CONTACTS 

SUBJECTS
Clear Concise Complete Communication Doctor Patient Partnership Advi

1003 -
1003 -    ..
1004 - Summary/Objective
1005 -
100501 - Follow up ref SDS 52 0000. ref SDS 49 0000.
100502 -
100503 - Kaiser's advice nurse in oncology excellent proactive management and
100504 - communications helping patients get guidance for timely treatment.
100505 - ref SDS 0 MW4O  Recommends tracking CA 15-3 cancer marker, and
100506 - contacting UCSF for 2nd opinion, when cancer does not respond to
100507 - treatment. ref SDS 0 MW4K  Millie thanks Arlette for help, ref SDS 0
100508 - NY8H; explains emotional toll trying to decide a course of action that
100509 - requires expertise with IBC. ref SDS 0 1L5P  Millie has heard Kaiser
100510 - does not have the best reputation, and feels her treatment has been
100511 - more than adequate. ref SDS 0 1L5X  Case study reviews issues on
100512 - Kaiser's work the past 5 years caring for Millie. ref SDS 0 K65G
100513 - Recent meeting at Kaiser illustrates IBC is a rare disease, which
100514 - doctors have less experience recognizing and treating. ref SDS 0 K65S
100515 - Millie presents challenge of busy doctor's finding time to study
100516 - ramifications of rare disease, like IBC, while treating a steady
100517 - stream of patients with more common cancers. ref SDS 0 K65L  Arlette
100518 - reports Kaiser oncology in Walunt Creek, CA has a good reputation, and
100519 - explains that doctors in the Oncology Clinic have experience treating
100520 - IBC, and doctors confer. ref SDS 0 NT8Y  Kaiser's Tumor Board meets on
100521 - Fridays to formally consider difficult cases and offer ideas for
100522 - treatment. ref SDS 0 NT9S  Kaiser sends patients to cancer centers for
100523 - treatment, when frontline practice supported by conferring, and Tumor
100524 - Board review seem inadequate. ref SDS 0 NT9X
100525 -
100526 -
100527 -
100528 -
100529 -
100530 -
100532 -  ..
1006 -
1007 -
1008 - Progress
1009 -
100901 - Clear Concise Complete Communication Doctor Patient Partnership
100902 -
100903 - Follow up ref SDS 52 8I5K.
100904 -
100905 - Millie received ref DRT 1 0001 from Arlette, responding to Mil's
100906 - letter, ref DIP 9 0001, submitted yesterday, ref SDS 52 GO9J, replying
100907 - to Arlette's letter commending Doctor Musci's work. ref DRP 9 0001,
100908 - received yesterday. ref SDS 52 8I5K
100910 -  ..
100911 - Called Millie and she asked to forward Arlette's letter to her at
100912 - N&P.  Did this.
100913 -
100914 -            [...below, Millie responds to Arlette. ref SDS 0 IM8K
100916 -  ..
100917 - Arlette says to Millie...
100918 -
100919 -    1.  Thanks for the update.  I am so glad your meeting went well
100920 -        with Doctor Musci. ref DRT 1 0001
100922 -  ..
100923 - Millie's letter to Arlette reported that she liked working with doctor
100924 - Musci yesterday, ref SDS 52 GO9J, and that examination indicates
100925 - cancer may have started to heal, following a long period of getting
100926 - worse, thus indicating delayed reaction to treatment, ref SDS 52 DT4R
100928 -  ..
100929 - Arlette's letter to Millie continues...
100930 -
100931 -    2.  Thanks for keeping me posted.  I got up early today to see if
100932 -        you had emailed me.  Till I hear from you again, my thoughts
100933 -        and prayers are with you. ref DRT 1 XZ6L
100935 -  ..
100936 - Arlette recognizes that clear, concise, complete communication in
100937 - Millie's letter last night, ref SDS 52 DT4X, strengthens patient care
100938 - called out in Kaiser's Healthwise Handbook, reviewed on 990625.
100939 - ref SDS 3 0806
100940 -
100941 -            [...Millie commends Artlette's support for patient care
100942 -            applying Kaiser's partnership model for effective
100943 -            communications. ref SDS 0 NY8H
100945 -  ..
100946 - Arlette's constructive letter today helps resolve Millie's concern
100947 - that clear, concise, complete communication has too much information
100948 - that prevents the medical team from providing effective care.
100950 -  ..
100951 - Arlette's close, careful attention to patient communication fits
100952 - requirements for effective support by the Advice Nurse that expedites
100953 - getting things done to ensure timely treatment called out in Kaiser's
100954 - Healthwise Handbook, reviewed on 990625, ref SDS 3 7H6J, and further
100955 - reduces the high cost of medical mistakes reported on 990912.
100956 - ref SDS 4 0001
100957 -
100958 -
100959 -
100960 -
1010 -

