In the Beginning February 1997
Although our society was established in 1868, the written record occurred some 81 years later. The official publication of our predecessor society, “The Sacramento Society for Medical Improvement” began in September, 1950 as “The Bulletin.” Dr Charles E Grayson, MD, was the editor. There were reporters for Sutter General, Sutter Maternity, Mercy, and the County Hospital. Each hospital had a brief written report monthly. There were reports from the medical staff meetings of each hospital as well as the monthly Society meetings which met on the third Tuesday. There was a book review column and a “Sense and Nonsense” column. Dr Grayson, in his first editorial, indicated that “The Bulletin” was not intended as a newsy chit-chat to be discarded after read, but a voice for our interest… expression of our opinions.
The second issue in October proudly announced: “It’s assured: the society is going to own, operate and control is own telephone answering service. Plans have been completed and the society exchange will go into operation in December upon the completion and the distribution of the new telephone directories. Enough members have signed up for the service to assure its actual establishment.” The vote was 4 to 1 in favor of the society having its own exchange. The telephone company cooperated by making a large investment in cables and equipment for installation at our headquarters office. “It will play an important part in helping our society fulfill its guarantee of good medical care twenty four hours a day to the residents of this community. There was one number– Hudson 1-0157–which was advertised as the outlet for medical service day and night in the public interest.
Forty years ago…
In 1957, “The Bulletin” format changed from a standard typing page size to about half that, or the “catalog” size. The hospital column, “Around the Hospitals” had changed to include Sutter General, Sutter Memorial, Mercy, and County. Mercy announced that they found four new precious and much needed beds; Sutter formed a staff society; and County instituted a four year training program in pathology. The burning issue for the society was a three part series on the California Physicians Service. Physicians were complaining about not having a voice in setting the fees for its 13,000 members which were spread over an area 1,000 miles by 200 miles… all of whom were limited for reading time… A new method of artificial respiration for babies under two years of age was reviewed.
Twenty seven years ago…
The name of our official publication was changed to “Sacramento Medicine” on January 1, 1970. It began in newspaper format. The burning issues with lead articles included “Malpractice rates: Why do they climb?” “The AMA . . . Needless or Necessary” and “No chiropractic in Medicare, HEW urges.”
Tomorrow…
We hope to bring you vignettes of yesteryear as recorded in our archives on a monthly basis. If you have vignettes from “Yesteryear,” we’d be interested in your contribution to our ongoing historical perspective. We welcome your input.
One Hundred Forty-seven Years Ago (1850-1857) March 1997
J Roy Jones, MD, in his History of the Medical Society of the State of California, recorded that on May 2, 1850, the Medico-Chirurgical Association of Sacramento was organized for the purpose of the “cultivation of science; the promotion of honor, dignity and interest of the profession, and the separation of the regular from the irregular practitioners.” The following month on June 22, 1850, San Francisco physicians came together to organize their first medical society. For two weeks, beginning on February 24, 1856, a daily notice appeared in the San Francisco and Sacramento newspapers stating: “WHEREAS, The time has come for medical men of the Pacific Coast to turn their attention to the elevation of the profession, and whereas an efficient State Medical Society would do much towards accomplishing the result, therefore, RESOLVED, That we the members of the Sacramento Medical Society and of the San Francisco County Medico-Chirurgical Society, consider it not presuming too much to take the initiatory steps by inviting the medical men of California generally to meet in convention for the purpose of organizing a State Medical Society…” The second annual session of the California State Medical Society was again held in Sacramento on Wednesday, February 11, 1857. President, Benjamin F Keene, the first president (from El Dorado Co) had expired on September 5, 1956 and senior Vice-President, Dr E S Cooper occupied the Chair. Dr J F Montgomery of Sacramento greeted the assemblage and expressed appreciation to the Sacramento Society for having been granted the privilege of being host to the State Society, reiterated the why, what and when for a general communion, and stated that if the objectives were attained, even in a measure, the profession would thereby command more of the public confidence. Delegates were received from the San Francisco Pathological Society, Sacramento Medical Society, El Dorado County Medical Society, San Francisco County Medical Society, San Francisco County Medico-Chirurgical Association, Yuba County Medical Society, and the Sacramento Pathological Society.
