PERSONAL HISTORY: Reflections on a Long Career

Note: Dr. Alpert wrote the following letter to friends and colleagues upon his retirement.

It is with a certain amount of sadness and apprehension that I announce the end of my career in clinical urology. The week of Aug 5th, 2013, will be my last in the urology department, where I started 39 years ago. I will be continuing on in my administrative role as our medical-legal chief, and will begin work on an exciting research project with Dr. Stephen VanDenEeden, an epidemiologist at our Division of Research. I have developed a novel proxy for PSA screening, and we will be looking at Kaiser Permanente Northern California data on our prostate-cancer patients to see if PSA screening in our patient population has decreased prostate cancer-specific mortality rates.

As I leave the world of clinical practice, I find myself reviewing our accomplishments over the last four decades. I came to San Rafael in 1974 after completing a urology residency at UCSF, and then a two-year military obligation at a Regional Air Force Medical Center in Southern California, where I was a staff urologist and chief of pediatric urology. I started as the first urologist at the Kaiser Permanente Medical Center in San Rafael as our new hospital was under construction, seeing patients in rented clinic space we had on Professional Center Parkway, and doing surgery in San Francisco.

Our new hospital opened in 1976, and with this, our growth in Marin County increased dramatically. By 1977 we were large enough to add a second urologist. I was delighted to hire Dr. Tony Eason, who was finishing the UCSF urology program a few years behind me. We were now growing pretty rapidly, much of it in Sonoma County, and in the early 1980s, we opened a small satellite clinic in Santa Rosa, and Tony began staffing the urology clinic there once a week. We soon had enough growth to justify hiring Dr. Gary Nicolaisen, who turned down an academic job at UCSF/San Francisco General to come to San Rafael.

The three of us were then the urology department over the next two decades. We did hire several additional outstanding urologists, but that was to create a new urology department for our medical center in Santa Rosa. The three of us practiced together in an era when there was no subspecialization, and we literally did everything. We did the usual open stone surgery, nephrectomies, prostatectomies, cystectomies, scrotal and testicular surgery, trauma, and urethral reconstruction.

With the arrival of Gary, who had spent a year with Dr. Rob Kahn at UCSF learning the new technique of percutaneous nephrostolithotomy, we embarked on minimally invasive stone surgery. And since Dr. Gene Catollica at Oakland, Dr. Arjan Amar at Walnut Creek, and I were the only urologists around the region with any experience or interest in pediatric urology, we had a large series of children we operated on for everything from hypospadias, UPJ obstruction, horseshoe kidneys with obstructed ureters, vesicoureteral reflux, congenital megaureters, a small series of Wilm’s Tumors, and even a rhabdomyosarcoma of the bladder in a 3-year-old, who has since graduated from college. An amazing array of pathology paraded through our medical center.

We also continued to maintain our association with UCSF as clinical faculty with their urology department, working with the UC residents at urology teaching rounds at the San Francisco VA Hospital, and regularly attending UCSF urology grand rounds. Since retirement, Tony has taken on a job with UCSF as clinical supervisor and attending physician at one of the UC resident clinics at the VA once a week, and I plan to continue in my current activities at UCSF.

I have held many positions in San Rafael. In 1977, I officially became a partner in The Permanente Medical Group, and since I now had a department member, was appointed chief of urology. In 1978, Dr. Al White, my first physician-in-chief, appointed me medical-legal chief, a position I continue to hold. In 1981, Dr. Richard Geist became our physician-in-chief and asked me to become the assistant physician-in-chief, a position I held until 2001. Under Richard, I also became our risk manager, headed up the Credentials and Privileges Committee, started a precursor of what would become a facility Ethics Committee, and spent six months as our acting physician-in-chief in 1990, when Richard was in Saudi Arabia for Desert Storm.

We did the first regional urology study in the early 1980s, showing the power of our large patient population in studying important clinical questions. Using all our regional urologists, we asked vasectomy candidates who had an orchiopexy for an undescended testis as a young child if they would undergo unilateral vasectomy on the non-operated testis. Our finding was that the vast majority of these patients were azoospermic after unilateral vasectomy, and the remaining few had extremely poor sperm counts of 1-3 million, meaning that orchiopexies done in childhood did not preserve fertility in the operated testes. This finding was independent of the child’s age at the time of the original surgery, which ranged from 1 to 10 years.

We also created the prototype for our current Member Physician Satisfaction program in 1985, when Richard asked if I could design a training program for our physicians to improve patient satisfaction. I enlisted the help of my psychologist wife, Dr. Geri Alpert, who had worked with well-known Harvard psychologist Dr. Robert Rosenthal for four years as her mentor and doctoral thesis advisor. We created a 19-item questionnaire aimed at determining a patient’s perception of the quality and caring of their physician. The questionnaire was given to patients as they departed the medical center.

We were able to show over a 12-month period that by merely giving these scores back to physicians, and showing them where they placed in their departments and in the medical center, we substantially improved physician performance. The results were so impressive that they were presented to The Permanente Medical Group board of directors, and then to the Kaiser Foundation Hospital board of directors. The project was picked up regionally and expanded into what is now known as the Member Physicians Satisfaction Program. This program continues to generate and document remarkable improvements in member satisfaction with physicians. I am proud to say that San Rafael has led that performance, perhaps because we had a several-year head start on the rest of the region.

When I turned 60 in 2001, I stepped down as chief of urology and assistant physician-in-chief, and cut my schedule down to 3.5 days per week. This schedule allowed me to continue part-time in urology, do my medical-legal job, and still have time for outside things like skiing, doing significant construction and remodeling projects, as well as ballroom dancing, theater, reading and sculpture (see photos). My new schedule should be another step down but still allow me to be both challenged and productive.

Fortunately, the urology department is in sterling condition. While Tony has been retired for five years and Gary will be retiring in November, we have been building a new department over the last 10 years. We have continued with my original policy of only hiring people who were smarter and better trained than we were, and we leave you with four superbly qualified and trained urologists.

---

Dr. Alpert retired from his 39-year clinical urology practice at Kaiser Permanente San Rafael in 2013.

Email: paul.alpert@kp.org