Volume 16, Issue 2
Spring 2004
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Feature Article
Dr. Robert S. "Tom" Thompson:
Group Health’s "father of preventive care" looks back at 32 years of
service
By Katie Saunders
In 32 years at Group Health, Robert S. "Tom" Thompson, MD,
has worn three hats—pediatrician, investigator at Group Health Center for
Health Studies (CHS), and director of Group Health Permanente’s Department of
Preventive Care. In the latter capacity, Thompson has used his skills as a
clinician, researcher, and policy-maker to help integrate preventive
services into the Group Health delivery system.
Commenting on why he augmented his one-on-one pediatrics practice with
endeavors in the public health arena, he says: "I wanted to make a
bigger ripple on the pond by applying public-health ways of thinking to
populations of people in health care organizations."
By all objective standards he has succeeded. In brief, Thompson’s
name is inextricably linked with Group Health’s Lifetime Health
Monitoring Program, Breast Cancer Screening Program, and automated
immunization tracking and reminder system, as well as a nationwide
increase in bicycle helmet use during the last decade. His semi-retirement
this spring marks the end of an era at CHS and an opportunity to celebrate
the career of a man Group Health Medical Director Hugh Straley, MD, calls
"Group Health’s father of preventive care."
Top
When Thompson came to Group Health in 1972, he had a clear goal: to
integrate evidence-based preventive services programs into large health care
delivery systems. "I never thought of myself as a
researcher first, whose research results might eventually benefit the
public’s health. A major focus of mine has always been on taking
interventions proven to work and building programs to successfully deliver
them," he explains. In other words, Thompson’s goal has been to
"translate research into practice"—a concept that is more
salient today than when he began practicing it more than 30 years ago.
Thompson says he sought to identify "holes that needed
filling" both in terms of knowledge and practice. That is, he looked
for instances where evidence of effectiveness was missing (e.g., bicycle
helmets, routine chest X-rays) or where effectiveness was a given, but the
intervention was not adequately delivered on a population basis (e.g.,
childhood immunizations). Again, this early emphasis on identifying
discrepancies between what is known and what is done in health care presaged the key message of the landmark Institute of Medicine report Crossing
the Quality Chasm published in 2001.
What accounts for Thompson’s clear focus and
"ahead-of-his-time" thinking? Basic personality may be key. He
recalls one of his medical professors at Johns Hopkins University saying:
"Remember boys, the commonest things are the commonest." That
sentiment resonated with Thompson, who described Hopkins at the time as a
place where the focus was on uncommon things, such as rare metabolic
disorders. "That wasn’t me," Thompson says. Rather, he
gravitated toward "big hitter" problems that affected large
numbers of people—areas in which a future "public health-er"
could make a difference.
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Thompson’s innate predisposition toward "the commonest" was
bolstered by his experience as an Epidemic Intelligence Officer for the
Centers for Disease Control and Prevention (CDC). While investigating
communicable disease epidemics in Washington State from 1967 to 1969, he
learned the importance of both the burden and potential preventability of
disease, and how epidemiologic tools can help to quantify these concepts.
Thompson realized that this same line of thinking could be extended beyond
communicable diseases to identify a broad array of public-health problems,
such as "epidemics" of potentially preventable bicycle
accident-related head injuries, inadequate childhood immunizations, and
domestic violence.
But where could a young physician/epidemiologist put such ideas to
practice? Thompson suspected Group Health might be a good match. He was
particularly impressed by the 1946 bylaws which read: "Group Health
will develop some of the most outstanding hospital centers and medical
centers anywhere, with a particular emphasis on prevention."
Further, he was attracted to the idea of capitated premiums, which largely
made moot the kinds of turf battles seen in fee-for-service settings and
helped clear the way to develop integrated programs to get "the
greatest good for the greatest number." Finally, he was inspired by
some of Group Health’s original members’ visions for integrating
prevention into the delivery system. He mentions a few specifically:
Aubrey Davis, Jack Cluck, Sandy MacColl, Carolyn MacColl, Ward Miles,
Eleanor Brand, Hilde Birnbaum, and Art Segal. "I owe quite a debt of
gratitude to some of the original Co-op founders," he says. "If
it hadn’t been for them, I wouldn’t have had a chance to take a run at
the thing in the first place."
