The Clinic in the Community
Starting with its namesake home town and expanding outward as it grew, the Palo Alto Medical Clinic played an integral role in the life and health of its community. Health care had been a key focus for Palo Alto residents since 1903, when a typhoid epidemic killed a dozen people. A few years later, the town became only the third in California to implement a full-time city health officer, following San Francisco and Los Angeles, and subsequent decades saw a number of forward-thinking public health initiatives, including mandatory tuberculin testing of cattle, diphtheria immunization and sewage treatment. In 1934, Palo Alto won praise from the state Department of Public Health for having a record "not excelled or equaled by any other city in California."
The Clinic was an important player in the community's public health efforts. The Department of Pediatrics, for example, for a time provided care to nearly every child in Palo Alto. Dr. Esther Clark led the town's campaign to immunize its children against diphtheria, scarlet fever, polio and other childhood ailments, as well as movements to put "keep out of reach of children" labels on medicine bottles and to control the safety of milk supplies. According to Dr. Lee, "When a team of Russians came to investigate health care in the U.S., eight of them were sent to Palo Alto because the State Department had found that it was the safest place in the world to be born, and one had less chance of dying in childhood and youth there than anywhere else in the country."
In 1953, Dr. Clark established the Children's Health Council, a not-for-profit organization that still provides services to children with disabilities more than 50 years later. Her leadership in this effort was just one of many ways Clinic physicians and staff members worked to improve the health and well-being of their community at large, beyond the basic delivery of medical care. Doctors also served as civic leaders, sitting on local boards and city councils. "The amount of community service done by an organization this size was unbelievable. Those kinds of things became a part of the culture," said former Clinic Executive Administrator John R. Johnson. Group practice made it easier to encourage this ethos, because physicians knew their compensation would not be hurt by time spent providing unpaid care and leadership. Indeed, community service was generally rewarded when the Executive Board allocated drawing accounts.
Today, community benefit is codified within the Palo Alto Medical Foundation's mission statement. The organization provides health education classes, support groups, lectures and resources that are open to the entire community; collaborates with local schools and agencies on health-related projects such as bilingual diabetes education; and provides financial and in-kind support to community health projects. Employees and physicians volunteer extensively, bringing their skills to bear in free health care screenings, food drives and work at community clinics that care for the underserved. The Clinic provides a substantial amount of uncompensated care for Medicare, Medi-Cal and indigent patients. And doctors continue to push the organization to think of ways it can do more to meet community need. "Ten years from now, I'd love to be running a Spanish outreach center or something like that," said internist Heather Linebarger. "I think as we expand, we're going to have to do it."
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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Bringing Care Closer to Home
As the Clinic grew in reputation, so too did the geographical base from which its patients hailed. By the 1980s, it had about 5,000 East Bay patients who crossed the bridge for care at the Palo Alto location, and the area was slated for a population boom. At the same time, managed care organizations were becoming more prevalent, increasing the need for primary care physicians. Some at PAMF began to believe it would make better sense to provide East Bay patients with that primary care closer to home. The "satellite" clinic, which would be based in Fremont, could then send its patients to specialists at the main clinic in Palo Alto – an idea in keeping with the Mayo model of small community clinics referring patients to the flagship for advanced care.
Not everyone liked the idea. Primary care physicians feared the satellite would take patients away from their practices. "The obstetrics department in particular violently opposed it, because they worried that their deliveries were going to drop if one didn't have to drive across the Bay to have a baby," said Dr. R. Hewlett Lee, who at the time was executive director of the physician partnership. Dr. Lee was a strong proponent of the satellite concept, but had to work at convincing others. The Fremont Center finally opened its doors on July 9, 1984, with four primary care physicians and seven support staff members.
The practice started slowly. "As a brand new office, we had a little extra time on our hands – completing Christmas cards and Friday celebrations were just a few of the ways we enjoyed each other's company and helped pass the time while waiting to get the office up and running with patients. But that initial slow period was short-lived," said Dr. Sue Knox, one of the Fremont Center's original physicians and now its medical director. Thanks to word of mouth and targeted marketing, the Fremont Center took off. "One of the successful approaches we took was to break into the local community by targeting people who bought new homes in the area. We figured they probably didn't have primary care doctors yet. Our thinking was that if we could get one person to come to us as a new patient, they would then move into their new neighborhood and tell their neighbors. In 1989, one local mailing was good enough to keep us busy for the next five years," said Dr. David Hooper, another Fremont founding physician and current vice president of clinical operations for the Foundation's Palo Alto Health Care Division.
