CONTACTS
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0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up
040502 -
040503 -
040504 -
040505 -
040507 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Received letter today saying...
040902 -
040903 - 1. DEPARTMENT OF VETERANS AFFAIRS
040904 - Medical Center
040905 - 4150 Clement Street
040906 - San Francisco, CA 94121
040908 - ..
040909 - 2. May 20,2017
040919 - ..
040920 - 5. The San Francisco VA Medical Center (SFV AMC) and our Community
040921 - Based Outpatient Clinics (CBOCs) remain available to assist you
040922 - with your legitimate medical, surgical, psychiatric, and social
040923 - needs as determined by your health care team. However, those
040924 - we serve are expected to follow a reasonable code of conduct
040925 - regarding their behavior. Unfortunately, for some time your
040926 - behavior has not fully conformed to this reasonable standard.
040927 - Those working with you have become concerned enough that you
040928 - have come to the attention of the Disruptive Behavior COmmittee
040929 - (DBC) and we are sending you this Letter of Concern in
040930 - response.
040932 - ..
040933 - "Reasonable code of conduct" relates to the reasons for behavior.
040934 - Where behavior is justified by securing medical care in time to be
040935 - effective, there can be no complaint of unreasonable conduct.
040937 - ..
040938 - Disruptive behavior relates to loud, angry, abusive language and
040939 - conduct that threatens providers. Nothing is cited that rises to
040940 - this standard.
040942 - ..
040943 - VA DBC letter continues...
040944 -
040945 - 6. In particular, it has been reported that you...
040946 -
040947 - 1. send lengthy, repetitive entails with multiple recipients,
040949 - ..
040950 - Patient regularly corresponds with medical team of 10 or so providers
040951 - to coordinate work on complex, difficult medical problems, e.g.,
040952 - erroneous stroke diagnosis, CVD, multiple hemotomas, orthopedic,
040953 - podiatry, and GI issues. Inter-related issues require comprehensive,
040954 - coordinated care.
040956 - ..
040957 - On 161012 1000 Doctor Simpson in Cardiology said: "You are the best
040958 - patient I've ever had." ref SDS 5 K589 This occurs because the work
040959 - is well managed.
040961 - ..
040962 - VA letter continues...
040963 -
040964 - 2. arrive without an appointment and demand to be seen,
040966 - ..
040967 - VA should submit evidence of patient demanding care, and arriving
040968 - without approval of providers?
040970 - ..
040971 - VA letter continues...
040972 -
040973 - 3. stop providers in the hallways inappropriately for
040974 - consultation,
040976 - ..
040977 - VA should submit evidence of stopping providers inappropriately.
040979 - ..
040980 - Doctors and nurses are routinely encountered in the halls, usually for
040981 - mere greeting. Sometimes providers ask questions, and sometimes
040982 - patients request clarification of guidance. This saves time
040983 - scheduling endless meetings, and writing prodigous Progress Notes.
040984 - Doctors know the patient will write down important understandings, so
040985 - these can be considered at the next scheduled meeting. This saves
040986 - time and money, and advances care by orders of magnitude.
040988 - ..
040989 - VA letter continues...
040990 -
040991 - 4. request tests and evaluations which your help care team
040992 - feel are not indicated while declining to receive those
040993 - they have recommended,
040995 - ..
040996 - VA should cite Progress Notes listing tests that have been
040997 - recommended, and declined by the patient.
040999 - ..
041000 - All patients request tests, which providers consider and approve or
041001 - defer.
041003 - ..
041004 - On 030508 Millie requested biopsy test to evaluate rising inflammation
041005 - for relapse of breast cancer. The doctor felt this was not indicated.
041007 - ..
041008 - On 030606, Millie again requested biopsy, PET scan, anything to test
041009 - ebb and flow of inflammation and elevated cancer marker. The doctor
041010 - felt this test was not indicated. ref SDS 1 P97J Kaiser agreed to
041011 - evaluate the matter again the following month after a CT scan was
041012 - performed. ref SDS 1 NV5H
041014 - ..
041015 - On 030710 Millie had the CT scan and it found all 3 symptoms of IBC
041016 - cancer. She again requested biopsy and other tests required to
041017 - support resuming treatment. ref SDS 2 7C6W The doctor felt this was
041018 - not indicated.
041020 - ..
041021 - VA letter continues...
041022 -
041023 - 5. and in other ways place excessive demands on the time of
041024 - staff and health care professionals.
041026 - ..
041027 - Patient has reduced demands on the time of health care professionals
041028 - by performing essential coordination, which otherwise doctors must
041029 - perform, and then write Progress Notes.
041031 - ..
041032 - On 170424 received call from Primary Care provider who reported the
041033 - patient has required extensive care the past 2 years to recover from
041034 - numerous afflictions, including stroke symptoms. She has contacted
041035 - providers and been told the patient coordinates very complex work to
041036 - obtain comprehensive care through correspondence that optimizes
041037 - outcomes and minimizes time and cost. Therefore, she does need to
041038 - meet with the patient. ref SDS 6 3O6M
041040 - ..
