially in our female physicians. We talk about the lack of maternal leave in most academic organizations, a lack of day care. How does Kaiser Permanente address those issues?
Dr. Isaacs: Our board of directors has a comprehensive compensation committee process which recognizes tenure, independent of gender. We recently studied our physician compensation, and there’s no difference between male and female compensation across the program. My executive team is over 50% women. We have both robust maternity and paternity leave benefit packages. We are working to develop on-site day care, which is the vision. I’d love to be able to do that. The logistics are hard. A major focus is on equity and also ensuring the support of physicians for life.
Dr. Chiu: Tell us about the new Kaiser Medical School [in Pasadena, California] as well. Have you had any input or direction in that, and what’s the thought behind that?
Dr. Isaacs: The goal of the medical school is to expand on what makes our program so successful. Kaiser Permanente is very much like a Mayo Clinic or a Cleveland Clinic in that it’s a non-university-based program where the care is highly academic. It was a natural step for us to establish a medical school, and the first class will matriculate in the summer of 2020. Dr. Mark Schuster, who was on the faculty at Harvard, is the dean, and he has an exceptional team working with him.
I should also mention that our Permanente Medical Groups have been actively engaged in undergraduate and graduate medical education for many years. KP Northern California, for example, has 16 residency programs, including family medicine, head and neck surgery, internal medicine, ob-gyn, pediatrics, and podiatric surgery, and 12 fellowship programs—and we have plans to add more of both.
TPMG physicians also train another 1,300 residents from affiliated programs, such as Stanford University and University of California, San Francisco. Plus, we train more than 800 medical students annually from nearly 90 medical schools from around the nation.
Dr. Chiu: Tell me the hardest part of your job and a lesson from a misstep or small failure that you may have had in your career.
Dr. Isaacs: I’ve had a lot of experience with change management. I touched on this a bit earlier, but in 2005, when I first became the physician leader of KP’s South Sacramento Medical Center, our organization decided to bring [the medical record system] Epic into Kaiser Permanente. The most important lesson that I learned then is that people need to understand exactly why it is we’re doing what we’re doing. If people understand the why, they are far more likely to rally around the project than if you’re just forcing something on them.
We had a very nice community hospital in South Sacramento that was doing good tertiary work, and we had an opportunity to be the first trauma center within the Kaiser Permanente national system. Trauma’s difficult, because you’re opening your door to some complexity—high-speed motor vehicle crashes, gunshot wounds, etc. It was important to inspire our physicians and help them understand that this was the right thing to do because it was in the best interest of our patients. Now we have a very strong ACS-accredited level 2 trauma center.
Dr. Chiu: What is your leadership style?
Dr. Isaacs: I lead with clear vision and encourage people to think about what’s possible. I believe my job as CEO is to encourage creative thinking by cultivating an environment in which our physicians and staff feel safe to push the envelope and continually think about new and better ways to advance the delivery of healthcare. I believe good leaders accept risk and trust their people. Our job is to clear a path.
Alexander G. Chiu, MD, is physician editor of ENTtoday.