Like its Palo Alto parent, the Fremont Center took its cues from the community. With a more multiethnic patient base, it hired bilingual doctors who understood the culturally different views of medicine held by the Chinese, Indian, Russian and other residents they served. Soon, the center also found it logical to add specialty services as patient need dictated. Primary care remained important, but before long, the tiny referral clinic had become a major multispecialty center in its own right. When it celebrated its 20th anniversary in July 2004, the Fremont Center had 50 doctors in 25 different disciplines, and was preparing to break ground on a 70,000-square-foot addition that would house almost 60 more physicians.
Ten years after the Fremont Center's opening, the Foundation expanded again, opening another small primary care satellite in Los Altos with three primary care physicians and one pediatrician. Although it stayed focused on primary care, the Los Altos Center too grew quickly, exceeding a 10 percent annual increase in patient volume in the subsequent decade and expanding to accommodate more than 30 physicians. Los Altos was followed in 1998 when PAMF bought the Women's Health Medical Group, a small obstetrics/gynecology practice in Portola Valley and the Portola Valley Woman's Health Center was born. In 1999, the Foundation opened a fourth satellite in the Redwood Shores area of Redwood City, also focused on primary care and pediatrics. Unlike Fremont, that clinic had no initial slow period: Patients began coming so rapidly that the number of office visits increased 600 percent within its first 12 months of operation. Much of this growth came from word of mouth. "We got a number of patients who told us, ‘You saw my friend last week and he said I had to come in,'" said Dr. William Black, the Clinic's medical director for San Mateo County and an internist at the Redwood Shores Center.
In addition to providing better regional access for patients, the satellite clinics offer physicians and staff members the choice of working in a smaller environment than the main Palo Alto Clinic. "We're all one organization, but each site does have its own flavor, whether it be the people who work there, the size, the location or the patient population. Different choices are appealing to our patients, and in recruiting," said Dr. Alireza Shafaie, internist and department head of the Redwood Shores Center. Though satellite physicians participate in partnership meetings and other events at the main Clinic, the centers are smaller neighborhoods where doctors can build close personal relationships, just as their predecessors did in the Clinic's early days.
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Addressing Inpatient Care
Although the Clinic itself had no hospital, its leaders were influential in planning for Palo Alto's inpatient needs. When Dr. Russel Lee arrived in Palo Alto in 1924, hospital care was provided in the three-story, wooden Palo Alto Hospital built in 1910, located off Embarcadero Road. Town growth and problems with the physical plant – including its propensity to catch fire – soon meant the hospital was inadequate to serve Palo Alto's needs, and in the late 1920s, community members launched a campaign to build a new hospital. A group of physicians led by Dr. Lee raised about $142,000 and the city generated $200,000 through a bond issue. The brand-new hospital opened in 1931 and proved to be a great asset to Clinic finances as well as the health of its patients, as people who had previously gone to San Francisco for care now preferred to stay on the Peninsula.
The Palo Alto Hospital was built on land leased from Stanford, but it was mainly used by community physicians. At the time, Stanford Medical School was located in San Francisco and used a hospital in the city to train new doctors. In the 1950s, however, Stanford President J. Wallace Sterling proposed bringing the medical school down to the university's main campus. (Dr. Lee, who counted Dr. Sterling among his patients, claimed some credit for that idea, later writing that "in bedside talks during an illness, I convinced [Dr. Sterling] that there was enough clinical material to justify moving the medical school down.") The influx of faculty physicians, combined with a booming population, meant that a larger hospital was needed, and in 1959, the Palo Alto Hospital closed and the joint Palo Alto-Stanford Hospital opened.
The new hospital was equally owned by the university and the city, an unusual arrangement that made it both Palo Alto's community hospital, with a medical staff of community doctors, and Stanford's teaching facility, with a separate staff of faculty physicians. This arrangement lasted only eight years before discord between the two staffs led Stanford to buy out the city's share. While community physicians could continue admitting patients to the newly named Stanford University Hospital, there simply were not enough beds to go around, even after the old hospital reopened as Hoover Pavilion. Community doctors were also dissatisfied with their lack of involvement in hospital operations.
Frustrated, the Palo Alto Medical Clinic decided to build its own hospital on a site between Bryant and Waverly streets. The city approved the plan but, as would later happen with the Clinic's 1991 campus proposal, fierce opposition arose from nearby residents concerned about changes to their neighborhood. The issue again came to a citywide vote in 1970, and despite door-to-door campaigning by the Clinic's doctors, was narrowly defeated. Initially disappointed, the Clinic began to focus instead on providing as many services as possible in the outpatient setting, a decision it subsequently found benefited both patients and physicians.
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