Forty years ago (March 1957)
Dear Editor: “…it was quite obvious that the chairman of our Medico-Legal Committee did not agree with the chairman of our Insurance Committee on the subject of Mal-Practice. The debate between these two gentlemen had been constructive and of considerable educational value … until recently. At the last meeting of the Sutter Hospital Staff the ex-chairman of the Medico-Legal Committee was granted time to make a speech… He is an excellent public speaker. Aside from the questionable propriety of such a speech at a hospital staff meeting, I for one, am convinced that the Society will eventually arrive at more mature and practical decisions in this matter if the arguments–pro and con–be confined to the pages of this journal. Although there are a few among us having rhetorical ability with the spoken word, most doctors are accustomed to present their ideas in writing and are more comfortable in this medium. Much of the unfair advantage of quick-witted repartee, ridicule and sarcasm is neutralized when ideas appear on the printed page. For example it looks rather ridiculous to say that we should ignore the advice of the Medical Protective Company of Fort Wayne, (the only company that is exclusively engaged in the business of malpractice insurance…for more years than any of us have lived). Yet this same idea, embellished with appropriate sarcasm, sounded real good in the speech at the Sutter Hospital…” The editor replied: “The ideas expressed in this column may be at times controversial. The widest possible latitude will be allowed, and there will be no editorial interference with the contents of the letters. All sides of any question will be considered.”
Twenty seven years ago (March 1970)
The cover article concerned the CMA Session which acted on abortion reform, national health, malpractice, a statement against strikes, reported the start of the CMA Continuation Medical Education plan, and announced a dues increase from $90 to $110… Dr Paul Hattersley had a column “The Publishing Sacramento Medic” which reviewed 6 publications by members and requested that doctors report their publications to him… Dr R Alexander had an “Eating Out” column in which he critiqued the Ram Restaurant, Marina Inn, and the Warehouse Cafe in Port Costa… Bill Dochterman calculated that the state premium for each MediCal recipient was $47.75 per month while the Foundation plan was $13.56 a month and suggested that the state simply buy each MediCal recipient a private insurance policy.
One Hundred Forty Years Ago (Jones: 1857-1862) April 1997
This was a turbulent period in California medicine as the nation was dealing with abolitionists and slave holders. When the state society met in San Francisco in February, 1858, there was “debt; a lack of harmony,..too many living within their own cosmic bubble refusing to comprehend or see or help remedy a critical situation…” The retiring president, Dr Henry Gibbons in his final address stated “that our Society is in a pathological condition.” At the annual meeting in 1859, Dr Beverly Cole read a report on female immigration to this country.// “We find … young, inexperienced women… who at the most critical period of their lives, and danger to their chastity and virtue… removed from the guardianship and healthful advice of their mothers.. yield to the solicitations of the opposite sex and seductive allurements… when…two in every three females, who have reached the age of fifteen, to be victims of this dissipation…” Eight or 10 doctors walked out on the speaker. The Western Press took up what they designated an insult to western womanhood. The editor of the Pacific Medical and Surgical Journal stated “one more word and we are done with California Medical Societies, and their stupid and nauseous reports…”\\The state society again met in Sacramento February 8, 1860 with only 14 doctors present (down from 100) .
Forty five years ago (April 1952)
The president Dan Kilroy, MD, chided the membership in the president’s column for poor attendance at the monthly scientific and business meetings… A good portion of the Bulletin was taken up with “Around the Hospitals” in which reporters from each of the hospitals summarize their staff and hospital news… The Editorial Board of the Bulletin was struggling with whether they should continue the excellent quality and general air of a first class bulletin and lose money, or cut corners and show a profit. The editorial board by unanimous vote, decided to maintain a high quality bulletin for a “reputation is more easily destroyed than regained…” New society members included Robert C Lewis, MD, Richard C Ripple, MD, and Charles M Webster, MD… The editor, Hale Giffen, MD, offered thanks to Paul Guttman for his vision of the library now housed in Sutter Hospital which was expanding considerably. He notes that this library will eventually pass into the hands of the County Medical Society.
