Day 2: Shadowing in Integrative Medicine / Internal Medicine, Kaiser Permanente Colorado

This way to Complementary Medicine, Lakewood Medical Offices, Kaiser Permanente Colorado

On day 2 of our shadowing experience, I got to actually observe integrative medicine care being delivered (data vs facts – facts are what you see yourself), by Dr. Meghan Dukes, DC, who is on Twitter, ready to be followed -> (@KPChiroDukes).

And, I understand what is meant by integrative medicine now. Meghan told me “alternative medicine” meant “something different than traditional (allopathic),” “complementary” means “in addition to allopathic medicine,” “Integrative” means “In addition and we talk to each other.”

Here, Meghan has access to the same electronic health record that other physicians and nurses do, which means she can integrate their allopathic medical treatments and their chiropractic ones. This is not the norm by any means in health care. The facilities in Lakewood are not nearly as customized to this practice as the ones at Midtown yesterday, but the thing is, they are inside the medical office building, right next to the other medical specialties we’re familiar with, including pediatrics.

I have never seen a chiropractor practice in person until now. I bet the vast majority of allopathic physicians out there would say the same (I/we’ve seen films of them, but not in person). If you take a condition like a bursitis, which is an inflammation of a lubricating sac over a joint, that’s something that we (allopathic physicians) typically treat with a steroid injection. Meghan, on the other hand, would treat with a physical manipulation to alleviate the source of the friction/inflammation in the first place. Steroid injections can be very beneficial for one time use; the mentality of management is different though – to an extent it’s a large part of what we have to offer because we haven’t been taught manipulation. A family physician may have been taught some limited manipulation (I have), nothing to the extent of what Meghan can do.

It’s also worth noting that an injection produces biohazardous / regulated waste, which costs about $2 per pound to process, compared to 3 to 8 cents per pound to process regular trash, of which not much is generated anyway in a chiropractic visit.

Interestingly, I asked Meghan if she’s exhausted after a day of seeing patients, she says less so than if she was sitting at a desk all day.

For the second part of my morning, I shadowed Anisa Moore, MD, an internist in the Lakewood offices. The thing about Lakewood Medical Offices is that there is a lot of innovation going on here, beyond just what is happening at Kaiser Permanente around health information technology.

There’s a unit called RADAR, which stands for “Regional acute diagnostic and referral center,” which allows members to get acute care services, like urgent consultations, referrals and imaging, staffed by emergency physicians, to manage conditions in a less intense environment than an emergency room can be. There’s also a team here known as the “Green Team,” who are pioneering different medical-home type models of care, again, fully supported by the technology of Kaiser Permanente and going beyond the innovation of the state of the art electronic health record system.

I didn’t shadow in either of those areas (data versus facts), and yet Anisa is an enterprising innovative internal medicine physician delivering excellent care enabled by technology. That’s the baseline. And she’s studying to be a process improvement expert to deploy those tools even more efficiently for her members and her team. Specifically, she’s interested in the use of technology to collaborate better with her team in real time, which is perfect since the team I am with is studying the collaboration of our clinicians 🙂

The patients of an internal medicine physician versus a family physician are typically going to have more complex medical conditions, and probably not any less complex family / social conditions either. The family physician and the internal medicine physicians need each other for this reason, and a medical office like Lakewood has the expertise to take care of fairly significant levels of complexity. I’ll leave it at that. And the fact that I am continually impressed by my internal medicine colleagues’ abilities in the area of multi-system complicated illness.

I didn’t shadow in the following areas, but I’d like to commend and thank the following areas for allowing our team to shadow: Lakewood Medical Offices Optometry, led by Karen Clark, OD, where process improvement is not a novel concept (see: Colorado Vision Essentials Sees 20/20 With UBTs | Labor Management Partnership), Pediatrics, whose Chief Scott Zimbelman, MD says is where the fun happens, and Allergy, a small department in any health system, that is very high performing in Colorado, led by Suzanne Fishman, MD. For internal medicine, thanks to Heidi Chang, MD, who’s the Chief of Primary Care at Lakewood Medical Offices. As I learn of the insights from my colleagues, I will post them here.

This shadowing experience was slightly different than the ones I usually do. It is the physician primary role to bring the patient story every conversation. That doesn’t mean only the physician should bring the patient story into every conversation. I favor as many people as possible understanding the member/patient experience in the health system. So thanks to my colleagues from California, Colorado, and Washington, DC, who came to learn with me and walk in the shoes of our members, and our nurses, physicians, and staff, who showed their paths to us at Lakewood Medical Offices.

We came to learn


Ted Eytan, MD