CONTACTS 
0201 - Stanford Medical Center                                                                                                                                            O-00000837 0706
020101 - Dr. Ellie Guardino, MD, PHD                                                                                                                                      O-00000837 0706
020102 - Assistant Professor Brest Oncology
020104 - Department of Medicine
020105 - Cancer Center                                                                                                                                                    O-00000837 0706
0202 - Stanford Medical Center                                                                                                                                            O-00000837 0709
020201 - Ms. Denise Ricigliano, NP                                                                                                                                        O-00000837 0709
020202 - Medical Oncology Nurse Practitioner
020204 - Department of Medicine
020205 - Cancer Center                                                                                                                                                    O-00000837 0709
0203 - University of California San Franci                                                                                                                                O-00000835 0404
020301 - Ms. Sheridan L. Tinker                                                                                                                                           O-00000835 0404
020302 - New Patient Coordinator
020304 - Admissions                                                                                                                                                       O-00000835 0404

SUBJECTS
UCSF Meeting Doctor Benz 2nd Opinion

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 14 0000. ref SDS 13 0000.
040502 -
040503 - Sent a follow up letter to Sheridan at UCSF asking about progress
040504 - preparing 2nd opinion for Millie. ref SDS 0 6L9O  Sheridan reported
040505 - that she contacted Doctor Benz and expects he will respond by 1700
040506 - next Monday. 041115. ref SDS 0 M13H  Denise wrote a thoughtful letter
040507 - explaining difficulties of big institutions that hamper efficiency and
040508 - accuracy. ref SDS 0 QX6L  She offered to help Millie get the 2nd
040509 - opinion from Stanford that has been pending since 041019. ref SDS 0
040510 - QY6U
040511 -
040512 -
040513 -
040515 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Millie submitted ref DIT 2 0001 following up her letter submitted on
040902 - 041018, ref DIP 1 0001 to Sheridan at UCSF asking about getting the
040903 - 2nd opinion from Doctor Benz. ref SDS 11 0001
040905 -  ..
040906 - Millie said to Sheridan....
040907 -
040908 -    1.  When time permits, could you let me know progress on getting
040909 -        the 2nd opinion Doctor Benz is preparing in my case, based on
040910 -        our meeting at UCSF on Oct 18, and per my letter to you
040911 -        following the meeting at that time.
040913 -         ..
040914 -    2.  Since meeting with Doctor Benz on 041018, ref SDS 10 0001, a new
040915 -        CT test reported on 041103 shows small blood clots that explain
040916 -        heaviness in the chest and coughing over the past 3 - 4 months.
040917 -        ref SDS 15 N43I  As a result, I am no longer on the Avastin
040918 -        trial, and am not getting treatment while the blood clot
040919 -        problem is being worked. ref SDS 15 N438  If Doctor Benz is
040920 -        still preparing his opinion, and would like to see the
040921 -        radiology report on the CT test on 041103, please let me know.
040923 -         ..
040924 -    3.  Please let me know if there is an additional charge for Doctor
040925 -        Benz to consider new testing data in preparing his opinion.
040926 -
040928 -  ..
0410 -
0411 -
0412 - 1534
0413 -
041301 - Doctor Benz to Submit 2nd Opinion from UCSF OA 041115
041302 -
041303 - Received ref DRT 2 0001 from Sheridan at UCSF responding to Millie's
041304 - letter sent earlier today, per above. ref SDS 0 VU9N
041306 -  ..
041307 - Sheridan says...
041308 -
041309 -        I have forwarded your email to Dr. Benz.  I am not aware if he
041310 -        is around this weekend since we have Thursday off, but I am
041311 -        sure he will respond either to me or to you by Monday 5pm.
041312 -        Hope you continue to improve and feel better. ref DRT 2 0001
041313 -
041314 -
041315 -
041316 -
041317 -
041318 -
0414 -

SUBJECTS
2nd Opinion Stanford Medical Center Cancer Center Doctor Guardino
2nd Opinion Written Doctor Guardino Stanford Issue Report on Finding
Stanford Meeting 2nd Opinion on Scope of Disease Treatment Options D
Stanford Issue Written Report on Findings and Recommendations for 2n
2nd Opinion Meeting Stanford Medical Center Ellie Todd Denise Examin
Letter Request 2nd Opinion from Stanford

2008 -
2009 - 1238
201001 -  ..
201002 - Stanford Refers Patients to Medical Records for 2nd Opinion
201003 - Efficiency Using Email for Accuracy Prohibited at Stanford
201004 -
201005 - Follow up ref SDS 14 HT9J, ref SDS 13 0000.