Thirty years ago (April 1967)
The lead cover article discusses the Health Manpower Revolution. The year 1967, one year after the introduction of Medi-Cal and Medicare, finds the government in a dilemma. Now that the laws… and regulations are drawn, there is an acute shortage of people to implement the programs… The President has ordered “crash” programs to provide manpower–to double the 100,000 nurses, technicians, aides, and orderlies now graduated annually. The articles outlines the various federal and state acts with huge expenditures to plan and develop health manpower programs… The society president, James Martin, MD, devotes his column to the previously adopted program for emergency care in the county based on a comprehensive study which now must be revised because of Medicare and Medi-Cal. The society activated a committee to make recommendations for emergency care… The editor, Howard Linder, MD, discussed the disappointment of society members with the present Bulletin format, which is more like a local Garden Society Newsletter rather than a classy lay-out with considerable substance and a variety of material. In this age of “Big Brother” government, the IRS has cast a shadow over publications of this type with their ruling on taxable advertising income. Several societies have eliminated advertising entirely and reduced their “Bulletins.” He states the entire matter boils down to money and whether or not added dues expense to improve the bulletin is justified. He concluded that a medical society of our size should have a more presentable publication rather than “press the zerox button” style to inform the membership of the bare necessities.
Tomorrow
Hospitals, pharmacies, and laboratories no longer need to advertise in the managed care environment. Without this revenue, is Sacramento Medicine important enough for our members that a portion of our dues should be allocated for its support?
One Hundred Forty-four Years Ago May 1997
In 1853 the City of Sacramento built its first City/County hospital to care for the indigent sick located at 10th and L streets. The hospital served the community for twelve years. A larger hospital replaced the first in 1870, and following its destruction by fire in 1878, a new hospital was constructed, containing 150 beds. The hospital treated only patients who could prove both their residence in the county and their indigence.
Forty five years ago (May 1952)
The editorial dealt with polypharmacy, the compounding of remedies containing many ingredients. He felt the moon must be right for the practice was again flourishing as he describe an adjunct for obesity that contain fourteen different substances–which could only have been dreamed up by a former employee of the Pullman Company. But he also deplored the little capsules sole by pharmaceutical houses which didn’t allow for individual variations. He concluded, “If this present tendency keeps up it is confidently predicted that the future pharmacist will need only to know how to read, how to count, and how to use the cash register.” … The Editorial Board of the Bulletin gave a new assignment to a member to interview patients, friends, and relatives to find out what they are saying about the medical profession. The first column started this month titled, “On Long Waiting Periods in the Doctor’s Office.” … There was a book review on “Cost of Medical Care” by Emily H Huntington. A survey of 455 families in the San Francisco area reveals that the average annual expenditure per family for medical care was 6% or their total income; 40% required no medical care during the year; 45% had health insurance; and 20% were covered by a pre-payment plan. Mrs Huntington stressed that 17% were unable to pay for their medical care from current earnings and found it necessary to either draw on their savings or borrow money… (Editorial comment was: “One cannot help but wonder what this economist thinks savings should be for.”) The average expenditure of the women was five times the amount spent by their husbands; 85% went to MDs (yearly cost $115) and 15% went to chiropractors, osteopaths, Christian Scientists, etc. (Yearly cost $45). “Advice to families to budget in advance for medical expenses is futile,” she said. “The only way that real protection can be accomplished is through a system of Compulsory Health Insurance.” (Editorial comment was: “Perhaps the kindest comment that can be made is that this work appears to be in the category of research-with-a-foregone-conclusion.”)
Thirty years ago (May 1967)
CMA delegates handled 107 resolutions with efficiency. A resolution to take no official stand on the recently proposed therapeutic abortion law was defeated; elimination of Medicare’s 3-day hospitalization requirement prior to admission to an extended care facility was encouraged; called for CMA to take all possible steps to eliminate the drug formulary under the Medi-Cal program; urged caution in the new field of weight reduction; a request to have airlines not provide complimentary cigarettes with meals was turned down; supported legislation requiring motorcycle operators to wear properly designed protective headgear; Medical Schools should explore ways to attract and train general practitioners; work with the California Bar Assn to alleviate the problem of vexatious litigation; explore education programs to the profession and to the public in regard to marihuana, LSD and other hallucinatory drugs. . . Reported that Americans are increasing their spending for health care, but they still spent more for liquor and tobacco ($21 billion) than for hospital, drug, and doctor bills combined ($20 billion). Physicians received 27.7 cents of the health care dollar, essentially unchanged from 20 years earlier at 28 cents. . . The problem concerning IRS’ position on unrelated advertising revenue and how it effects the Sacramento Bulletin was reviewed by the Executive Director, Bill Dochterman.
