Staff Meeting in the Cancer Detection Center on May 13, 1992. (Revised as of June 1, 1992)
Those present: Drs. Belz, Amra, Kotek, Dennis, and of staff, Mr. Stanley Williams, Mrs. Jill Hill and Mrs. Kay Ellingson.
The background of the present meeting lay in a discussion with Dr. Belz some weeks ago in which he noted increasing difficulties since the last visits of the Colon Cancer Control Study group. He had noted some apparent decrease in the number of patients attending on the three days that the Clinic is running. This had been studied by Jill Hill, who found that CDC patients seen in 1989 had been 1,969, in 1990 1,546, and in 1991 1,268, and the first trimester numbers each of those years were 628, 523, and 474, respectively, whereas thus far, that is, for the first four months of 1992, only 412 patients had been seen. The Clinic runs on Wednesdays, Thursdays and Fridays for this reason. and Fridays seem invariably to be far too full, whereas Thursdays and Wednesdays are light. He noted that the patients wanted to come on Friday, largely for personal reasons, but also because flexible
sigmoidoscopy is available on Fridays at the present time. On those Fridays, two rooms are given over to the flexible sigmoidoscopy examinations and at least one room and sometimes two are given over to Dr. Prem; this leaves little space for the three other examining physicians to handle the numbers, which commonly run from 17 to 20 or 21. On top of this there is great confusion in the operation when the
attendance is high, and sometimes, but much less often, there is inexplicable confusion with small numbers of patients as well. The general examiners have found that if they start at 7:00 a.m. doing examinations, they can accomplish a great deal before 9 a.m. This organization has been affected by vacations, Martha Arneson, proving a very superb organizer under such circumstances.
Difficulties arise when Dr. Prem attends somewhat irregularly, at times arriving later than 9 a.m. when scheduled and on some occasions failing to appear at all, without prior notice. The same has been true of the flex-sig. examiners. These matters will require diplomatic intercommunications.
Dr. Amra noted that scheduling is difficult and confirms that Friday is a particularly difficult and busy day. The Calm Cancer Control Study group had an advantage in that there was outside funding to cover all expenses for the patients involved. He noted that the appointments were very steady and uniform in that study and found upon inquiry one person spent full time in Colon Cancer Control Study telephonic communication with the patients well ahead of time and again two days ahead of the appointment. In contrast he noted that Wednesday a week ago there were 17 patients with appointments, and only four appeared. Today (Wednesday) there were 17 listed with appointments, and only 6 showed. In his opinion, this is eroding and destroying the Cancer Detection Center.
Jill Hill noted that attendance is steadily dropping off and provided the figures given above. She suggests that we maintain communications with our patient clientele on a regular basis, perhaps a quarterly newsletter in each of which publications the message might dwell on one particular subject or another such as PSA or Hemoccult or Chest Films or Mammograms as examples.
Dr. Amra raised a question of the financial aspect of arrangements and led up to the question of how we might be able to get Medicare to pay for screening examinations, it having been made clear that although the State of Minnesota requires payment for screening examinations, the Medicare programs in the State have been delegated to the Blue Cross and Blue Shield outfit, and because  Medicare does not pay for any screening, Blue Cross and Blue Shield have been able to get way without paying either. It was agreed among the group that we might
very well go back to Mrs. Ann Russell far her advise under the circumstances.
Stanley Williams suggested that we might redistribute the flex-sig. examinations over the week rather than concentrate them all on Friday, so that particular examination would be available to all patients no matter what day they might attend the Cancer Detection Center. As it is at the present time, the flex-sig program is essentially destroying the Cancer Detection Center. If the Colon Rectal group cannot manage to cover the matter evenly throughout the week, then we might very well approach the problem of covering it in some other fashion, a matter which might be taken up in that vane with the Colon Cancer group,  specifically Dr. Rothenberger.
Dr. Amra showed a certificate indicating that he took a course in training in colonoscopy in Wisconsin 10 or 12 years ago and that he has several other certificates for repeats on said course at home, the thought being that he and Dr. Belz both have experience with the examination and might very well provide us with the regularity of availability that is needed. He suggested that the matter of the
clinic appointments might require the hiring of a full time separate person in the office, an estimate well born out by the experience of the Colon Cancer Control Study.
Dr. Belz suggested that we get an 800 phone number in order to facilitate intercommunication with patients prior to their times of appointment. After some discussion around the table, the thoughts appeared to center upon sending a card perhaps five weeks ahead of the proposed appointment date asking the patient to call CDC on the 800 number, during which conversation the date would be settled. Then a formal written confirmation with necessary information upon it would be sent to the patients. Finally, there would be a second phone call to the patient 48 hours ahead of time.