201006 -
201007 - Received ref DRT 1 0001 from Denise dated 041108 responding to
201008 - Millie's letter to Stanford, ref DIP 3 0001, dated 041103 requesting a
201009 - telephone number to call at Stanford for obtaining Doctor Guardino's
201010 - 2nd opinion, ref SDS 14 GS6M, based on her examination of Millie
201011 - performed 041019. ref SDS 12 0R49
201013 -  ..
201014 - Denise says in her letter on 041108...
201015 -
201016 -    1.  I am so sorry it is costing you time. I really have to
201017 -        apologize for not being able to just email you. That is one
201018 -        area where HIPPA (the government agency that 'watches over' the
201019 -        medical stuff) is very very strict. The hospital policy is that
201020 -        only the dept. of  medical records is custodian of these legal
201021 -        documents. The rest of us are not allowed to 'hand out' the
201022 -        information. ref DRT 1 0001
201024 -  ..
201025 - Denise responds to Millie's letter on 041103 requesting that Stanford
201026 - submit the 2nd opinion via email for timely review, efficient handling
201027 - and accurate understanding. ref SDS 14 P26T
201028 -
201029 -     [On 041203 Michael reports challenges finding computer files in
201030 -     big organizations. ref SDS 16 OC5F
201032 -  ..
201033 - Doctor Guardino met with Millie for 45 minutes on 041019.  Denise
201034 - seems to indicate that government regulations prevent doctors from
201035 - writing a letter to the patient confirming understandings in order to
201036 - avoid error, and further prevents the doctor from reviewing patient's
201037 - understandings submitted on 041030, ref SDS 13 0001, in order to
201038 - improve accuracy.  This seems to conflict with good medical practice
201039 - calling for feedback to make the doctor patient partnership effective
201040 - for health care, reported on 990625. ref SDS 6 3190
201042 -  ..
201043 - Is this a new way of working???
201044 -
201045 -
201047 -  ..
201048 - People Find Ways to Help People
201049 - Give Up on Communication Fear Accountability Stifles Accuracy
201050 - Fear Accountability Stifles Communication Efficiency Accuracy
201051 - Lesson Learned Big Institutions Don't be Nice Accurate Efficient
201052 -
201053 -
201054 - Denise continues...
201055 -
201056 -    2.  I hope you are not offended--it is just the hassels of being in
201057 -        a big institution that has many rules in place. (being a big
201058 -        place, we are often a target for lawsuits, on frivolous, minor
201059 -        'bending' of the rules.  I have learned a BIG lesson once, and
201060 -        won't subject myself to it again, even to be nice. Though I
201061 -        will help you get what you need...) thanks! ref DRT 1 FJ6I
201063 -  ..
201064 - After explaining chapter and verse difficulties that resist helping
201065 - patients, Denise offers to find a way to help the patient.  That is
201066 - the quint essential "can do" spirit for improvement.
201067 -
201068 -        [...below, give Denise a simple task of providing a telephone
201069 -        number that enables exercising the spirit without great effort.
201070 -        ref SDS 0 O67X
201072 -         ..
201073 -        [On 041203 Michael reports challenges finding computer files in
201074 -        big organizations. ref SDS 16 OC5F
201076 -  ..
201077 - The "big lesson" Denise has learned is to give up on communication,
201078 - noted by Drucker, reviewed on 931130. ref SDS 3 3851  On 040203 this
201079 - was characterized by the shop worn homile:  "You can't fight City
201080 - Hall." ref SDS 8 XI41
201082 -  ..
201083 - Denise presents a challenge for competent, well intentioned people to
201084 - take initiative assisting patients, without being accountable for
201085 - frivolous "bending of the rules?  One solution is to change the rules.
201086 - This was discussed with California Supreme Court Justice Stan Mosk on
201087 - 911130. ref SDS 1 7007
201089 -  ..
201090 - Suppose the "rules" were changed to require good medical practice by
201091 - aligning the work with patient history, called out by industry
201092 - standards, reviewed on 950721, ref SDS 4 1740, and further requiring
201093 - timely communication to make the doctor patient partnership effective
201094 - with timely feedback, called by industry standards on 990625.
201095 - ref SDS 6 3190  If the rule was change to require good management then
201096 - would people stop fearing that taking the initiative "bends the rule"?
201098 -  ..
201099 - Denise's worry about "hassels of big organizations" relates to the
201100 - challenge of bureaucracy, reviewed previously....
201101 -
201102 -        Fear accountability stifles
201103 -        communication, intelligence,
201104 -        discovery........................... 980405, ref SDS 5 5065
201106 -         ..
201107 -        Bureaucracy stifles initiative,
201108 -        innovation, efficiency, accuracy
201109 -        in order to avoid
201110 -        accountability...................... 040203, ref SDS 8 E44K
201112 -         ..
201113 -        Command control of people
201114 -        prevents command and control
201115 -        of the work......................... 040203, ref SDS 8 MB7K
201117 -         ..
