Collegiality: Sharing Responsibility – and Friendships
When the Palo Alto Medical Clinic was still relatively small, the physicians and their families would go together to the Big Game, the annual football match between Stanford and the University of California at Berkeley. "We all went in a bus, and Esther Clark would pass around ‘cough medicine' – you could have bourbon or scotch, whatever was best for your ‘cough'," recalled Bunny Cressman, wife of retired surgeon Ralph Cressman. "And we sang. Russ Lee always sang, ‘We never mention Aunt Clara, her picture is turned to the wall, where she lives on the French Riviera, Mother says she is dead to us all.' We sang that once back up, and once back down."
Through traditions like this, the Clinic became "family" for many physicians, spouses and children, especially for those who were new to the Bay Area. At the time, young doctors could generally afford homes close to the Clinic in Palo Alto, Menlo Park or Mountain View, making it easy for people to see each other outside of work. They socialized in large groups and small get-togethers. "There was a great effort made for the more senior people to invite the younger people to their houses for dinner, three or four couples at once," said Dr. Richard Maser, a plastic surgeon. His son Benjamin, now a Palo Alto Medical Clinic plastic surgeon, remembers that most of his father's friends were fellow Clinic doctors. New doctors were acclimated to the group practice culture by the founders themselves: Drs. Russel Lee and Esther Clark each had every newcomer and his or her spouse over for a meal. And the organization was small enough that the doctors knew the names of each other's children.
Those personal relationships helped strengthen professional relationships within the partnership. Even as their numbers grew, Clinic partners had a strong sense of being a community of physicians who helped each other provide patients with comprehensive care. "I don't remember ever feeling defensive about saying, ‘Here's a problem, I'd like to share it with you.' That spirit, I think, is still very strong," Dr. Harry Hartzell said. Physicians would regularly walk down the hall or call fellow partners with questions and receive quick answers, saving patients the time and money of an appointment with a specialist. When formal referrals were needed, doctors knew their colleagues and could pick the most appropriate expert for the patient's particular needs. Referrals were expected and easy – in some cases, perhaps too much so. Dr. Gordon Campbell remembers seeing a long string of patients with back and neck aches who had been referred by primary care physicians. "I was so tired of seeing these cases that I gave a talk at one of the partnership meetings about how to take care of neck aches, thinking, boy, I'll really get rid of these cases. Well, then they sent me more, because I was clearly an expert."
To ensure that personal and professional relationships continued to thrive as the group expanded, Dr. Lee created the "Clinic Club," a room where doctors could get together over lunch. "There was one big table, and there was a mom and pop in the kitchen serving lots of Eastern European food," said Dr. Hartzell. "We sat around the table and everybody got to know everybody." A number of informal consultations took place over that table, as doctors of different specialties traded advice about difficult patient cases. The Clinic Club remained in existence until 1999, when the group moved to the new campus in Palo Alto, which has a cafeteria for both Clinic physicians and Foundation employees.
A Constant State of Expansion
In addition to the health care provided by its physicians and staff, the Clinic had a very tangible link to the city of Palo Alto through its physical presence. Its buildings were never large enough to serve an ever-growing patient base, and the town was well-aware of the group's constant need for new space.
The Clinic's habit of running out of room began even before its official incorporation. Dr. Milton Saier, one of the last doctors to join the group while it was still in Dr. Tom Williams' original offices, was given a tiny kitchen on the second floor as his office. "All that I had was a sink and a table with a chair, and you could either sit in the sink or sit in the one chair, where the patient sat," he said. In 1932, the nascent group moved its six doctors into a new building at the corner of Homer Avenue and Bryant Street that was designed by Dr. Esther Clark's brother, architect Birge Clark, to house up to 12 doctors. "We thought that was as big a group as you would want to have," said Dr. Clark. That thinking proved wrong, and the facility – later called the Roth Building – was too small in just a few years.
Another new building, adjoining the Roth Building, was constructed shortly after the war. Business Manager Walter Drugg announced that the building would be able to house 35 doctors and 100 staff members, surely enough to accommodate the Clinic's needs. This too proved wrong, and as patient demand continued to rise, the Clinic again was squeezed. It began to acquire additional individual sites near the existing buildings. "We proceeded to buy as much of the block between Waverly and Bryant, and Channing and Homer, as we could," Dr. Lee said. It also acquired office space on El Camino Real. Some relief came in 1961, when the three-story Lee Building was completed. It was big and modern, and allowed the Clinic to bring many of its doctors close together again. But it was not enough, and the Clinic's expansion continued, accompanied by complaints from residents about traffic congestion, parking difficulties and noise.