That run began in 1972 when Thompson was hired as a pediatrician, an
occupation that grew out of his love of kids. Three years later, he was
named director of the newly-created Preventive Care Research area, later
to become the Department of Preventive Care (DPC). DPC, a branch of Group
Health Permanente, is sited within Group Health Center for Health Studies where
Thompson has held the position of scientific investigator since the Center’s
founding in 1983. Until 1997, Thompson divided his time between his
one-on-one clinical practice and his "public health" practice,
after which he devoted his time entirely to program development, research,
and administration related to prevention.
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Thompson’s vision and analysis were instrumental in the establishment
of Group Health’s Breast Cancer Screening Program (BCSP) in 1984, one of
the first instances of a health plan organizing and insuring screening
mammography for its entire enrolled population. In 1998, analyses by DPC’s
Stephen Taplin, MD, MPH, and colleagues showed that the rate of late-stage
breast cancers was lower at Group Health than that of the surrounding
community, and that the rate of late-stage disease was lower among BCSP
participants at Group Health compared to those who did not enroll in the
program. Thompson gives a lot of credit for the program’s start-up to
Group Health President and CEO Cheryl Scott. At that time, Scott was a
relatively new regional administrator who had the practical know-how
needed to translate a program vision into a reality, he says.
It was about this same time that Thompson homed in on injuries as an
area ripe for study. Teaming up with the University of Washington’s Fred
Rivara, MD, MPH, who later became director of the Harborview Injury
Prevention and Research Center, Thompson tackled the problem of bicycle
accident-related head injuries, which were responsible for about 600
fatalities each year in the U.S. in the 1980s. Although bike helmets
seemed like a logical solution to this problem, evidence was lacking as to
their effectiveness in preventing head injuries.
In a landmark case-control study published in 1989 in the New
England Journal of Medicine, Thompson, Rivara, and Diane Thompson
(Thompson’s wife) showed that use of bicycle helmets reduced the risk of
head injuries more than six-fold; the risk of a brain injury was reduced
more than eight-fold. Speaking of a ripple effect, bicycle helmet use has
since taken off throughout the U.S., with 20 states and 125 municipalities
having enacted bike helmet laws for minors. The annual number of bicycle
accident-related head injury fatalities averaged 552 per year for the four
years 1998-2001, compared to 663 per year for the four years 1987-90, a 17
percent decrease despite an increasing U.S. population.
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According to Thompson, once he entered the injury field, it was only a
matter of time before he and Rivara focused their energies on intentional
injuries, particularly domestic violence. Thompson cites statistics that
50 percent of homicides involving women have a domestic-violence
component. "If you’re a public health person like me, can you walk
away from something like that? I can’t," he says. So, he and
colleagues are trying to improve health care responses for domestic
violence. But he admits, "we have a long way to go." Part of the
problem is that the issue gets buried. Thompson explains that if one
relied on medical records of adult Group Health female enrollees, lifetime
rates of domestic violence would appear to be about 1 percent. On the
other hand, telephone survey data from 836 GHC women age 18-64 indicate
that lifetime rates are more like 45 percent. (This includes the entire
spectrum of violence, from threats, to controlling behavior, to rape and
other physical violence.) In an earlier attempt to raise the profile of
this issue among health care providers, Thompson and colleagues designed an
intensive multi-level, multi-factor intervention that resulted in a
four-fold increase in asking patients about domestic violence as recorded
in the chart. Thompson continues to work on this troublesome problem under
the umbrella of a 4-year, $2.5 million grant to study domestic violence’s health effects
and associated health care costs.
Immunization is another word inextricably connected to Thompson. In
1990, then-CHS Director Ed Wagner and Information Technology Manager Gene
Hart sent Thompson a CDC Request For Proposal with a handwritten note:
"We think this has your name on it." The document described a
multi-site research project that would study rare and not-so-rare
complications arising from childhood immunizations. Thompson saw this as a
golden opportunity to obtain funding to implement a Co-op-wide automated
immunization tracking and reminder system. In brief, his dream was
realized and the impact was immediate. By the first quarter of 1995, 90
percent of Group Health 2-year-olds received adequate immunizations,
compared to pre-tracking system rates of 63 percent in 1993.