041041 - In Millie's case...
041043 - ..
041044 - On 040504 - 18 months later - the doctor went into the Chemotherapy
041045 - Infusion clinic, and knelt down in front of Millie. He put his hands
041046 - on her hands resting on the arms of the infusion chair, where she was
041047 - at last getting essential treatment requested in May the previous
041048 - year.
041050 - ..
041051 - The doctor said he was very sorry treatment was delayed. Last year he
041052 - thought Millie's requests were excessive demands on the time of staff
041053 - and health care professionals to treat stage II cancer. Now it turns
041054 - out delayed treatment caused stage II cancer to advance to stage IV
041055 - IBC cancer that can never go into remission. Millie's only course was
041056 - to get her affairs in order. ref SDS 3 WI8F
041058 - ..
041059 - VA letter continues...
041060 -
041061 - 6. Furthermore, you send the emails unsecured even though you
041062 - have secure messaging available to you.
041064 - ..
041065 - Public email delivery, like public mail service, is an independent
041066 - medium that supports binary management of communication. Binary
041067 - electronic mail service provides the best security for comprehensive
041068 - care coordinated among a large, diverse medical team, and delivered in
041069 - time to be effective.
041071 - ..
041072 - VA letter continues...
041073 -
041074 - 7. These behaviors taken as a whole have become quite disruptive
041075 - and also end up taking time away from the care of other
041076 - veterans. Note that this behavior will now be monitored and
041077 - the DBC will need to respond should such misuse of the system
041078 - continue.
041080 - ..
041081 - Disruptive behaviors per se, are sometimes essential for effective
041082 - collaboration within doctor patient partnership.
041084 - ..
041085 - Patient coordinating care enables timely, accurate, thorough
041086 - collaboration among medical team. This saves time of doctors having
041087 - to do complex, tedious work, including writing Progress Notes.
041089 - ..
041090 - An example occurred in Neurology, where a provider anguished over not
041091 - having enough time to perform the work, reported on 160722 1304.
041092 - ref SDS 4 6S5P
041094 - ..
041095 - Monitoring behavior entails providers investing time to submit
041096 - complaints, per above. ref SDS 0 E488
041098 - ..
041099 - VA DBC letter continues...
041100 -
041101 - 8. We understand that some of your behaviors may represent an
041102 - expression of feelings of stress or other emotional reactions.
041103 - However, these behaviors are not acceptable as they disrupt
041104 - clinical operations in an inappropriate manner. If you are
041105 - interested, the following benefit you have as a veteran might
041106 - of interest to you. A clinician can contact you to discuss
041107 - approaches you might find useful in dealing with feelings of
041108 - stress while at the same time more effectively getting your
041109 - needs met (such as+· Stress Reduction classes, Assertiveness
041110 - Training classes, and related interventions). If you have any
041111 - questions about such interventions, please call our Office of
041112 - Patient Experiences at: 415-221-4810 x26650 or ask a clinician
041113 - as noted above. A Patient Experience Specialist or the
041114 - clinician will ensure that your concerns and questions are
041115 - communicated to the DBC if s/he is unable to answer and address
041116 - them directly.
041118 - ..
041119 - Sometimes clinical operations must be disrupted to advance clinical
041120 - objectives.
041122 - ..
041123 - Patient's experience with difficulties treating achalasia,
041124 - fundoplication problems, collateral side effects diagnosing stroke,
041125 - determining causation under prognosis of death with recurrence, where
041126 - the procedure that caused symptoms are needed repetitively, and
041127 - increase in medications causing severely elevated blood pressure.
041129 - ..
041130 - This experience causes stress to resolve the problems.
041132 - ..
041133 - VA DBC letter continues...
041134 -
041135 - 9. Sincerely,
041137 - ..
041138 - 10. San Francisco VA Medical Center Disruptive Behavior Committee
041139 -
041140 - 1. Robert Baczek, Chief, VA Police
041141 - 2. Bob Potts, RN
041142 - 3. Michael Drexler, PhD
041143 - 4. Sara Duffy, NP
041144 - 5. Jamye Kubick, MH Supervisor
041145 - 6. Stephen Robinson, MD
041146 - 7. Laurel Barber, NP
041147 - 8. Arnel Bael, Pt. Exp. Spec.
041148 - 9. Alison James, PsyD
041149 - 10. Teresa Timmons, MD
041150 - 11. Emily Keram, MD
041151 - 12. David Villasenor, MD
041152 - 13. Debby Mason, MSA John
041153 - 14. Marrinan, RN
041154 - 15. Natalie Purcell. PhD
041155 - 16. Thais Williams, LCSW
041156 - 17. Marlin Nissen. fu~
041157 - 18. Shannon Stevens, LCSW
041158 - 19. Sierra Shumate. Extern
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