SUBJECTS
Patient Communication Crucial 1st Step Accurate Diagnosis IBC Red Ra

2203 -
220401 -  ..
220402 - Patient Communication Crucial 1st Step Accurate Diagnosis
220403 - CA 15-3 Criteria Delayed Response Treatment IBC Waxes Wanes
220404 - 2nd Opinion Best Practice Evaluate IBC Ebbs Flows Delayed Response
220405 - Ebbs Flows Waxes Wanes 2nd Opinion IBC Delayed Response to Treatment
220406 -
220407 - Arlette's letter to Millie continues...
220408 -
220409 -    3.  It is hard to tell what is going on, but at least we have hope.
220410 -        We'll see what CA 15-3 says.  If you say IBC ebbs and flows,
220411 -        then maybe that is what is happening. ref DRT 1 LM5L
220412 -
220413 -            [On 060810 CA 15-3 rises sharply from 71 to 87 indicating
220414 -            IBC worsening. ref SDS 55 2N5J
220416 -  ..
220417 - Arlette comments on Millie's concern that IBC has waxed and waned over
220418 - the years, noted in the 2nd opinion from Doctor Benz at UCSF, received
220419 - on 041117, ref SDS 19 OS6W, and so at this time there is no certainty
220420 - that visual improvement on 060808 represents actual subsidence of
220421 - disease, as set out in Mil's letter yesterday on 060808, ref SDS 52
220422 - DT8U, and citing the meeting with the doctor, also, on 060808.
220423 - ref SDS 51 HT5K
220425 -             ..
220426 -            [On 060817 CA 15-3 73 dramatic improvement, reversing 6
220427 -            month rise of cancer marker, now falling back below
220428 -            critical 80 level, ref SDS 56 TS5O; supports observation
220429 -            impression on 060808 that IBC red rash subsiding and
220430 -            breaking up, ref SDS 51 VO6G, further reported on 060817,
220431 -            ref SDS 56 NU6L, evidence patient experiencing delayed
220432 -            response to treatment under scenario #1, developed on
220433 -            060808. ref SDS 51 J16O
220435 -  ..
220436 - Arlette's letter to Millie continues...
220437 -
220438 -    4.  I hope not, but I would get over to UCSF right away, if I were
220439 -        you, once CA 15-3 is back and we know what is going on.
220440 -        I can get an updated packet ready for you.
220441 -        ref DRT 1 OL6H
220443 -  ..
220444 - Urgency getting a 2nd opinion "right away," reflects Arlette's letter
220445 - on 060807 on IBC aggressive disease that goes through the patient like
220446 - a "hot knife through butter," ref SDS 49 7Q8H, and cited by Millie in
220447 - her response later today, shown below. ref SDS 0 K65S
220449 -  ..
220450 - After getting this letter Millie asked about progresss scheduling a
220451 - meeting at UCSF for a 2nd opinion.  Planning for this project began on
220452 - 060721. ref SDS 36 IS6F  Patient history to support the effort was
220453 - updated on 060722. ref SDS 40 6L4M  Request for 2nd opinion was
220454 - submitted to UCSF on 060725. ref SDS 44 ST9O  UCSF has not yet
220455 - responded to the letter nor to several follow up calls.
220456 -
220457 -            [...Millie responds saying she is trying to get a meeting
220458 -            at UCSF for a 2nd opinion to assist her and Kaiser with the
220459 -            relapse problem. ref SDS 0 1L5P
220461 -             ..
220462 -            [...in another record today, called Margaret and scheduled
220463 -            meeting on 060821 at UCSF for 2nd opinion. ref SDS 54 YK6N
220465 -  ..
220466 - Not sure what an "updated packet" might entail and how it would be
220467 - used.
220468 -
220469 -            [...Millie's letter asks Arlette about this. ref SDS 0 OL6H
220470 -
220471 -            [...Arlette will assemble Millie's medical records for a
220472 -            2nd opinion at UCSF, and "update" means the records will
220473 -            start from the date of the last 2nd opinion issued by the
220474 -            doctor. ref SDS 53 4S5O
220475 -
220476 -
220477 -
220478 -
2205 -