Forty-five Years Ago (June 1952) June 1997
CMA had a debate on their association with CPS (Blue Shield). They re-affirmed that CPS is inextricably linked with the CMA despite the allegations from within and without the profession, “What are the doctors doing in the insurance business?” …If CPS can be channeled for low income group, the Committee feels it will be a true expression of the principle of service which has been the hall mark of our profession since the beginning of history… In closing, I give you one direct quote from the report: “He who controls the payment of medical care costs controls medicine–whether that be the state, the commercial insurance companies, the hospitals, industry, labor or doctors themselves.” –Dave Dozier, MD.
Thirty years ago (June 1967)
An article by James E Bryan, former executive administrator of the New York County and the New Jersey State Medical Society, was reprinted and is relevant today. A brief excerpt including the ten commandments (non-Mosaic) are as follows:
If the medical school is your medical mother–the womb in which your professional skills took on shape and substance–then your county medical society comprises your medical family. For whatever else it may do for you, your county medical society provides the family environment which will nurture, protect and enlighten you throughout your professional youth and maturity.
The county medical society–and indirectly, the state association and AMA–uniquely embraces all physicians; the teacher, researcher, health officer, administrator and the great body of clinicians. Thus the county society is the skeletal structure and central nervous system that coordinate all the diversely specialized parts of the total body of medicine. And as specialism has expanded and proliferated, this coordinating function of the county society has become ever more vital to the integrity of the profession…
Until a doctor has accepted–without reservation–the concept of his county society… as his professional family and as the one association embracing his total profession, there’s little benefit he can derive from the society, and very little he’s likely to do for the society, either…
And I think it’s equally important–in adjusting our philosophical stance toward the county society-to recognize that the really vital services it will and can render you, as an individual, are intangible, literally immeasurable and incalculable, in terms of dollars and cents…
The medical society exists primarily as an instrument through which its members can achieve certain ends that they could never hope to achieve alone. This instrument should do the following for you.
1. It represents you and your colleagues in public health and welfare programs. 2. It interprets you–your training, motives, problems, professional aims and objectives–to your community.
3. It tries to nurture a favorable public concern toward your profession by helping people to understand and appreciate medicine’s contribution to the public welfare.
4. It guides the development of medical practice in relation to other callings and economic groups.
5. It protects your legal status as a doctor.
6. It protects the public against exploitations by quacks and frauds, and keeps medical competition on a professional plane.
7. It controls the depredations of the small minority of doctors whose interest in the profession is only an economic one.
8. It promotes and guides the prepayment plans and other economic devices designed to help patients’s pay for your services at the least burden and sacrifice to themselves.
9. It helps your profession to meet its collective responsibilities to the public and avoids the necessity of the public resorting to political devices to solve these problems.
10. It helps you to survive and have your voice heard as a responsible professional man in an increasingly interdependent and socialized society.
Forty-five Years Ago (July/August 1952) July/August 1997
The lead article was the medical society’s new phone number from HUdson 1-0157 to HUdson 1-2771 to allow for more trunk lines in rotation… The AMA selects our exchange as example in nationwide survey.
The editor is concerned about the criticism of the CPS, the California Physician Service (Blue Shield). He argues that the reason doctors are unable to set fees on which insurance might be based is because doctors can’t set fees based on a diagnosis because every diagnosis requires different responsibilities. Some pneumonias are easy to treat and some develop complications. The price of automobiles, beef, and pants increase in cost constantly… a physician’s fee is a fee for service and the value of the service varies enormously… The editor also supports hospital costs stating, “I doubt there is a group in the entire country which has tried harder to keep costs down than hospital administrators.
The State Personnel Board announced raises in salaries of physicians employed by the state… to $644 per month for a beginning physician and surgeon 1 to an ultimate $1,100 for Director of Clinical Services.
The Laboratory Corner by C M Blumenfeld, MD discusses the importance of the biopsy examination from two points of view. One is that the surgeon must give enough data to facilitate the pathologist to make the most accurate diagnosis possible. Normally it is the pathologic diagnosis which defines the final diagnosis in the medical record.
The “Around the Hospitals” column announces that Mercy is building a new pediatric addition… John Babich is back in town after three year residency in St Louis… Jack Chambers, who was an accomplished carpenter was laying bricks. Just getting ready for the day that socialized medicine might come… Stories about doctors vacations experiences completed the column.
