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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"