SUBJECTS
Clear Concise Complete Communication Doctor Patient Partnership Advi

2903 -
2904 - 1247
290501 -  ..
290502 - Patient Commends Communication Kaiser Team Care Partnership Effective
290503 -
290504 - Millie submitted ref DIT 1 0001 answering Arlette's letter this
290505 - morning, ref DRT 1 0001, shown above. ref SDS 0 8I5K
290507 -  ..
290508 - Millie says to Arlette...
290509 -
290510 -    1.  I asked Rod to forward your email to my office, because I
290511 -        wanted to respond quickly.  I'm not sure what you mean by an
290512 -        "updated packet."  Would you please clarify?
290513 -
290514 -            [...see below for more. ref SDS 0 4S5O
290516 -  ..
290517 - Millie asks about Arlette's offer to assemble "updated packet," in her
290518 - letter this morning. ref SDS 0 3J4O
290519 -
290520 -            [...Arlette will assemble Millie's medical records for a
290521 -            2nd opinion at UCSF, and "update" means the records will
290522 -            start from the date of the last 2nd opinion issued by the
290523 -            doctor. ref SDS 0 XX4F
290525 -  ..
290526 - Millie's letter to Arlette continues...
290527 -
290528 -    2.  I know you are a busy person and I appreciate all that you have
290529 -        done for me.  I don't know I got such a caring person in my
290530 -        corner; I'm only thankful. ref DIT 1 0001
290532 -         ..
290533 -    3.  You are a sweetheart, and thanks for taking the time to put up
290534 -        with my long winded emails. ref DIT 1 HU7N
290536 -  ..
290537 - Millie commends strong support by the advice nurse for patient care,
290538 - per above, ref SDS 0 MW4O, and under Kaiser's Team Care partnership
290539 - model, also, cited above. ref SDS 0 NX7O
290540 -
290541 -
290542 -
290543 -
2906 -

SUBJECTS
Emotional Toll Patient Bombarded Advice Well Meaning Caring Friends

3703 -
370401 -  ..
370402 - Emotional Toll Patient Bombarded Advice Well Meaning Friends Relatives
370403 -
370404 - Millie letter to Arlette continues...
370405 -
370406 -    4.  I'm continuously bombarded by caring people telling me what I
370407 -        should do, i.e., go to AD Anderson in Texas (they're supposed
370408 -        to be the best Cancer Center), Mayo Clinic in Rochester, and
370409 -        even Rod badgering me to get second opinions.  I'm almost to
370410 -        the point of burying my head in the sand with so many people
370411 -        telling me what I should be doing.  I will attempt to see
370412 -        Doctor Benz at UCSF.  But, with his heavy schedule who knows
370413 -        when that will be.
370414 -
370415 -           [...in another record today, called Margaret and scheduled
370416 -           meeting on 060821 at UCSF for 2nd opinion. ref SDS 54 YK6N
370417 -
370418 -
370419 -
370420 -
3705 -

