THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: October 28, 1999 05:13 PM Thursday; Rod Welch

Received letter from Doctor Boulris on Glucosamine and MRI.

1...Summary/Objective
2...Need Medical Guidance on Using Glucosamine with Chondroitin
3...MRI on Right Knee May Disclose Treatment Options
4...Medical Communication Needs Support for Effective Partnership
5...CEO Reports Kaiser Committed to Quality Team Care

ACTION ITEMS.................. Click here to comment!

1...Question -- how is a study initiated on team care and communication
2...Question -- how is doctor/patient partnership and communication
3...Question -- what authority sets good medical practice.
4...Question -- how does Kaiser help physicians practice medicine the
5...How does the doctor help the patient obtain a second opinion called

CONTACTS 
0201 - Kaiser Permanente                                                                                                                                                  O-00000652 0202
020101 - Dr. Craig M. Boulris, M.D.; Orthopedic Surgeon
020102 - Orthopedic Department                                                                                                                                            O-00000652 0202

SUBJECTS
Medical, Kaiser
Exam 990910 Knee Treatments
MRI on Knees
Report Omits Prescription Glucosamine, Chondroitin

0806 -
0806 -    ..
0807 - Summary/Objective
0808 -
080801 - Follow up ref SDS 49 0000, ref SDS 48 0000.
080802 -
080803 - Received ref DRT 2 0001 from Craig via email responding to ref DIP 2
080804 - 0001 submitted on 991018. ref SDS 49 0001
080806 -  ..
080807 - Craig does not offer guidance on using Glucosamine with Chondroitin,
080808 - and advises MRI cannot help diagnose the pain in the right knee based
080809 - on xrays of the left knee.
080811 -  ..
080812 - The letter shows potential for improving team care by communication
080813 - training and support. ref SDS 0 8499
080814 -
080815 -      [On 991109 Tom Driscoll will reivew Team Care issues. ref SDS 57
080816 -      0001]
080817 -
080818 -      [On 991123 Jeanne Bradely contacted Tom also. ref SDS 58 0001]
080819 -
080820 -
080821 -
080823 -  ..
0809 -
0810 -
0811 - Progress
081201 -  ..
081202 - Need Medical Guidance on Using Glucosamine with Chondroitin
081203 -
081204 - My letter ref DIP 2 9599 submitted on 991018, ref SDS 49 0001, cites
081205 - research on 991011 that found a professional report, ref SDS 48 3099,
081206 - published by the...
081207 -
081209 -                         ..
081210 -                        The Medical Letter
081211 -
081212 -
081213 - ...dated 970926 which seems to indicate that...
081214 -
081215 -      Chondroitin used with Glucosamine has been found to maintain
081216 -      viscosity in joints, stimulate cartilage repair mechanisms and
081217 -      inhibit enzymes that break down cartilage. ref OF 3 2058
081218 -         ..
081219 -      However, there is no guidance in the report on usage that
081220 -      has yielded these results.
081221 -
081222 -         [On 000124 Doctor Vincent Yamamoto was not familiar with the
081223 -         Medical Letter. ref SDS 66 1680]
081224 - ..
081225 - Craig's letter on 991011 suggests 1.5g per day of Glucosamine,
081226 - ref DRP 1 4118, but does not mention Chondroitin, as reported on
081227 - 991011. ref SDS 48 3120  Millie and I purchased a combination product
081228 - manufactured by Shiff, with ingredients as shown in the SDS record on
081229 - 991011. ref SDS 48 4940
081231 -  ..
081232 - The letter therefore asks Craig to comment on dosage.
081234 -  ..
081235 - Craig's letter today says...
081236 -
081237 -      Several substances have been placed in combination with
081238 -      Glucosamine to try to enhance the effect of cartilage
081239 -      preservation. Two of these are Chondroitin sulfate and a substance
081240 -      called MSM.  Some pills contain all three substances.  No good
081241 -      studies have shown any documented positive effects of these two
081242 -      other substances, so no one really knows whether they do any good
081243 -      or whether they are a waste of money. There has been some
081244 -      evidence to suggest that Glucosamine is helpful. ref DRT 2 0001
081245 - ..
081246 - This response does not address the Medical Letter report that
081247 - appears to endorse use of Chondroitin with Glucosamine, as reported on
081248 - 991011. ref SDS 48 5933
081250 -  ..
081251 - Saying that no good studies have been done... is not grounds to avoid
081252 - professional guidance.  The letter from Don Harms on 991026 advising
081253 - that Glucosamine and Chondroitin have helped him, ref SDS 53 3392, is
081254 - not a "good study," but is an indication that this combination might
081255 - be helpful.  Is it Kaiser's policy for patients to follow information
081256 - from friends, or from professionally trained physicians?
081258 -  ..
081259 - Surely, a constructive statement can be fashioned that does not
081260 - require Kaiser to endorse anything, yet guide the patient in applying
081261 - new methods based on the current state of the record.
081262 - ..
081263 - Is the Medical Letter discredited or not a respected authority
081264 - among professional practitioners?
081266 -  ..
081267 - If not, that should be disclosed to help the patient avoid reliance
081268 - on unsupported advice.
081270 -  ..
081271 - If the Medical Letter is good authority, then the doctor should
081272 - provide guidance on usage, as requested by the patient. ref DIP 2
081273 - 9599
081275 -  ..
081276 - Can we formulate diagnostics to measure improvement, so we acquire
081277 - stronger evidence of usefulness for Glucosamine and Chondroitin?
081278 -
081279 -     [On 000121 Jeane Bradley, Site Coordinator at Park Shadelands,
081280 -     submits treatment advice. ref SDS 65 1680]
081281 -
081282 -     [On 000124 Doctor Vincent Yamamoto was not familiar with the
081283 -     Medical Letter. ref SDS 66 1680]
081284 -
081285 -
081286 -
081287 -
081288 -
081289 -
0813 -

