ADayintheLife–NeighborhoodHealthcare
At6:30a.m.myalarmremindsmethatIhaveworkintwohours.Anall‐too‐short45
minuteslater,Ileavemyhousetomakethe30‐miledrivetoworkatNeighborhood
Healthcare(NHC)inEscondido,CA.Uponarrivingattheclinic,Iwalkintotheprovider
office,acorneroftheclinicwherethedoctorandfournursepractitionerscanworkon
charting,fillingprescriptions,andgettingadvicefromeachotheronthebesttreatmentsfor
complicatedpatients.Isetdownmythingsatacomputerandlogon.Oncethenurse
practitionerI’mshadowingcomesin,shelogsmeintotheprogramonwhichallofNHC
runs:eClinicalWorks(eCW).
eCWisaprogramthathasalloftheelectroniccopiesofanyandalldocuments
pertainingtoanypatient.Intherightcornerofthemainscreenarecounters,sometimes
referredtoas“jellybeans,”thatcontain:numbersofpatientsthathavearrivedandare
readytobeseenontheschedule,labresultsofotherpatients,telephoneencountersto
whichtheprovidermustrespond,andunrevieweddocumentspertainingtopatients(e.g.,
recentERdocuments,healthinsurancechanges,patientself‐healthassessments,andso
on).
OnceIlogontoeCW,Idoaquickreadingofthehistoriesofpresentillnessandother
pertinentillnesses/diagnosesofthepatientscomingintotheclinicforthemorning,and
brieflyconveythisinformationtotheprovider.Throughoutmycollegecareer,Ihave
workedtosynthesizeinformationinasuccinctandcoherentmanner,andenjoyputting
theseskillstouseinaclinicalsetting.Igivethenursepractitionerabriefsummaryof
patients’medicalhistories,theirrecenthospitalizations,reasonsforrecentclinicvisits,and
pertinentpersonalhistories.Thishasproventoberelativelyhelpful,asshehashad
hundredsofpatientsoverthe15yearsshehasworkedatNHCandmaynotremember
minuteyetpertinentdetailsaboutthepatientstobeseenthatday,andIlikehelpingherin
anywayIcanbeforeweseepatients.
Wenormallyseeourfirstpatientat8:45a.m.,andseepatientscontinually
throughoutthemorninguntiltheclinicclosesforlunchatnoon.Atnoon,thenurse
practitionerdoessomeoftheimportantyetmonotonouschartingthatneedstobedone
afterpatientencounters.“Charting”isadocumentationtechniquewhenaprovider
documentseverythingaboutthepatientvisit,includingacompletereviewofbodysystems
checkedduringtheappointment,reasonsforprescribingmedicationsormakingspecialist
referrals,conversationswiththepatient,anddiscussionofproceduresperformedfor
patients.Thesedocumentsget“locked”soonafterchartingiscompleted,uponwhichone
canonlychangethedocumentunderspecificcircumstances.Thisisdonetohavea
concrete,unchangeablerecordofthevisittowhichtheprovidercanreferlater–or
anotherprovider,shouldthepatientchoosetoswitchproviders.
Whileseeingpatients,thenursepractitionerallowsmetoauscultate,orlistento
withastethoscope,thelungsofpatientswithCOPD,auscultateheartmurmurs,and
observevariousprocedureslikepackingabscesses(openandinfectedskinwounds),
extractionsofcomedones(infectedskinlesions),andspecialbreathingtreatmentsfor
patientsshortofbreath.Sometimesbeforeapatientprocedure,Iconveyeitherlast‐minute
criticalinformationorclarificationquestionsbetweentheprovidersandthemedical
assistants,liketheprecisesuppliesneededorwhetherwehavelocalanesthetic,(e.g.,
Lidocaine)instockattheclinicsoaprocedurecanbedone.Ireallyenjoywatchingmedical
proceduresbecausetheyhighlighttheimportanceofprimarycareproviders.Whilesome
viewprimarycareprovidersasjusta“gatekeeper”tospecialists,observingprocedureshas
shownmethatprimarycareprovidersneedtobetalentedinmanyskillstomaintainthe
welfareoftheirpatients.Additionally,procedureshighlighttheimportanceofteamworkin
amedicalsetting.
AnotherfacetofshadowingatNHCthatIthoroughlyenjoyisseeingpatientsona
regularbasis.WorkingasanEMTwiththeBrandeisEmergencyMedicalCorps,Irarelysee
patientsmorethanonce,orpursueanykindoffollow‐upafterItransferthemtothenext
levelofcare.However,atNHC,patientsareseenroutinely,fromasoftentoeveryfewdays
toassparinglyaseveryfewmonths.Forexample,newpatientswithlargelyuncontrolled
diabetesneedtocometothecliniceveryfewdaystogettheirbloodsugarcheckedandto
attenddiabetesclassesheldbyprimarycareprovidersattheclinic.However,patientswith
theirchronicconditionsundercontrolcanbeseeneveryfewmonthsorsoaslongasthey
cancontinueahealthylifestyle.