SUBJECTS
Kaiser Not Best Reputation Patient Cannot Complain Gotten More than

5503 -
550401 -  ..
550402 - Kaiser Does Not Have Best Reputation Millie Has Gotten Good Treatment
550403 -
550404 -
550405 - Millie's letter to Arlette continues...
550406 -
550407 -    5.  Kaiser apparently doesn't have the best reputation.
550409 -  ..
550410 - Kaiser's reputation varies according to patient experience.  Treating
550411 - many patients yields a range of experiences, including some who have
550412 - suffered from medical mistakes, reported generally in health care on
550413 - 990912. ref SDS 4 0001
550415 -  ..
550416 - Millie's letter to Arlette continues...
550417 -
550418 -        I cannot complain.  I feel the care I've been given is more
550419 -        than adequate.
550421 -  ..
550422 - Mistakes Lessons Learned Medical Practice Case Study Health Care
550423 - Medical Practice Case Study Kaiser Mistakes Lessons Learned Improve
550424 - Lessons Learned Improve Medical Practice Case Study Kaiser Mistakes
550425 - Case Study Kaiser Mistakes Lessons Learned Improve Medical Practice
550426 -
550427 - Lessons learned in Millie's case are listed on 040517, ref SDS 12
550428 - PW8F, reflecting experience resolving medical mistakes from hectic
550429 - schedule that limits time for review and anlaysis listed in the case
550430 - study on 040416. ref SDS 11 GN7J  Recent study on 060428 shows how
550431 - hectic schedule reduces time for reading test findings; doctors are
550432 - forced to rely on first impressions from analyst summarizing the gist
550433 - of findings.
550435 -  ..
550436 - This study focuses on opportunities to strengthen communication for
550437 - effective doctor patient partnership.
550439 -  ..
550440 - Kaiser's reputation was previously reviewed favorably on 050422 by
550441 - another cancer patient, ref SDS 23 LX5O, who also cited earlier on
550442 - 050414 opportunities for improvement, ref SDS 21 TE5X, that
550443 - complements review of the Kaiser Papers on 020221. ref SDS 5 EG4K
550444 -
550445 -           [...below Arlette explains Kaiser Oncology in Walnut Creek
550446 -           has a good reputation, and doctors are experienced treating
550447 -           IBC using Kaiser's team care practice to confer, ref SDS 53
550448 -           NT8Y, along with the Tumor Board. ref SDS 0 NT9S
550450 -  ..
550451 - Experience working with UCSF on 041018, ref SDS 17 YS9G, and the next
550452 - day with Stanford on 041019, ref SDS 18 0001, indicates superior work
550453 - with Kaiser's team care practice emphasizing a doctor and patient
550454 - "partnership," reviewed earlier on 990625, ref SDS 3 4185, and based
550455 - on strong communications, ref SDS 3 TD6Q
550457 -  ..
550458 - Medical mistakes in Millie's patient history are listed on 040416.
550459 - ref SDS 11 GN7J
550461 -  ..
550462 - Millie's patient history over the past five (5) years, and leading up
550463 - to mastectomy surgery on 051021 is reported on 050812. ref SDS 28 6L4M
550464 - Excluding work by the Infusion Clinic, key events on quality of care
550465 - for oncology show only about 20 or so issues that can be improved...
550466 -
550467 -        1.  Meeting review PET scan test
550468 -            report listing IBC symptoms;
550469 -            examination finding symptom
550470 -            IBC; diagnosis cellulitus,
550471 -            no action on IBC................. 030109, ref SDS 28 NJ5F
550473 -             ..
550474 -        2.  Meeting rising symptoms cancer
550475 -            relapse, biopsy deferred......... 030508, ref SDS 28 GU6F
550477 -             ..
550478 -        3.  Emergency meeting evaluate rising
550479 -            symptoms IBC relapse; biopsy
550480 -            PET scan test deferred........... 030606, ref SDS 28 E49H
550482 -             ..
550483 -        4.  Meeting review CT test findings
550484 -            rising symbptoms IBC diagnosed
550485 -            reaction to radiation
550486 -            treatment........................ 030710, ref SDS 28 UF77
550488 -             ..
550489 -        5.  Meeting to schedule treatment
550490 -            cancer relapse in neck; treatment
550491 -            deferred to treat IBC symptoms
550492 -            that require immediate treatment,
550493 -            misdiagnosed as
550494 -            cellulitus....................... 040318, ref SDS 28 IO4H
550496 -             ..
550497 -        6.  Doctor normally biopsies symptoms
550498 -            of IBC; biopsy deferred in this
550499 -            case during 2003, because biopsies
550500 -            invariably come back negative
550501 -            because IBC very rare, serious
550502 -            cancer........................... 040504, ref SDS 28 KY5K
550504 -             ..
550505 -        7.  Meeting doctor gives patient
550506 -            report on biopsy performed at
550507 -            request of patient; no discussion
550508 -            no explanation of IBC; patient
550509 -            discovers after the meeting that
550510 -            biopsy diagnoses IBC, independent
550511 -            research discovers very rare,
550512 -            aggressive cancer; tumor board
550513 -            not informed of IBC biopsy
550514 -            report........................... 040517, ref SDS 28 GR4F
550516 -             ..
550517 -        8.  Meeting doctor decides not to
550518 -            submit biopsy to Tumor Board
550519 -            to update analysis based on
550520 -            new findings of IBC.............. 040614, ref SDS 28 ST47
550522 -             ..
550523 -        9.  Meeting doctor removes patient
550524 -            from treatment drug trial with
550525 -            Taxol and Avastin, because Avastin
550526 -            side effects are pulmonary emboli,
550527 -            and CT test discovered blood
550528 -            clots; requires resuming
550529 -            treatment because IBC rash
550530 -            symptoms, CA 15-3 not yet
550531 -            resolved......................... 041104, ref SDS 28 9F3N
550533 -             ..
550534 -       10.  Meeting doctor defers resuming
550535 -            treatment of IBC with Taxotere
550536 -            previously effective, in order to
550537 -            invest time finding another drug
550538 -            trial for patient................ 041130, ref SDS 28 VY5M
550540 -             ..
550541 -       11.  Tumor Board review rejected
550542 -            evaluate status change patient
550543 -            removed from treatment due to
550544 -            pulmonary emboli, IBC
550545 -            relapsing........................ 041130, ref SDS 28 6K7F
550547 -             ..
550548 -       12.  Written work up evaluate patient
550549 -            status change and treatment
550550 -            options submitted with illegible
550551 -            diagram on examination table
550552 -            sanitation tissue
