Shadowing at Washington, DC’s Bread for the City (“almost 50% of the time spent in the community”)

I spent yesterday afternoon shadowing Randi Abramson, MD and the team from Bread for the City @BreadfortheCity, in Washington, DC, which (from its web site):

provides vulnerable residents of Washington, DC, with comprehensive services, including food, clothing, medical care, and legal and social services, in an atmosphere of dignity and respect.

Why? For the usual reasons –

  • Bread for the City is a Washington, DC institution, with a history of service, and a modern medical care program using a state-of-the-art EHR
  • Ever since my work with California Healthcare Foundation, I have been drawn to the impact of HIT and patient/family access to information the safety net (I/they/we believe it is huge)
  • Bread for the City has an impressive, dare I say, incredible social media presence. They are telling their story through their flickr feed, tweets @BreadfortheCity, and blog, Beyond Bread.

In fact, I found Bread for the City because of this blog post that popped up on my RSS feed, by an intern, describing the history of the Shaw Neighborhood, in the city that I tend to like so much. I happened to meet Greg Bloom who does much of this work the following week at Social Justice Camp and the rest is history.

Oh, and the other important reason I went – if I can walk to it, I’ll do it. So I went.

Bread for the City has a beautiful new building that’s wired for the 21st, maybe even the 22nd century – you can’t help but notice the exposed data cables that follow you (or you follow) throughout the environment – from the food pantry to the medical center. Maybe a bit of a metaphor for how social services and ultimately how the determinants of health are visibly connected here.

This a new expansion that preserves the architecture of the previous facility, while at the same time providing clients/community members the dignity of accessing services privately and comfortably.

For the first part of my visit, I shadowed “Dr. Randi” (as one patient affectionately called her), who’s a primary care internist and the Medical Director. It’s kind of amazing to see what modern, HIT-enabled medical care is like. There’s the community feel of the clinician office, with a laptop garden in the center, and clinicians following each other with electronic charts in hand with more knowledge and information about their patients (and more accountability for it) than ever.

Bread for the City is an early adopter of the eClinicalWorks EMR, as part of a District of Columbia program started in 2007. I think this makes these clinicians both more experienced about what an EHR can do, and more aware of what an EHR should and could do. That puts them in a very good position to recommend improvements to the system and I can tell a lot of innovative ideas will come from this practice. Dr. Randi herself is an animated, welcoming, primary care physician, who connects patients to all of the members of the care team, including health education, and nutrition right then and there. The cases can be tough, I learned later in my visit how important these interconnections are…

The quote in the title of my post is a riff on the common phrase put in physicians notes, “over 50% of time was spent on educating the patient” for billing purposes. I went on a walking meeting with Julia Eddy, who supports the EHR installation especially in the area of data reporting. I looked back on my photographs and it impressed me that I really did almost spend more time walking the community than in the community service center. Note the Marion Street Intergenerational Garden, and a neighborhood that is really working to find its identity.

We happened upon a friendly dog and owner, resting and tired after their one hour walk, how awesome is it to see walkability in action. This is where you can learn a lot about people’s health.

Last stop was health education and Tonya Hamilton, who’s an Americorps volunteer and just about to become a registered nurse. I’m going to make a confession – I have never shadowed a health educator in a medical office. Ever.

She took me through what this is like, and, I agree so much with what she told me, “Everyone needs education. The question (I help them ask) is why?” This is “why?” as in “Why do I have diabetes? Why is my blood pressure high?” She walked me through a trip to Medline Plus, and how some clients she discovers can’t read, when she asks them to read the screen back to her. We all know that there are things patients don’t ask their doctor sometimes. This brings me back to Dr. Randi’s approach, which is a simple,”why don’t you talk to Tonya for a bit?” which can result in a very meaningful conversation.

Maybe physician and health educator don’t know how meaningful their contribution is all the time because they’re not in the same room, but I saw it. Huge.

Since this blog is about “what did I learn yesterday?” I would say that I learned that there are so many ways / places that people can be supported by other people, with different skill sets to achieve health / be healthier.

Even though everyone I met has a specific role at Bread for the City, I could tell that all of them think way beyond what they are doing in the moment and how it comes together. It’s kind of like they are virtually walking the NoMa/Shaw neighborhood to see how they can help things be better. There’s no patient access portal set up here (yet), but I think Bread for the City will be very successful when they launch one, because being there for the community isn’t going to be a new thing for them.

Thanks a ton to everyone at Bread for the City for the opportunity to see how they serve people, and a special thanks for making sure that the physician shadows everyone on the team, not just the other physician. If you do any shadowing or observation work, always make sure to spend time with everyone who cares for patients and families.

Photos below, enjoy.

[miniflickr photoset_id=”72157626187213664″]Photos of/from Bread for the City[/miniflickr]


Just saw your post on BfC! We've been working with them through eHealthDC and got a chance to see the new facility in late December during their first week in the space. The space and moreover the care team were impressive. I was particuarly struck by Dr. Randi's blog post about the new facility that I think is worth sharing: Look forward to chatting with you about your visit.


Thanks for posting the link to the Bread blog and associated CNN video, it really brings this work to life. I am glad that eHealthDC will be working to make sure Dr. Randi is a great doctor and a meaningful user of electronic health records!


Ted Eytan, MD