Thompson remembers learning of the findings. "I ran down the hall
screaming, showing these graphs to anyone who would look at them," he
recalls, chuckling. The immunization program, greatly expanded from its
early days, continues to thrive under the helm of DPC’s Lisa Jackson,
MD.
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These successes did not go unnoticed on the national level. In 1996,
Thompson was one of 15 people invited to be part of a CDC Task Force on
Community Preventive Services, a group that influences public health
policy nationwide. For example, the Task Force issued a report in 2001
that analyzed evidence of the effectiveness of .08 blood alcohol state
laws (vs. .10 or higher). The report showed that the mere existence of
such laws resulted in a 9 percent decrease in traffic fatalities related
to alcohol-impaired driving. These statistics, counter to the alcohol
industry’s claims that the lower limits were not demonstrably safer,
were of great interest to the congressional appropriation committee with
oversight for the National Highway Traffic Safety Administration’s
budget. The result was a phased-in requirement that .08 blood alcohol laws
be enacted or the states would lose a portion of their federal highway
transportation monies. Again, the impact was immediate. When the Task
Force report was issued in 2001, 21 states had such laws; today the laws
exist in 47 states.
Looking back over 30 years, what are the highlights for Thompson?
"In terms of science, the bike helmet study was numero uno," he
says. "When you learn about science in school, they give you the
impression that you get results and wondrous things happen. Your discovery
spreads world-wide; disease is stamped out. With bike helmets, that’s
pretty much what happened! In terms of health effect, it’s about a tie
between breast cancer screening and immunizations."
Thompson realizes that achievements such as the bike helmet study do
not occur in a vacuum. Collaborations—both inside and outside Group
Health—are key. "At Group Health you’ve got good people, smart
people, and they want to help on the whole, rather than put up innumerable
barriers," he says. He continues to learn a lot from his colleagues
at CHS and his clinician friends. And over the past decade especially, he
has enjoyed mutually beneficial collaborations with several investigators
he has mentored, including DPC physician/investigators Steve Taplin, Lisa
Jackson, Tim McAfee, Rob Reid, and Beverly Green; Harborview pediatrics
chief Brian Johnston; UW Maternal and Child Health Program director
Colleen Huebner; and CHS Research Associate Amy Bonomi, MPH.
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While productive collaborations are clearly one reason for Thompson’s
success, there’s no denying the force of his personality. He allows that
he can be quite determined if the situation calls for it. As just one
example, Thompson submitted his original domestic violence grant five
times before it was funded. Thompson traces some of this persistence back
to his high school and college sports experiences, where he emerged as a
natural leader. "One thing that sports taught me was to never give up—never.
When I see a big problem that needs fixing, I can bring a lot of energy to
that," he says.
To what will Thompson devote this energy when he semi-retires? He plans
to work one or two days a week on the domestic violence grant. An avid
outdoorsman, Thompson also looks forward to spending more time at the
house he and his wife, Diane, recently built just outside the boundary of
Mt. Rainier National Park, an area he calls his "church." A
grandfather six times over, he anticipates spending more time with family
and other important people in his life. "I think as you get older,
you realize that the people connections are key," he says. In the
remainder of his "spare" time, he hopes to do more international
traveling and pursue an interest in horticulture.
Despite all of his accomplishments, Thompson remains quite understated.
When asked to sum up his career at Group Health, he said, "I think I
helped put health promotion and disease prevention on a pretty well
recognized and a relatively firm footing here." Contrast this
statement with Group Health Medical Director Hugh Straley’s assessment
of Thompson. "Tom has helped put GHC on the national map as a place
where prevention and innovation thrive. He is a national treasure and we
are a much better place because of him."
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Save the date!
Dr. Robert S. "Tom" Thompson will be the featured speaker at
the Fifth Annual Birnbaum Lecture at the Seattle Sheraton on Thursday,
November 18. This luncheon event—co-sponsored by the Group Health
Community Foundation and Group Health Center for Health Studies—is held each year
to encourage research that benefits patient care at Group Health. It is
funded by an endowment from Group Health founding members Hilde and Bill Birnbaum. More details to come.
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