550553 -            paper............................ 041130, ref SDS 28 6K75
550555 -             ..
550556 -       13.  Meeting IBC symptoms rise; doctor
550557 -            defers treatment with capecitabine
550558 -            and Taxotere recommended in 2nd
550559 -            opinion by Doctor Benz at UCSF
550560 -            in order to treat patient with 2
550561 -            more cycles of AC which had been
550562 -            ineffective in 2002, but, was
550563 -            cited in complementary 2nd opinion
550564 -            by Doctor Guardino at Stanford,
550565 -            and so Kaiser hoped this would
550566 -            qualify patient for drug trials
550567 -            with capecitabine................ 041230, ref SDS 28 QT6Y
550569 -             ..
550570 -       14.  Meeting doctor IBC worsens
550571 -            again under treatment with AC;
550572 -            rather than switch to capeticabine
550573 -            and Taxotere, 2 more treatments
550574 -            with AC prescribed; protocol
550575 -            nurse reports patient cannot
550576 -            qualify for drug trials, which
550577 -            was original rationale for
550578 -            starting with AC................. 050204, ref SDS 28 S76K
550580 -             ..
550581 -       15.  Meeting doctor objects to 2nd
550582 -            opinions raising issues for
550583 -            due diligence review on Kaiser
550584 -            recommendation for mastectomy
550585 -            surgery to increase local
550586 -            control; urges patient to
550587 -            approve surgery.................. 050913, ref SDS 28 265F
550589 -             ..
550590 -       16.  Kaiser's due diligence Time Out
550591 -            requirements to verify need, scope,
550592 -            credentials, plans for surgery
550593 -            not performed.................... 050923, ref SDS 28 2N4N
550595 -             ..
550596 -       17.  Meeting doctor urges patient
550597 -            consent for mastectomy surgery
550598 -            without Time Out due diligence
550599 -            and for the purpose of
550600 -            palliation....................... 051007, ref SDS 28 MI3F
550602 -             ..
550603 -       18.  Blood clots pulmonary emboli
550604 -            hypecoagulable state work up
550605 -            recommended 2nd opinion based
550606 -            on family history and patient
550607 -            history of blood clot problem
550608 -            while on Avastin trial; work up
550609 -            not performed; Kaiser internal
550610 -            review cites risks of surgery
550611 -            ordered by primary care physician
550612 -            in Oncology; resolved by primary
550613 -            care physician ordering patient
550614 -            to end treatment with Coumadin for
550615 -            blood clots on grounds of causation
550616 -            by Avastin drug trial, and
550617 -            patient removed from trial 11
550618 -            months earlier................... 051007, ref SDS 28 MI45
550620 -  ..
550621 - Millie's patient history for mastectomy surgery on 051021, and follow
550622 - on care, with relapse 9 months later is reported on 060722.
550623 - ref SDS 40 XQ7H
550625 -  ..
550626 - Key events relating to improving quality of care include...
550627 -
550628 -       19.  Due diligence surgeon's report
550629 -            Kiaser requirements waived to
550630 -            explain necessity for surgery
550631 -            missing from patient
550632 -            history.......................... 051021, ref SDS 40 WR4K
550634 -             ..
550635 -       20.  Case study Kaiser changes
550636 -            purpose of surgery from local
550637 -            control to palliation............ 051027, ref SDS 40 C79L
550639 -             ..
550640 -       21.  Esophagitis likely diagnosis
550641 -            PET scan test pending review
550642 -            for treatment.................... 060217, ref SDS 31 DH4O
550644 -             ..
550645 -       22.  Read medical test findings - case
550646 -            study doctors do not have enough
550647 -            time to read findings and correlate
550648 -            clinically with compelx patient
550649 -            history that discovers symptomatic
550650 -            trends in time for proactive
550651 -            management; there is only enough
550652 -            time to read summaries and rely
550653 -            on 1st impression from the
550654 -            gist of findings................. 060428, ref SDS 32 VG5L
550656 -             ..
550657 -       23.  Pulmonary emboli blood clot
550658 -            problems primary care physician
550659 -            notified evident findings of
550660 -            family genetic cause no action
550661 -            to perform hypercoagulable
550662 -            state work up and resume
550663 -            Coumadin treatments.............. 060722, ref SDS 40 RT5N
550665 -             ..
550666 -       24.  Pulmonary emboli symptoms reported
550667 -            patient tired, difficult breathing
550668 -            climbing stairs at home and the
550669 -            BART station; patient reminds
550670 -            doctor about report of son's
550671 -            doctor finding genetic cause for
550672 -            pulmonary emboli; doctor orders
550673 -            CT test and requests report on
550674 -            son's genetic findings of
550675 -            pulmonary emboli................. 060929, ref SDS 58 CV5L
550677 -             ..
550678 -       25.  Pulmonary emboli diagnosed from
550679 -            CT test on 060930; doctor orders
550680 -            treatment with Lovenox
550681 -            and Coumadin to
550682 -            resume........................... 061002, ref SDS 60 MI5I
550684 -             ..
550685 -       26.  CT test 060930 doctor not aware of
550686 -            findings enlarged right ventricle
550687 -            heart disorder diagnosed in findings;
550688 -            hectic schedule not enough time
550689 -            to read test findings cannot
550690 -            remember reading patient's letter
550691 -            asking about severity; Kaiser
550692 -            cannot determine severity of
550693 -            pulmonary embolism comparing with
550694 -            original findings on 041103; cannot
550695 -            compare right and left ventricle
550696 -            for impact on pulmonary
550697 -            embolism......................... 061020, ref SDS 61 VJ4J
550699 -             ..
550700 -       27.  Medical chart mistakes patient history
550701 -            problems diagnosed, communications,
550702 -            medications, examinations doctor
550703 -            progress notes errors and
550704 -            omissions........................ 061110, ref SDS 62 FE4I
550705 -
550706 -
550707 -
550708 -
550709 -
550710 -
5508 -