SUBJECTS
MRI on Knees

1203 -
120401 -  ..
120402 - MRI on Right Knee May Disclose Treatment Options
120403 -
120404 - Follow up ref SDS 49 6720, ref SDS 48 1880.
120405 -
120406 - My letter, ref DIP 2 0001 submitted on 991018, ref SDS 49 0001, cites
120407 - research on 991018 showing an MRI, or similar examination technique,
120408 - ref SDS 49 4620, can help diagnose the cause of pain in the right
120409 - knee, toward formulating a treatment plan, which Craig said is
120410 - difficult to do in his report on 991011. ref SDS 48 3088
120412 -  ..
120413 - The letter requests comment on whether examination technologies might
120414 - help discover isolated pockets of cartilage loss in the right knee,
120415 - ref DIP 2 2211, which he diagramed as possible causes of pain, in the
120416 - meeting on 990910. ref SDS 31 1224
120417 - ..
120418 - Craig's letter today says...
120419 -
120420 -      An MRI would not be expected to be useful in your case.  MRIs are
120421 -      useful in meniscus and ligament tears, which your history and
120422 -      exam do not suggest you have.  MRIs do not show cartilage loss
120423 -      well. ref DRT 2 1980
120424 -
120425 -      It is extremely unlikely that you have the very localized wear
120426 -      that can be treated with cartilage replacement techniques.  These
120427 -      are usually the result of a specific traumatic event in young
120428 -      people and use of such techniques are controversial even in these
120429 -      individuals.  These techniques do not work at all on wear
120430 -      underneath the knee cap.  Your picture is one of more chronic
120431 -      gradual wear and tear on the articular cartilage (which is the
120432 -      type of wear more than 95% of patients have).  It is expected to
120433 -      respond best to the previously mentioned treatments. ref DRT 2
120434 -      3645
120435 - ..
120436 - Craig's comment that...
120437 -
120438 -      Your picture is one of more chronic gradual wear and tear on the
120439 -      articular cartilage (which is the type of wear more than 95% of
120440 -      patients have).
120441 -
120442 - ...is accurate for the left knee, and there is general agreement that
120443 - cartilage replacement under existing practice is not a good treatment
120444 - plan for the left knee.  We are trying to address this problem with
120445 - Glucosamine and Chondroitin, per above. ref SDS 0 3621
120447 -  ..
120448 - However, the meeting on 990910 showed the xray on the right knee is
120449 - normal, ref SDS 31 1224, and so provides no evidence from which to
120450 - conclude an MRI would not help diagnose the cause of pain, which he
120451 - reported on 991011 is difficult to do based on traditional use of
120452 - xrays and physical examination.
120453 - ..
120454 - If we can identify the cause of pain in the right knee, that may
120455 - help determine treatment, separate from the left knee which suffered
120456 - distinct and severe damage from a fall in 1972, as shown in the
120457 - medical history reported on 990625. ref SDS 6 5152
120458 - ..
120459 - Do we really feel comfortable having a report of chronic pain,
120460 - and no evident cause?   Wouldn't it be better to do the MRI to find
120461 - out as much as we can about a condition that has no evident cause for
120462 - chronic pain?
120464 -  ..
120465 - If we conclude by default that "pockets" of cartilage have been
120466 - damaged, discussed by Craig on 990910, ref SDS 31 1224, is it good
120467 - practice to avoid replacement efforts because these methods are for
120468 - younger people, without making any effort to ascertain the scope of
120469 - the problem?
120470 -
120471 -    (Posted this as issue #5 to record on 991028. ref SDS 47 8966)
120473 -     ..
120474 -    [On 000118 discussed with Jeanne. ref SDS 63 3248]
120476 -     ..
120477 -    [On 000120 Jeanne scheduled 2nd opinion. ref SDS 64 0001]
120479 -     ..
120480 -    [On 000124 cause of pain in right knee diagnosed. ref SDS 66 2860]
120481 -
120482 -
120483 -
1205 -