Thirty years ago (July 1967)
Headline: Dwight L Wilbur, San Francisco internist, was unanimously elected president-elect of the AMA. Dr Wilbur’s father served as AMA president in 1924 as well as former US Secretary of the Interior and President of Stanford University. The new president-elect’s son, Dr Dwight L Wilbur, III, is a Sacramento internist.
A three column article excerpted a paper delivered by Paul Harvey, ABC news analyst and commentator at the 1967 AMA meeting in Atlantic City on June 17. He chided the profession for confusing the public urging increased Government responsibility for our “welfare.” He noted that 30 million citizens are getting all or part of their medical care from the Government. Yet renowned physicians lend their names to further efforts to provide “government medicine” for all our citizens. Why? Not one of the 26 “Physicians for Health Care for the Aged through Social Security” is a full-time practicing physician: yet because doctors’ names are news, they have influence all our of proportion to their numbers and clinical experiences. I do not impugn the integrity of these distinguished doctors, but I am concerned that they allow their reputations in one field to lend undue importance to their advice in another; thus, a handful of articulated doctors are self-appointed spokesmen for the rest.
And a final brief note that San Diego County Medical Society is urging all hospitals in the county to discontinue the sales of cigarettes and announces that one-third have already taken such measures. (Editor’s Note: Even 5 years later, I was unable to implement this at American River Hospital in 1972.)
Forty-five Years Ago (September 1952) September 1997
The Board of Directors was asked to give its opinion on society members listing their names, addresses, and telephone numbers in directories other than Sacramento. The Board felt this procedure is not in good taste and is a discourtesy to physicians of other communities where the listing would appear.
An inquiry was made if any of the society members present had ever seen a case of Hay Asthma or Summer Catarrh in California. This disorder was under investigation in the Atlantic States where many individuals were so harassed by the annual recurrence of the disease that they fled regularly from their houses to seek places of refuge. It was concluded that Haying Asthma did not occur in California.
Doctors were informed of the serious adoption problem in Sacramento County, one of the larger, more populous counties. Direct costs of care for children in foster homes was estimated at $45,000 a year. One child had over twenty separate placements, eighteen children had more than five placements. The only agency authorized in this area was The Children’s Home Society of California. However, nonagency adoptions exceed agency adoptions 10-1. Physicians who helped unmarried mothers during the last stages of pregnancy secure legal release received the resented “Gray Marketeer” designation.
Thirty years ago (Sept 1967)
New abortion law goes into effect. This allows the termination of pregnancy in JCAH hospitals if the pregnancy is the result of rape or incest, and the DA’s office concurs such a crime occurred, or the physical and mental health of the mother is in grave jeopardy, and unanimous approval from a committee of the medical staff of not less than two members of the medical staff. No abortion may be performed after the 20th week of pregnancy.
The society sponsored new tax-sheltered Keogh Retirement plan for members and their employees will take place in October. Wells Fargo Bank was retained as the Trustee to manage the Keogh contributions.
Dr Orland Wiseman, an antique car enthusiast, tells about the “Horseless Carriage Club of America and his own two antique finds. In 1949 he found a 1911 Firestone in a field outside Stockton, and in 1950 he found a 1912 Cadillac in a barn in Willows. He then describes the restoration which comes after the acquisition. If you know of a 1908 Winton, he offers to cancel out the afternoon and follow your directions to acquire it.
Forty-five Years Ago (October 1952) October 1997
Considerable space in this issue is given to legal aspects of the adoption process. This was a continuation of the article started in the Sept 1952 issue.
There were also several pages on infant mortality and child health.
Among the various hospital reports, Sacramento County Hospital announce, in addition to their night courses for aspiring lab techs, that there were 479 autopsies done the previous fiscal year. The current rate was 75%.
The editor deplores the poor re-imbursement for insurance physicals which at $5 minus the usual costs leaves $1.46 for a 30 minute examination.