SUBJECTS
IBC Rare Disease Many Doctors Not Familiar Doctor Musci Seemed Unfam

6003 -
600401 -  ..
600402 - IBC Rare Cancer How to Handle Relapses Kaiser Experience
600403 -
600404 - Follow up ref SDS 52 DT8U. ref SDS 49 JR9Y.
600405 -
600406 - Millie's letter to Arlette continues...
600407 -
600408 -        I do know that IBC is a rare cancer and not all doctors are
600409 -        familiar with it.  I asked Doctor Musci how many cases he has
600410 -        handled, and it took him a moment to respond.  He admitted not
600411 -        many and the few cases he has handled had not relapsed.
600413 -  ..
600414 - Recent background on Millie learning IBC is a rare and aggressive form
600415 - of cancer that goes through the patient like a "hot knife through
600416 - butter," which is often misdiagnosed because very few doctors have
600417 - experience treating IBC reported in the record on 060807, ref SDS 49
600418 - JR9Y, and citing initial discovery of IBC, also, presented on 060807.
600419 - ref SDS 49 J69M
600420 -
600421 -            [...below Arlette explains Kaiser Oncology in Walnut Creek
600422 -            has a good reputation, and doctors are experienced treating
600423 -            IBC using Kaiser's team care practice to confer,
600424 -            ref SDS 53 NT8Y, along with the Tumor Board. ref SDS 53
600425 -            NT9S
600427 -  ..
600428 - Millie's letter to Arlette continues...
600429 -
600430 -        This is my main concern.  How to handle relapses.  Does Kaiser
600431 -        have the personnel to do research with this particular cancer?
600432 -        With the doctors busy schedules, how do they do anything more
600433 -        than see patients?  It's not the doctors' fault, it's the
600434 -        system.
600436 -  ..
600437 - Millie's letter yesterday presented concern of limited experience
600438 - recognizing when the patient has IBC, and not something else, because
600439 - the disease waxes and wanes, ref SDS 52 DT8U, as occurred to Millie in
600440 - 2003, and discussed with the backup doctor on 060808. ref SDS 51 HT5K
600441 - The primary care physician has emphasized urgency of timely treatment
600442 - before disease cascades out of control, reported on 041130.
600443 - ref SDS 20 Y66F
600444 -
600445 -
600446 -
600447 -
600448 -
600449 -
6005 -

SUBJECTS
Reputation Oncology Department Kaiser Walnut Creek Good Doctors Expe

8703 -
8704 - 2022
870501 -  ..
870502 - Reputation Kaiser Oncology Good Doctors Confer Treating IBC
870503 -
870504 - Received ref DRT 2 0001 from Arlette responding to Millie's letter
870505 - earlier today, ref DIT 1 0001, and reported in the record shown above.
870506 - ref SDS 0 IM8K
870508 -  ..
870509 - Arlette says to Millie...
870510 -
870511 -    1.  By a new packet, I mean updated information since you last saw
870512 -        Doctor Benz (i.e., recent labs, xrays, progress notes).
870513 -        ref DRT 2 0001
870515 -  ..
870516 - Arlette answers question in Millie's letter, per above, ref SDS 0
870517 - OL6H, from Arlette's earlier letter this morning discussing support
870518 - for Millie getting a 2nd opinion, per above. ref SDS 0 3J4O
870520 -  ..
870521 - Arlette's letter to Millie continues...
870522 -
870523 -    2.  Actually, we here in WCR oncology do have a good reputation and
870524 -        there are other Doctors here in our Department that have dealt
870525 -        with IBC, and they confer. ref DRT 2 6I6F
870527 -  ..
870528 - Millie's letter this morning discusses challenges treating IBC that
870529 - requires experience to prevent disease from cascading out of control.
870530 - ref SDS 0 K65S
870532 -  ..
870533 - Millie's patient history for the past 5 years has been very good
870534 - compared to other cancer centers, like Stanford, and UCSF, with only
870535 - 20 or so issues that need improvement, per above. ref SDS 0 K65K
870537 -  ..
870538 - There is no record of any work product, contemporaneous notes, or
870539 - writings of conslutations and opinions from doctors conferring,
870540 - meeting or collaborating on Millie's case.
870542 -  ..
870543 - The doctor planned to confer with the radiologist for a 2nd opinion on
870544 - diagnosis and treatment, reported on 020726. ref SDS 6 YO6K  Review
870545 - of the Medical Chart on 041014 shows no evidence of conferring.
870546 - ref SDS 16 HT6N
870548 -  ..
870549 - Case study on 050923 shows significant challenge accomplishing due
870550 - diligence to collaborate applying Kaiser's team care requirements.
870551 - ref SDS 29 N45O  There is one report of the surgeon conferring with
870552 - the primary care physician, and this occurred from chance encounter
870553 - while passing in the hallway near the cafeteria. ref SDS 29 7K6K
870554 -
870555 -
870556 -
870557 -
870558 -
8706 -

