Whenever patients take the time to write a special note to their doctor expressing gratitude for the care they received, it prompts physicians to really appreciate the Palo Alto Medical Foundation’s coordinated network of care. That’s exactly what happened when Joann Falkenburg, M.D., a family medicine physician in PAMF’s Alameda Division, received a thank-you note from her patient Celine Leung, a retired financial services advisor. The message read: “Had it not been for your recommendation, along with Dr. Claribel Taylor’s, to order an EKG before my routine colonoscopy and cataract procedures, I might not be here today.”

Dr. Falkenburg and Claribel Taylor, M.D., a gastroenterologist at PAMF’s Fremont Center, wanted Celine to have an electrocardiogram (EKG) before she underwent these two procedures, just to make sure her heart was healthy. When the EKG revealed an anomaly, they referred her to PAMF cardiologist Ingrid Hogberg, M.D., for further testing. Although Celine was nervous to see a cardiologist for the first time, she is very glad she did — because those next test results shocked her.

After closely monitoring Celine through a Holter device, Dr. Hogberg detected a congenital heart defect plus an arrhythmia, or irregular heartbeat. These issues were hampering the electrical connections between the upper and lower chambers of Celine’s heart and would require an implantable cardioconverter defibrillator (ICD) to remedy.

“I never knew I was experiencing any heart problems, and they found a heart defect!” Celine says. “If I had gone for the colonoscopy and cataract procedures without having had the EKG, I could have died.”

Dr. Falkenburg feels fortunate as well. “My ability to communicate with specialists across our system and refer patients for tests through a single electronic patient record resulted in catching a life-threatening congenital heart defect in Celine,” she says.

A Connected Care Team

A unique benefit of family physicians working within the multispecialty environment of PAMF is that they can follow patients throughout their lives — and even care for multiple generations of families—while having access to top doctors in nearly every specialty. “Our organization allows me to care for patients from birth to the nursing home,” Dr. Falkenburg says. “We build longstanding relationships with them, which helps me care for everyone at a very personal level.”

Celine is a prime example. She has been under Dr.Falkenburg’s care for nearly 20 years. Her fiancé, Richard, had been going to the PAMF Alameda clinic in Fremont for decades, and it was his doctor who recommended Dr. Falkenburg for Celine. Then once Richard’s doctor retired, he also became her patient.

“I love Dr. Falkenburg,” Celine says. “She is the best because she listens to me and empowers me to take responsibility for my health. Honestly, I want to stay fit and improve myself for her. I don’t want to let her down.”

Many other patients feel the same way about Dr.Falkenburg. “I have patients who have retired to the foothills or the Central Valley who still come back to me for their annual exams,” she says. But because of Sutter Health’s unified electronic health record, Dr. Falkenburg also feels comfortable recommending former patients to specialists at Sutter facilities in their new hometowns. She knows these physicians will have access to her years’ worth of notes on patients and can reach out to her through the EHR if necessary.

Celine greatly appreciates the way her doctors stay connected. “When I went for a checkup on my cataract surgery recently, my ophthalmologist, Dr. Amy Sheh, knew about my heart condition and showed genuine concern for my well-being,” she says. “And I know PAMF physicians don’t only do this for me — they treat everyone the same way.”

How Philanthropy Helps

The amount of time that Dr. Falkenburg and her colleagues are able to spend with their patients is being tested by a shortage of exam rooms at the PAMF Alameda campus. They are looking forward to a philanthropy campaign that will add eight exam rooms to their primary care services by moving the entire cardiology department to a different floor.

“Philanthropy helps us maintain the cutting edge in terms of care delivery, providing new equipment and better diagnostics such as the pulmonary function test machines we received a few years back,” Dr. Falkenburg says. “Space is a subtle issue, but it’s important to have a healing environment and enough room to care for patients comfortably. We are grateful for our philanthropy partners.”

These days you can find Celine at ClubSport Fremont, taking Zumba classes and playing tennis regularly. “My friends call me the bionic woman and say I shouldn’t be exerting myself so much,” she laughs. “But I prefer to say if you don’t use it, you lose it, and my ICD is there to help if my heart has a problem. I am so thankful for my entire PAMF care team. Working together, they all saved my life!”