Thirty years ago (Oct 1967)
Members of the Society have been receiving information from banking institutions encouraging them to use credit cards. The Judicial Council of the AMA has regarded the use of credit mechanisms as unethical. However the past year the AMA softened its official position on the use of credit cards in a more permissive direction by citing local option as the determining factor. In view of these developments the Board of Directors considered this issue at length. It was the conclusion of the Board that the use of credit cards in the Society’s jurisdictional area for the payment of medical bills is not recommended. Arguments which formulated this decision included the following: The banks charge a $25 enrollment fee. Physicians charges are discounted 3% to 6%. The doctor must maintain an account at the bank where the drafts are deposited. He must post a sign in his office. The patient must pay 1 1/2% interest after thirty days which increases the cost of medical care to our patients. Thus credit card usage is not considered in the best interests of the profession or our patients.
The new measles vaccine has reduced reported cases of measles to one-third of the previous year.
The Insurance Review Committee issued extensive guidelines to all health plan underwriters to streamline their work, that the health plan retain a local physician to serve as its medical advisor, that the involved physician and the insurance carrier be present as necessary, and for the insurance carrier to abide by the committee’s recommendation.
The president of the California Medical Association urges the state’s physicians to continue treating Medi-Cal patients with the same high level of care that they have been providing since the program’s inception even though there is confusion about whether the state will pay them for their services later. “The risk of nonpayment is minor compared with the on-going care of ill people during this fiscal crisis,” according to Doctor Morrison.
Forty-five Years Ago (November 1952) November 1997
The November 1952 issue of Sacramento Medicine illustrates that practice issues, just as today, were of major concern. The lead article was written at the request of the editorial board concerning the handling of professional collections. John Collins, manager of a credit bureau, discusses the controversy around the recovery of professional accounts. It has long been recognized that professional accounts are a problem in view of the fact that they are not, in most cases, voluntarily incurred as are purchases made in a commercial establishments. This is compounded by the fact that no ailing person is ever knowingly refused service by a doctor. This combination requires the study of each debt as a separate problem to be handled by people trained in the proper attitude and cognizant of the importance of maintaining the high regard of the patient for the profession as a whole. In the field of collection there are two distinct attitudes. There is the co-operative or merchant controlled agency guided by a board of directors in the credit granting and collection work with a professional man on the board who is actively engaged in its work. And there is the independent collector who rightly has the purpose of earning as much money on his investment as is possible. Hence, every account he accepts presents a challenge to be handled in the least possible time, recovered as rapidly as possible, while obtaining as high a commission earned as the contract will permit. This commission is quite standard from 50% on small accounts dropping to 25% on large accounts. Professional accounts are generally mixed in with commercial collections. In either case, it is important for the medical office to work closely with the agency. The author from RCA felt that credit bureau accounts do better since they have the force of being the credit grantor for future needs of the patient.
California Medical Association reported a surplus for the fiscal year and anticipated a surplus for the following year. Some members of the association feel that both a balanced budget and a reduction of state dues would be possible if some unessential expenditures were reduced or eliminated.
The women’s auxiliary has been so successful in their nursing scholarships program that 18 county medical auxiliaries have joined the program. The auxiliary has given a total of 87 scholarships including 24 this year to girls from all ten of the Sacramento County high schools.
The California Chiropractic Association has engaged a professional signature-gathering firm to secure the filing of approximately 150,000 valid voter’s signatures to present an initiative measure to the California legislature authorizing the issuance of “Chiropractic Physician” certificate. This would authorize the holder to do practically everything done by a physician and surgeon except “major surgery, practice dentistry, and optometry.”
The average hospital bed accommodates forty patients a year up from twenty patients a year 20 years ago. During this time physicians incomes increased 41%, hospital rates increased 135%, and production workers earnings increased 165%. During this time the physician’s share of the medical dollar decreased from 32 cents to 28 cents whereas the hospital portion increased 66% from 14 cents to 23 cents. Despite these increases, the American public is spending three times as much for alcohol, recreation, and tobacco as for medical care.
Thirty years ago (Nov 1967)
A San Francisco newspaper report claimed that 1200 California physicians received $70,000 each from Medi-Cal. This precipitated a personal visit by Mr Carel Mulder, director of the Office of Health Care Services, to appear before the CMA Council on November 4, 1967, for a full explanation and apologies. It seems that some reporter had taken the total MediCal gross payment and divided it by the number of physicians receiving payment to come up with $70,000. Mr Mulder pointed out that this included a very large sum paid to the Social Security Administration as premiums in accordance with the buy-in provision of Title 18-B. Also large groups including Permanente were treated as one provider. Doctor Dwight Wilbur pointed out that this seems to be the sign of the times.