SUBJECTS
Default Null Subject Account for Blank Record

9503 -
950401 -  ..
950402 - Tumor Board Hears Difficult Cases Every Friday Best Practices
950403 -
950404 - Arlette's letter to Millie continues...
950405 -
950406 -    3.  You may also be addressed at our Tumor Board, which we have
950407 -        every Friday, and there are pharmacists, oncologists from all
950408 -        over, and a variety of other people. ref DRT 2 6N6J
950410 -  ..
950411 - Millie's case has been reviewed twice by Kaiser's Tumor Board, shown
950412 - in the record on 040517. ref SDS 12 AW6M  At that time, Kaiser did not
950413 - resubmit the matter for further review after getting the biopsy report
950414 - that diagnosed IBC, which changed patient status from stage II to
950415 - stage IV. ref SDS 12 9M6M
950417 -  ..
950418 - Subsequent requests for Tumor Board review have not been performed by
950419 - Kaiser.
950420 -
950421 -        [On 061218 case study shows difficulty getting Tumor Board
950422 -        support at Kaiser. ref SDS 66 6W3X
950424 -  ..
950425 - Scope of Tumor Board hearings appears superficial.  There is no record
950426 - of patient history submitted for review, nor of participants being
950427 - prepared, and there is no transcript on what was presented, what
950428 - questions were asked, research, and follow up.  The doctor/patient
950429 - partnership was ignored in the process.
950430 -
950431 -        [On 061218 research Tumor Board purpose and procedures in
950432 -        relation to experience at Kaiser. ref SDS 66 FW9K
950434 -  ..
950435 - On 041130 Millie had been removed from treatment for IBC due to
950436 - pulmonary emboli, and was rapidly relapsing while Kaiser searched for
950437 - a drug trial, was described as too simple for review by the Tumor
950438 - Board on whether to treat with Taxotere, which had been effective and
950439 - was not a known cause of pulmonary emboli, and further to consider
950440 - treating with Taxotere and capecitabine recommended by UCSF in a 2nd
950441 - opinion received on 051117.  Why this could not be reviewed by the
950442 - Tumor Board is not clear in the record. ref SDS 20 YR91
950443 -
950444 -
950445 -
950446 -
9505 -