SUBJECTS
Doctor's Report No Subject, No Alignment
Team Care
Policy Procedures on Communication
Decisions Shared
Responsibility Shared
Quality Care
Empowerment Diffuses Authority, Flatter Organizations
Empowerment Slippery Slope to Entropy

2110 -
211101 -  ..
211102 - Medical Communication Needs Support for Effective Partnership
211103 -
211104 - Craig's letter today, ref DRT 2 0001, responding to a request on
211105 - 991018 for guidance on taking medication, ref DIP 2 0001, is to be
211106 - applauded for trying to provide timely communication.  Most doctors
211107 - are unwilling to try due to a heavy patient load, explained in the
211108 - letter on medical mistakes. ref DIP 1 1445
211110 -  ..
211111 - On 990625 training for doctors and patients is needed, ref SDS 6 5358,
211112 - on how to apply guidance in Kaiser's Medial Handbook on Doctor/Patient
211113 - Communication, ref OF 1 5418, which identifies 8 ways to work with the
211114 - doctor, ref OF 1 4977, and explains constructive communication as
211115 - "ping pong." ref OF 1 1395
211116 -
211117 -     [On 991101 discussed training with Jeanne. ref SDS 55 1718]
211119 -      ..
211120 -     [On 991108 cultural pressures suppress literacy. ref SDS 56 7380]
211122 -      ..
211123 -     [On 991123 called Jeanne to follow up. ref SDS 58 0001]
211125 -      ..
211126 -     [On 991221 study finds doctors omit key information in 90% of
211127 -     communications with patients. ref SDS 61 0001]
211129 -      ..
211130 -     [On 991227 letter from Tom Driscoll illustrates communication
211131 -     training needed at executive management level. ref SDS 62 0001]
211132 - ..
211133 - On 990913 training for doctor/patient communication to support
211134 - partnership was recognized. ref SDS 34 0844
211136 -  ..
211137 - Communication should be clear, concise and complete, cited in the
211138 - record on 991025 explaining Com Metrics. ref SDS 52 3355  Alignment
211139 - with questions, sources and medical history is needed to avoid
211140 - ambiguity which otherwise leads to misunderstanding, rework, and lost
211141 - time, money, stress, i.e., failed communication, as cited in the
211142 - record on 991028 sending a letter to Morris at Intel on this subject.
211143 - ref SDS 54 3216
211145 -  ..
211146 - Based on Craig's letter today, training is needed on following
211147 - points...
211148 -
211149 -     1.  Letter needs a subject.
211150 -         ..
211151 -     2.  Letter should refer to the source document, as the basis
211152 -         for information provided.
211154 -          ..
211155 -         Say something like responding to your call, letter, or
211156 -         meeting on such and such a date.
211157 -         ..
211158 -     3.  Identify the specific question being addressed, and
211159 -         sources reviewed, so the patient has context to orient using
211160 -         information in the doctor's letter, as noted on 991011.
211161 -         ref SDS 48 2303
211163 -          ..
211164 -         Say something like... You ask x, y and z...
211166 -          ..
211167 -         This can be done easily in email by using cut and past to
211168 -         grab the patient's language.
211169 -
211170 -
211171 -
2112 -

