I had my first opportunity to shadow at Kaiser Permanente, one of our project sponsors. At this Oakland, California practice, about half of internist Victor Silvestre’s patients speak only Spanish. To date, the only clinician-patient encounters I had observed in the exam room were with the aid of an interprete, so I was looking forward to the possibility of shadowing a purely (from my perspective) foreign-language encounter (Dr. Silvestre is fluent in Spanish).

With only a couple of college semesters of Spanish two decades ago, I can follow some of Spanish conversations but not that well. What became clear to me throughout the visit was how much I could understand about the interaction between Dr. Silvestre and his patient. It was less about my limited Spanish comprehension and more about the patient’s non-verbal cues, the interplay between doctor and patient, and her considerable animation in describing her symptoms and concerns. Not in any way to downplay the huge barriers that language difference can create in access to high-quality health care, but the episode highlighted for me how much of effective clinician-patient interaction relies on non-semantic communication (an issue for those of us who are assessing the role of asynchronous and non-visual interactions–we need to figure out what are the right times and wrong times to use them).

Dr. Silvestre not only was able to diagnose her effectively and provide reassurance (clearly one of the important patient outcomes for this visit) but he also prescribed Spanish-language Ix for her. He printed out Spanish “patient instructions” (content that Kaiser Permanente worked with Healthwise to create) to help guide continuing home treatment of bronchitis as well as symptoms to be aware of that could suggest the need for additional treatment. This Ix reassured the patient and gave her confidence in managing this part of her health and what specific turns of events should trigger a call or return to Dr. Silvestre.

When the doctor had to step out for a moment, the patient turned to me and asked, “¿Hablas espanñol?” I replied, “Un poco.” She immediately began to try to engage me in friendly Spanish conversation after that, though Dr. Silvestre returned (although part of me wanted to try to, our goal in shadowing is–as much as possible–to be a fly on the wall in hopes of observing the clinician-patient encounter as it would otherwise take place).

My other exam room experience (entirely in English) with Dr. Silvestre was completely different in many ways, not the least of which was the way that the electronic health record was a more present part of the encounter–I think in part due to the fact that Dr. Silvestre was addressing a wider range of health conditions for the middle-aged man versus the woman who was exclusively focused on the acute condition (Vic, was this your perspective as well?). In preparation for both patients, Dr. Silvestre made considerable use of multiple features of the electronic tools in advance of the visit to help him frame what the critical issues were that the encounter might cover.

The other aspect of this particular shadowing experience that was so educational for me was to see how Kaiser Permanente’s new HIT tools (e.g., Epic, HealthConnect, etc.) have already substantially affected how at least one primary care physician helps his patients to manage their health. Dr. Silvestre began his day by using the EHR to find out if any patients had gotten admitted to the hospital overnight and then did a little digging to try to figure out why. He used HealthConnect to help him manage his communication with his patients and exchanged several electronic messages with them during the time we were there. In most cases, the messages effectively answered the questions (actually, at least a couple of the messages were from family members of the person with the health issue rather than the patient emailing directly), though one circumstance highlighted that, occasionally, there is no substitute for sychnronized communication. A string of messages resulted in some confusion for both the doctor and the family member about what exactly was being tested. At a certain point, Dr. Silvestre realized that the answer was to pick up the phone and call directly (to a cell number, not a land line, which probably increased the chances of connecting on that first attempt). Effective commuication was once again restored.

It was a great opportunity to visit someone who is comfortable with new HIT applications and who has such a diverse patient practice–as always, I learned so much both from clinician and patient. In this case, I think I also got a glimpse into the future of how KP primary care physicians will be serving KP members in the future–a combination of: in-clinic encounters in multiple languages supported by both HIT systems and health content modules to prescribe; and considerable care management activity delivered asychronously in a way that is convenient for both clinician and member.

Thanks again to Vic, Carol, Monica, and the whole office.

(I think Ted will have pictures up here soon.)

–Josh

This entry was posted on Wednesday, December 5th, 2007 at 1:27 pm and is filed under Uncategorized. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.