SUBJECTS
2nd Opinions Tumor Boards Common Practices Kaiser Pays to Perform Re

A603 -
A60401 -  ..
A60402 - 2nd Opinion Best Practice Kaiser Routinely Sends Patients Evaluation
A60403 - Kaiser Pays for 2nd Opinions Routinely Sends Patients for Evaluation
A60404 -
A60405 - Arlette's letter to Millie continues...
A60406 -
A60407 -    4.  If, after all that, we don't feel confident, we naturally send
A60408 -        you on to UCSF, Stanford, or any other facility that we feel
A60409 -        might help you.  We have sent people to Washington DC, Texas,
A60410 -        all over.  So, I do think you will get very good care from us.
A60411 -        ref DRT 2 6I67
A60413 -  ..
A60414 - Millie has received excellent care from Kaiser compared to other
A60415 - providers.  Quality, however, ocurs along a continuum, particularly
A60416 - when people are busy treating many patients, attending meetings, and
A60417 - conferences, running departments, etc.  The challenge is how to
A60418 - configure "precision access," explained in NWO, ref OF 13 PX6J, that
A60419 - empowers people with command and control of the record so that a
A60420 - rising flood of information does not overwhelm limited span of
A60421 - attention, noted by research on 990303. ref SDS 2 LX6F
A60423 -  ..
A60424 - Health care, particularly treating cancer, is highly complex work that
A60425 - touches a broad range of medical practices, as the immune system
A60426 - weakens and the body succumbs to an increasing number of diseases.
A60427 - This makes proactive management with careful review essential to avoid
A60428 - overlooking small details that cause serious consequences, reviewed
A60429 - previously on 921127. ref SDS 1 0674
A60431 -  ..
A60432 - Best practices for 2nd opinions are reviewed on 040318. ref SDS 10
A60433 - 425H
A60435 -  ..
A60436 - 2nd opinions are not related to "feeling confident," but rather
A60437 - provide independant review of the record for correlations,
A60438 - implications, and nuance which first line practitioners do not have
A60439 - time to perform, shown by the case study listed above. ref SDS 0 K65G
A60440 - Second opinions provide an infusion of diverse ideas to synthesize
A60441 - that strengthen diagnosis and treatment, reported by primary care
A60442 - physician on 041130. ref SDS 20 5X4J
A60443 -
A60444 -            [On 060821 Doctor Benz reports UCSF has several clinical
A60445 -            trials for treating Millie's IBC. ref SDS 57 W66J
A60447 -             ..
A60448 -            [On 060929 2nd opinion letter from Doctor Benz confirms
A60449 -            that Millie qualifies for 2 trials at UCSF. ref SDS 59 Z55K
A60451 -             ..
A60452 -            [On 061201 primary care physician at Kaiser advises
A60453 -            treatment for IBC now failing, schedules meeting on 061208
A60454 -            to plan changing treatment. ref SDS 63 RU6J
A60456 -             ..
A60457 -            [On 061208 doctor reports Kaiser can find no clincial
A60458 -            trials to treat Millie, ref SDS 64 P24L; proposed trying
A60459 -            older Navelbine technology, ref SDS 64 RW5I; Millie asked
A60460 -            about implementing Benz 2nd opintion for treatment on
A60461 -            clincial trial at UCSF with cetuximab and carboplatin,
A60462 -            ref SDS 64 P256, based on Arlette's report today, that
A60463 -            Kaiser routinely makes referrals to give patients good
A60464 -            care. ref SDS 0 NT9X; doctor requests assistance finding
A60465 -            recommendations on clinical trials in Benz 2nd opinion.
A60466 -            ref SDS 64 WQ5F
A60468 -             ..
A60469 -            [On 061218 Millie letter to Kaiser assisting the doctor to
A60470 -            find location in UCSF 2nd opinion that proposes 2 drug
A60471 -            trials to treat Millie's cancer. ref SDS 65 Q74O
A60473 -             ..
A60474 -            [On 070105 Kaiser makes referral for Millie to get
A60475 -            treatment at UCSF with a clinical study for cetuximab and
A60476 -            carboplatin, implementing Benz 2nd opinion. ref SDS 67 PK68
A60478 -             ..
A60479 -            [On 070118 performing critical details are difficult to
A60480 -            manage action items until crisis arises that bring
A60481 -            forgotten tasks into span of attention. ref SDS 68 XF5G
A60483 -             ..
A60484 -            [On 070119 treatment delayed; UCSF reported Kaiser failed
A60485 -            to issue authorization for Millie's referral for treatment
A60486 -            in the cetuximab carboplatin clinical study. ref SDS 69
A60487 -            AS96
A60489 -             ..
A60490 -            [On 070119 primary care physician at Kaiser reports
A60491 -            authorization for referral was submitted to UCSF.
A60492 -            ref SDS 69 LW9N
A60494 -             ..
A60495 -            [On 070123 UCSF reports authorization not received from
A60496 -            Kaiser, treatment deferred. ref SDS 70 4Q54
A60498 -             ..
A60499 -            [On 070123 Millie notifies primary care physician treatment
A60500 -            to prevent cancer from cascading out of control delayed
A60501 -            again by delay with referral authorization, ref SDS 70
A60502 -            J94L; Kaiser reports doctor on vacation. ref SDS 70 LP4L
A60504 -             ..
A60505 -            [On 070124 UCSF reports payment authorization problem
A60506 -            solved; plans to schedule Millie for treatment. ref SDS 71
A60507 -            PQ4Q
A60509 -             ..
A60510 -            [On 070124 Kaiser reports referral authorization problem
A60511 -            solved. ref SDS 71 WR3J
A60513 -             ..
A60514 -            [On 070125 UCSF schedules Millie for treatment on 070131.
A60515 -            ref SDS 72 YF8U
A60517 -             ..
A60518 -            [On 070126 thanked Arlette for coordinating doctor's
A60519 -            authorization referring Millie to get treatment at UCSF.
A60520 -            ref SDS 73 F184
A60522 -             ..
A60523 -            [On 070829 Arlette surprised UCSF charging Millie for
A60524 -            clinical trial treatment; promises to invesigate why this
A60525 -            is different from prior referrals. ref SDS 74 EF6J
A60527 -             ..
A60528 -            [On 070831 Arlette commended for assisting Kaiser and UCSF
A60529 -            develop procedures to implement confusing regulations on
A60530 -            payment of patient care on referral. ref SDS 75 P14W
A60532 -             ..
A60533 -            [On 070906 Millie received research from Arlette on why
A60534 -            UCSF billed extra charges to Millie for clinical trials.
A60535 -            ref SDS 76 HC4I
A60537 -             ..
A60538 -            [On 070909 letter notifies Kaiser and UCSF results of
A60539 -            Arlette's research ref SDS 77 6O5Q
A60540 -  ..
A60541 - Kaiser has had significant challenges performing 2nd opinion processes
A60542 - to support diagnosis and treatment on grounds that IBC is no different
A60543 - from other cancer diseases treated by Kaiser, reported on 040318.
A60544 - ref SDS 10 AW6M  This was discussed again on 040614, and the doctor
A60545 - cited Kaisers experience treating IBC was adequate. ref SDS 13 AW6M
A60546 - Later, on 040909 the doctor said that Kaiser's policies prevent
A60547 - support for 2nd opinion because Kaiser has a lot of experience
A60548 - treating IBC. ref SDS 15 X842
A60550 -  ..
A60551 - Feeling "confident" can be the best grounds for 2nd opinion, because
A60552 - arrogance leads competent people to overlook critical details,
A60553 - reported on 921127. ref SDS 1 0674
A60554 -
A60555 -
A60556 -
A60557 -
A60558 -
A60559 -
A60560 -
A60561 -
A60562 -
A60563 -
A60564 -
A60565 -
A60566 -
A60567 -
A606 -