SUBJECTS
Default Null Subject Account for Blank Record

2203 -
220401 -  ..
220402 - CEO Reports Kaiser Committed to Quality Team Care
220403 -
220404 - Received letter, ref DRT 1 0001, addressed to "members" dated 991015,
220405 - from Robert Pearl, MD, who is the CEO of the Permanente Medical Group.
220406 - The letter is also signed by Richard Pettingill, President, California
220407 - Division of the Kaiser Foundation Health Plan and Hospitals.
220409 -  ..
220410 - Robert reports that Kaiser is committed to quality care, service and
220411 - value. ref DRT 1 0001
220413 -  ..
220414 - Robert's letter to members aligns with goals for quality Team Care,
220415 - ref DRT 1 8715 and ref DRT 1 7521, that are set out in Kaiser's
220416 - brochure reviewed on 990625, ref SDS 6 6970, and which invites
220417 - patients to be an active participant in health care, ref SDS 6 8008,
220418 - implementing the Kaiser Healthwise Handbook calling for doctor and
220419 - patient partnership. ref SDS 6 4185
220421 -  ..
220422 - Kaiser's team care guidelines call for capturing patient medical
220423 - history, also, reported on 990625, ref SDS 6 5740, in order that
220424 - doctors are able to "know" the patient's medical history. ref SDS 6
220425 - 6970
220427 -  ..
220428 - Kaiser has received awards for quality, and was rated by a consumer
220429 - magazine as the best health plan in California and among top 10 in the
220430 - country. ref DRT 1 4674
220431 -
220432 -      Robert would likely agree that awards are fine, but continual
220433 -      improvement is critical to maintain quality and patient trust.
220435 -       ..
220436 -      In medicine, quality is good business.
220438 -       ..
220439 -      [On 991101 Patient Assistance unable to schedule meeting with
220440 -      doctors on Team Care issues. ref SDS 55 0966]
220442 -       ..
220443 -      [On 991107 national initiative announced to reduce medical
220444 -      mistakes. ref SDS 60 0001]
220446 -  ..
220447 - Kaiser conducts over 1,000 research studies each year to maintain
220448 - quality of care. ref DRT 1 8715
220449 -
220450 -    Question -- how is a study initiated on team care and communication
220451 -                between doctor/patient; how are results applied
220452 -                to improve patient care?
220454 -         ..
220455 -        The record on 991008 shows 6 issues that warrant study,
220456 -        ref SDS 47 9055, and which Patient Assistance is having
220457 -        difficulty getting reviewed, as reported on 991021, ref SDS 50
220458 -        2255, and again on 991024. ref SDS 51 0001
220460 -         ..
220461 -        Does this record warrant study?
220463 -            ..
220464 -           [On 991206 Tom Driscoll cited study at Kaiser's Santa Clara
220465 -           facility of an Internet based system. ref SDS 59 0645]
220467 -            ..
220468 -           [On 991207 President Clinton announces national initiative
220469 -           to reduce medical mistakes. ref SDS 60 0889]
220471 -  ..
220472 - Physicians are evaluated by colleagues annually. ref DRT 1 8715
220473 -
220474 -    Question -- how is doctor/patient partnership and communication
220475 -                evaluated?
220476 -
220478 -  ..
220479 - Physicians have freedom to practice medicine the way medicine should
220480 - be practiced. ref DRT 1 4602
220481 -
220482 -    Generally, this is the theory X versus theory Y tension cited by
220483 -    Drucker in his book on management practice reviewed on 931130.
220484 -    ref SDS 2 9677
220486 -     ..
220487 -    "Freedom" is theory Y "empowerment" practice cited by Jim Scott at
220488 -    Fluor Daniel on 960501. ref SDS 3 1852  On 970710 Intel reported
220489 -    "empowerment" prevents management that ensures good practice.
220490 -    ref SDS 4 1431
220492 -     ..
220493 -    On 990625 report that there isn't enough time for doctors to follow
220494 -    Kaiser guidelines on good practice. ref SDS 6 1978
220496 -     ..
220497 -    Letter on 990924 on high cost of medical mistakes cites pressure to
220498 -    reduce costs leads to exigent care, ref DIP 1 1445, which reduces
220499 -    "freedom" to provide medicine as it should be done. ref SDS 40 8055
220500 -
220501 -      [On 991101 Patient Assistance unable to schedule meeting with
220502 -      doctors on Team Care issues. ref SDS 55 0966]
220504 -       ..
220505 -      [On 991109 Tom Driscoll will reivew Team Care issues. ref SDS 57
220506 -      0001]
220508 -       ..
220509 -      [On 991207 President Clinton announces national initiative to
220510 -      reduce medical mistakes. ref SDS 60 0889]
220511 -
220513 -     ..
220514 -    Question -- what authority sets good medical practice.
220516 -     ..
220517 -    On 990625 received, during visit with the doctor, a Kaiser
220518 -    Healthwise Handbook that says it has guidelines on the way medicine
220519 -    should be practiced, in partnership with the patient. ref SDS 6
220520 -    3822