By 1991, the group had more than 150 doctors, and its aging, cramped facilities were spread out across a nine-block area. Hoping to better integrate its services, make room for new technology, accommodate continued patient growth and truly become a "Mayo Clinic of the West," the Foundation proposed creating a new, centralized medical campus on a 2 1/4-block area south of downtown Palo Alto. The plan won approval from the city, but was challenged by residents of the surrounding area who thought the campus would be too big for their neighborhood. The issue went to voters in a June 1992 referendum and was approved, but just a few months later, after signing an affiliation agreement with Sutter Health, the Foundation changed its plans. With better access to capital, it instead acquired property just across the CalTrain tracks on El Camino Real, where it could build a facility large enough to house all of its services in one place. The new Palo Alto Clinic opened its doors in 1999.
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A Self-Perpetuating Model
So important was the group's sense of collegiality and shared responsibility that Clinic partners screened for it when hiring new physicians, many say. After Dr. Russel Lee's retirement, the Clinic continued to follow his policy of only hiring new physicians when they were absolutely needed and at the top of their field. But another vital factor was the candidate's compatibility with his or her prospective peers. Though the organization could tolerate a wide range of personalities and practice styles, a physician had to be willing to compromise, negotiate and put the good of the group first. Such intangibles were hard to gauge on paper, and hiring was in some ways a "primitive process," said Dr. Myron Gananian. While a candidate's background, training and references were always considered, "there was a lot of instinct about it."
By the mid-20th century, the Clinic had already developed a national reputation for excellence and, like a winning college football team, generally drew top applicants. But quality on paper was not enough. Once a candidate's background was vetted, it was "basically about whether you liked him or not. If he seemed to share the same institutional values that we had, you'd think he would be able to work out," said Dr. R. Hewlett Lee. The entire department would have a chance to meet the prospective partner and vote on whether he or she would be a good fit. Hiring instincts were usually correct: In the Clinic's history, only a handful of physicians have ever been asked to leave. As an extra level of evaluation, new physicians have since the 1930s come on board first as "probationers" who work for at least two years as Clinic employees before being elected into the partnership by their peers.
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Collegiality in a Crowd
Today, the Palo Alto Medical Clinic has nearly 300 physicians spread across its Palo Alto location and four satellite offices. Having "a life outside of work" is of explicit importance for both male and female physicians, and many Clinic physicians work part-time to spend more hours with their families. With the cost of living so high in the Palo Alto area, young doctors are forced to buy houses farther away and have spouses who also hold jobs, making it hard to socialize outside of work. With the constant demand of paperwork, Clinic doctors often play catch-up at their desks over lunch, rather than eating together. Can collegiality, cooperation and community survive in this modern environment?
Perhaps the group is bigger, and perhaps they see each other less frequently outside the office, current Clinic doctors say, but their professional relationships with one another remain unchanged. Although they may not know each of their partners closely, physicians still lend support to one another within "neighborhoods" – at the department or satellite level, or among their age-matched peers – and have colleagues in other specialty areas to whom they turn for help. Easy consultations and referrals are still the expectation and the norm. "Two or three times a day, I'll walk down the hall and ask someone if they've seen something before or what they think about various problems," said family practitioner Linda Harris. F. Marland Chancellor, another Clinic family practitioner, added that having straightforward access to specialists allows him to focus more fully on his patients' primary care needs. "My attention can be primarily turned toward preventive medicine for them and building long-term relationships with the community," he said.
Collegiality continues to be key in hiring decisions, with the entire department weighing in on whether a candidate feels like a good match. And close relationships help doctors derive more personal satisfaction from their jobs. "I think what I enjoy most about working at the Palo Alto Medical Clinic is the people. On a day-to-day basis, the folks that touch my life are wonderful, and they make it a very positive working experience," said surgeon Karen Whang.
With Dr. Russel Lee and Dr. Esther Clark no longer around to take every new doctor to dinner, senior physicians teach their new colleagues about the merits and responsibilities of group practice. Dr. Joann Falkenberg, who heads the Department of Family Practice at the Fremont Center, tells new hires, "You know, our culture really isn't to punch the time clock and work 9 to 5 and maybe shave that hour off the end of your day. Our culture really is to see all the patients we can see and to help our partners out, even stay a little late if we need to some days."
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