Ithinkthiscontinuityofcareisakeyaspectofpractitionersmaintainingastrong
rapportwiththeirpatients.ShadowingatNHC,Ihavelearnedthevalueofhavingatrusting
relationshipwithpatients,andthinkthatthiswillapplywelltoothersettings.Forexample,
thisfallIamworkingasaCampusAmbassadorfortheGiftofLifeBoneMarrow
Foundation,asanadvocatetoaddmorepeopletothebonemarrowregistry.Ithinkthat
buildingastrongrapportwithpatientsatNHCwillhelpmebeabetteradvocateattheGift
ofLifeandotherorganizationsbecauseIwillbetterunderstandthepatientperspective
and,asaresult,canbetteradvocatefortheirneeds.
ThegeneralpatientexperienceatNHCisnotunlikemostpatientexperiencesat
otherclinics,withonemajorexception:thecompassionoftheproviders.Asapatient
arrives,(s)heiscalledbacktothemedicalassistantofficewithinminutesofhis/her
appointmenttime.Themedicalassistantweighsthepatientandtakesthepatientbackto
anexamroomtocompletemeasuringvitalsigns,recordpersonalandmedicalhistories,
anddocumentanychangesinmedications.Withinafewshortminutes,theprimarycare
providerenterstheexamroom,greetsthepatient,andasksaboutthepatient’shealth
usingcompassionandgenuineconcern.Upuntiltheentranceoftheprovider,the
experienceatNHCislikethatofanyotherclinic.However,itisthistrusting,caring,and
genuinenatureoftheprovidersatNHCthatmakesapatientvisitsmooth,efficient,and
highquality.Theprovidersandmedicalassistantsworkextremelywelltogethertosupport
suchexperiencesattheclinic.
Regardingmythreespecificexpectations,Ihavemadesignificantprogressontwo:
learninghowtoeffectivelyprovideforapatientwithstronglanguagebarriers,and
learninghowhealthcareprovidersworktogethertoprovidethebestpatientcarepossible.
ManyofthepatientsatNHCspeakSpanish.Therefore,thenursepractitionerrelieson
medicalassistantstoserveastranslators.IamrelativelyfluentinSpanish,soIalways
enjoylisteningtotheconversationbetweenthepatientandnursepractitionerthroughthe
medicalassistant.Onetime,however,themedicalassistantwasunabletocorrectly
translatewhatthepatientwassayingtotheprovider,soIsteppedinandtranslatedforthe
interaction.Thatwasaprettybigaccomplishmentformebecauseitrequiredtrustonthe
partoftheproviderandthepatient,andIwasabletohelpinsomeway,howeversmall.
OnedayIhopetobeaphysicianforpatientswhoprimarilyspeakSpanish,sothiswasan
importantaccomplishmentforme.Translationcanbeparticularlychallengingbecauseitis
criticaltocorrectlyexplainmedicalprocedures,medications,orpatientconcerns,andone
slip‐upcouldcausemajorproblemslikeprescribingincorrectmedicationsorincorrectly
referringthepatienttoaspecialist.
Ihavebeenabletodevelopnotonlymytranslationskills,butalsomyinterpersonal
skillsduringthisinternship.Witheverypatientinteraction,Ilearnmoreaboutthe
compassionrequiredbyprovidersfortheirpatientsandtheappreciationpatientshavefor
theirexcellentproviders.Intalkingwithpatients,Ihavebeendevelopingrapporttoapoint
atwhichsometrustmeenoughtotellmeverypersonaldetailsabouttheirphysicaland
mentalhealth.Thisinternshiphasalsocontinuedtodevelopmypatience,astherehave
beensomepatientswhodemandtheyreceiveaparticulartreatment,evenifitisn’t
indicatedfortheirproblem.Ihaveworkedhardtoexplainwhycertaintreatmentsor
proceduresareunnecessary,sometimesmultipletimes,toconveythereasoning
adequatelytothepatient.Ibelievepatiencewillbevitalforcontinuinginthehealthcare
field.
Intermsoftheotherexpectation,Ihaveobservedtheprovidersworkingtogetherto
determinethebestpossibletreatment(s)forcomplicatedpatientscenarios.Theyputtheir
entireselvesintothesepatients,anditshowsthroughexcellentpatientcareandpatient
satisfaction.Whilehelpingthesepatientscanbechallengingduetosocioeconomicstatus,
mentalorphysicaldisabilities,orlanguagebarriers,theseprovidersactlikethesearemere
bumpsintheroad,androlloverthesecomplicationstoprovidetheirpatientswiththecare
theydeserve.IaspiretobeascreativeandeffectiveasNHCprovidersareintheir
treatmentdecisions,andcan’twaittoseewhatelseIlearnduringthetimethatremains.