After nearly two hours of meeting Dr. Dennis summarized the points that looked to him be most relevant:
1. Dr. Rothenberger must be consulted with regard to consistent flex-sig. coverage whenever the Cancer Detection Center is operating.
2. Scheduling must be reorganized so that patients attend when they have appointments and so that the numbers remain constant from day to day 
throughout the week.
Five weeks before a proposed appointment, CDC will send a post card to the  involved patient stating that the time has come for a return visit and asking the patient to phone the CDC on the proposed "800" number.
If the patient calls, a date will be set at least four weeks ahead; if the patient does not call, the CDC should call the patient to set the date.
When the date has been set as above, a formal appointment slip with directions for preparation will be sent, including a kit for stool guaiacs, the patient to test 3 consecutive stools (two samples or smears per stool) and mail the packets back for
a proposed $10.00 discount in the CDC charges.
N.B. As a measure to determine the frequency of positive stools in patients who have any at all, patients with guaiac positive stools will be sent enough additional guaiac kits to cover 12 more consecutive stools for a total of 15 stools tested by
the time of arrival of the patient at the CDC.
These extra kits will be paid for out of research funds.
At 48 to 72 hours before the appointment, CDC will make a reminder phone call to the patient.;
3. Since so many patients wish to come for examination in connection with shopping trips and so forth in the Twin Cities, we should explore the possibility of having the clinic operative on Monday and Friday and one other day during the week rather than Wednesday, Thursday and Friday.
4. It is essential that we "drum up trade" A. newsletter was suggested. A diagram was recently drawn up in the office of the manner in which the Cancer Detection Center can cut the risk of death by cancer by more than one third; also items like the PSA, mammograms, Pap smears and so forth might be sent to our clientele,
enough so the importance of attendance at the CDC is not forgotten by our patients
5. It is medically not acceptable to get a guaiac study on the day the patient comes to the Cancer Detection Center. It is too small a sample to be meaningful to get a stool specimen digitally at that time alone. This should be arranged at the time of the initial card 5 weeks ahead of time and patterning conversation with the customer to stress the red flag that the guaiac test should wave.
6. Economic considerations for CDC: This arose first in regard to the guaiac test in advance of coming to appointment. If we were to restructure our charges, the patient could be assured of a 10 percent or $10 discount if the guaiacs are returned as requested.
7. Since we have been unsuccessful consistently to get insurance companies to cover any part of our screening program, it would be wise to re-consult Mrs. Ann Russell with regard to the course of wisdom.
8. Impressed with the frequency with which the local medical physician fails to proceed with urgent tests recommended in reports from the CDC, Dr. Dennis proposed a checkup with the referring physician one month after the visit of each of those patients who has urgent recommendations listed in the communication after said visit. (This results from the case of Everett Young, for whom colonoscopy was urgently recommended in 1990, The patient twice declined to have it done. Obstructing cancer of the colon was diagnosed in 1991, thirteen months after the last visit to the CDC, and the patient is now deceased). Dr. Dennis volunteered to scan reports to LMD's and be responsible for doing the follow-ups.
9. This is a follow-up on the preceding number. We should round out with biopsies and other studies here. At least offer same to the patient with the knowledge of the home physician that we are doing them now. We should get mammograms read, even if informally, before the patient is allowed to leave the X-Ray Department so that, if additional films are needed, they may be gotten at once rather than to send word to the home physician to get additional films made sometime later only then to have to send films back and forth for comparisons. Another example of
rounding out our procedures here before the patient leaves would be to take off the polyps of the intestine at the time of the flex-sig examination so that a definitive diagnosis may be given to the home physician. In the third place appointments with Dr. Delaney for suspected breast lesions are currently being done; in the fourth place Dr. Fraley has already agreed to make somebody available to come down to the CDC in the afternoon if the CDC is in operation, without having the patient have to be called back for care here in case he wishes to have it. The CDC should have the same sort of arrangements with the Dermatology Department.
10. There is now a provider number in the name of Clarence Dennis. The number is F417DE.
Services in the CDC for which insurance is to be billed should be so billed in the name of Dr. Dennis with said provider number. Dr. Dennis's own SS# should not be given here since that would involve him with the IRS.
11.  There has been a series of untoward events in the past several months. In one case the blood samples sent to the outside laboratory for husband and wife were exchanged and required much work to clarify, and the most recent item is a Pap smear taken about four or five days ago in which the specimen was lost after leaving CDC. In this last case Dr. Dennis agreed to ask Dr. Prem's advice before proceeding. The matter has been nicely handled, and the patient is happily making an appointment to return to Dr. Prem.