201118 -        Cultural of denial prevents big
201119 -        organizations from experimenting
201120 -        to improve the work, and instead
201121 -        apply requirements as suggestions
201122 -        that cannot be accomplished by
201123 -        approved tools and methods, noted
201124 -        by Sean O'Keefe at NASA............. 030826, ref SDS 7 8K4G
201125 -
201126 -
201127 -
201129 -  ..
2012 -
2013 -
2014 - 1311
2015 -
201501 - Millie submitted ref DIT 1 0001 responding to the letter from Denise,
201502 - per above, ref SDS 0 QX6L, and based on her offer to help. ref SDS 0
201503 - QY6U
201505 -  ..
201506 - Millie said...
201507 -
201508 -    1.  Thanks so much for your letter on Nov 8.  It's good to know
201509 -        people are trying, even though admin and legal constraints in
201510 -        big organizations prevent efficiencies. In my career spanning
201511 -        50 years, like you, I have learned a lot of "lessons," and so I
201512 -        know how you feel about getting cross-wise with the boss.
201514 -  ..
201515 - Lessons learned...
201517 -  ..
201518 - Millie continues...
201519 -
201520 -    2.  Accordingly, this is not to convey medical information, nor to
201521 -        request that you submit anything to the doctor, but rather to
201522 -        provide context.  Last week I was told that a new CT test on
201523 -        041103 showed a few small blood clots in my lungs. The doctor
201524 -        advised that these clots likely cause heaviness in the chest
201525 -        and coughing I have reported over the past 3 or 4 months, and
201526 -        discussed with Doctor Guardino, when we met on 041019.  At that
201527 -        time Doctor Guardino commented that Xrays showed no problems.
201528 -        Now there is new data.
201530 -         ..
201531 -    3.  In particular, the CT test report dated 041103 states in
201532 -        part...
201534 -         ..
201535 -        "Since the previous exam, [...on 040921 which Doctor Guardino
201536 -        saw] there are now filling defects within the primary branches
201537 -        of the right upper lobe and right lower lobe pulmonary arteries
201538 -        consistent with pulmonary emboli. A small hiatal hernia is
201539 -        identified."
201541 -         ..
201542 -    4.  As a result, I have been taken off the Avastin trial, and so
201543 -        face a different set of decisions.  Hopefully medications will
201544 -        clear the clots in a few weeks and I can get chemo treatment
201545 -        again.
201547 -         ..
201548 -    5.  I visited Stanford on 041019 for a 2nd opinion on treatment in
201549 -        light of the Avastin trial, as set out in my letter to Stanford
201550 -        on 041002. Now that the trial has ended for me, and I am no
201551 -        longer getting treatment, the challenge is to devise a new work
201552 -        plan.  In our meeting on 041019 (the part you didn't attend)
201553 -        Doctor Guardino indicated she had some ideas which she would
201554 -        present in her opinion, and, further, she planned to call my
201555 -        doctor at Kaiser to discuss her views.
201557 -         ..
201558 -    6.  Since Doctor Guardino has not yet submitted a 2nd opinion, I
201559 -        would like her to be apprised of this change in my condition in
201560 -        order to offer useful comments?
201562 -         ..
201563 -    7.  Since blood clots visible in the CT test on 041103 are cited as
201564 -        a possible cause of problems going back many months, I am
201565 -        curious if Doctor Guardino observed any evidence of blood clots
201566 -        from her examination of CT scan films on 041019.  At that time
201567 -        she mentioned having looked at all of the prior scans going
201568 -        back to 2002.  The narrative reports do not mention blood clots
201569 -        for the prior scans, but we have found uneven reporting, and so
201570 -        prior scans may also show clotting.  Did Doctor Guardino notice
201571 -        this when she made her review on 041019?
201573 -         ..
201574 -    8.  Again, I realize you probably cannot convey any of this to the
201575 -        doctor, and it is not my intent to encourage action contrary to
201576 -        Stanford policy.  You have been great, and I don't want to do
201577 -        anything that impacts you.
201579 -         ..
201580 -    9.  Could you please tell me how patients get timely information to
201581 -        the doctor for rendering a current opinion?
201583 -         ..
201584 -   10.  For example, would it help for me to print this letter and mail
201585 -        it to the doctor, along with a copy of the new CT test results?
201586 -        What is the address for mailing?  Would Stanford want another
201587 -        $600?
201589 -         ..
201590 -   11.  Finally, could you give me a telephone number to call medical
201591 -        records to get what is currently available, or should I wait to
201592 -        see how this new information impacts the doctor's report?
201594 -         ..
201595 -   12.  Thanks very much for help working with the "Stanford system" to
201596 -        get a new treatment plan.
201597 -
201598 -
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