220522 -     ..
220523 -    Question -- how does Kaiser help physicians practice medicine the
220524 -                way it should be practiced?
220526 -     ..
220527 -    Is there training and backup to follow Kaiser guidelines on good
220528 -    medicine and partnership with the patient, under team care goals,
220529 -    cited above? ref SDS 0 1152
220531 -       ..
220532 -      [On 991109 Tom Driscoll will reivew Team Care issues. ref SDS 57
220533 -      0001]
220535 -       ..
220536 -      [On 991206 Tom reviewing Com Metrics to support Team Care.
220537 -      ref SDS 59 1891
220539 -     ..
220540 -    How does the doctor help the patient obtain a second opinion called
220541 -    out in Kaiser guidelines? ref OF 1 4266
220542 -
220543 -        See example on the MRI issue above. ref SDS 0 6375
220545 -     ..
220546 -    Suppose a doctor does not have time to review medical history to
220547 -    prepare for a meeting, or to submit xrays and medical history to a
220548 -    specialist for a meeting with the patient on referral, or is unable
220549 -    to write a coherent letter answering questions on treatment, how
220550 -    does Kaiser help the doctor and the patient get the work done as a
220551 -    team, in a timely, cost effective manner?
220553 -     ..
220554 -    Suppose a patient's wife calls the doctor on Saturday, two days
220555 -    after surgery on a knee, and says her husband is suffering extreme
220556 -    pain, and wants to see the doctor immediately.  Suppose the doctor
220557 -    says he cannot see the patient because he promised his wife and
220558 -    kids they would go sailing this weekend, and offers that discomfort
220559 -    is normal following surgery.  Suppose the wife explains her mom has
220560 -    provided morphine medication, and yet her husband is crying in
220561 -    pain, so the doctor agrees to see the husband at his office the
220562 -    following Monday after returning from his sailing trip, and ahead
220563 -    of other patients, and then hangs up.
220565 -     ..
220566 -    What backup does Kaiser provide for the doctor and patient to work
220567 -    out a stronger treatment plan, so the doctor can go sailing to
220568 -    spend quality time with his family, and the patient can obtain
220569 -    timely attention for quality care to remedy failed treatment?
220571 -     ..
220572 -    How does Kaiser Team Care help doctors and patients coordinate
220573 -    Kaiser resources so that competent, timely treatment occurs, based
220574 -    on accurate medical history?
220575 -
220577 -  ..
220578 - Robert reports Kaiser's computer systems and state-of-the-art
220579 - technology give physicians immediate access to critical information
220580 - they need to care for you at any of our Northern California facilities
220581 - 24 hours a day, 365 days a year.  This gives your physician details of
220582 - the care you receive from any Permanente Medical Group physician or
220583 - health care professional in Northern California. ref DRT 1 9604
220584 -
220585 -    On 990625 Kaiser reported that the patient chart has the best
220586 -    information and it is not in the computer, so the most important
220587 -    information is not available at other facilities. ref SDS 6 2144
220588 -
220589 -       [On 991207 Tom Driscoll confirmed the medical chart is not yet
220590 -       online. ref SDS 59 0330]
220591 -    ..
220592 -    Suppose the wife in the above scenario disregards the
220593 -    doctor's treatment plan to wait until Monday, because she fears for
220594 -    her husband's life.  Her mom, who is dying of cancer, volunteers to
220595 -    stay with the kids, while she drives the husband to emergency care
220596 -    at the nearest hospital.  Suppose she contacts her family physician
220597 -    who is not with Kaiser because she doesn't know what else to do.
220598 -    Suppose that doctor prescribes blood thinner, because it appears
220599 -    looking at the situation, without having a report on medical
220600 -    history, that the problem is "clotting."
220602 -     ..
220603 -    How does Kaiser Team Care and computer data base support emergency
220604 -    treatment by others, with relevant medical history showing that the
220605 -    real problem is excessive bleeding from a ligament in the surgery
220606 -    performed on the knee two days earlier, so that blood thinner does
220607 -    not kill the patient, as nearly happened to Steve on 971106?
220608 -    ref SDS 5 4980
220609 -    ..
220610 -    How can technology and patients form a stronger partnership
220611 -    with doctors so that freedom is used constructively to enhance
220612 -    quality team care?
220613 -
220614 -      [On 991207 President Clinton announces national initiative to
220615 -      reduce medical mistakes. ref SDS 60 0889]
220616 -
220617 -
220618 -
220619 -
220620 -
220621 -
220622 -
220623 -
220624 -
220625 -
220626 -
220627 -
2207 -
Distribution. . . . See "CONTACTS"