[Blue Cohort] Module 1

[Adam Qazi]

Module 1 SOAPs

Beyond Health Care, Heiman HJ et al.

Social Determinants, Marmot M.

• This topic was modified 6 years, 7 months ago by Adam Qazi.
• This topic was modified 6 years, 7 months ago by Adam Qazi.

[Adam Qazi]

Submitted by Kalyan Sreeram (8/18/17):

S: Ms. S is a 48 yo patient who presents to GMAP clinic more than 6 months following her previous encounter with Rheumatology for management of longstanding RA. She is motivated to manage her health appropriately. This week we read an article that describes the social determinants that lead to inequity in healthcare provision and outcomes. This patient has been homeless due to lack of income after working as a home care nurse over the last 1.5 years, ever since she was diagnosed initially with RA per her account. Poverty and unstable home situation both seem to serve as deterrents to optimal healthcare and follow up. Due to poverty and accessibility issues, the patient was unable to follow up with any physicians for over 7 months, despite needing much more frequent follow up for her condition. This has also caused her to engage in some riskier behaviors (e.g., drifting to occasionally unsafe living situations out of necessity). One she mentions is where she was coerced into intermittently using cocaine as part of arrangement to stay at a particular living situation.

O: This patient exhibits multiple factors that may compromise optimal health management. These include poverty, inaccessibility, financial instability, homelessness. Some things I mentioned to her were to try and control variables she could control. For instance, I encouraged her to file for disability insurance and control health risk factors she can control. For instance, she has extensive history of smoking. I counseled her on the benefits of quitting, as well as asked her to think of anything that may have helped her quit. She then mentioned nicotine gum helps significantly, and I made sure to refill that medication on this visit.

A: Although I may have provided her actionable benefit in some aspects, there are plenty about which I need to be more aware or cognizant. I have thankfully never had to deal with homelessness and distinct poverty in my life, so it does require effort for me at baseline to truly empathize with those situations. Furthermore, I think treating patients to evidence-based guidelines is impossible if patients and providers are unable to forge consistent and repeatable access to one another. Social determinants of health often get in the way of us providing ideal evidence-based therapy to motivated patients who seek it.

P: I plan to understand the reasoning behind guidelines and always critically assess why they may exist; they are hard to apply to the underserved patient. More importantly, I plan to keep thinking about ways to deliver preventive care to the patient who cannot follow up effectively due to circumstances beyond my or the patient’s direct control. Last, I hope to increase our level of communication among other providers and specialists that are seeing the patients we see.

It is hard for us to actually eliminate social inequities. However, taking the previously mentioned steps collectively as providers may help us at least circumvent social inequities to still provide somewhat effective care. We may not be able to overcome social inequities for our patients by ourselves, but we may have a chance by working as a connected team. Once we do that, then we can consider trying to tackle the larger problem of how to eliminate social inequities.

[Adam Qazi]

Submitted by Muhammad Adil Sheikh (8/20/17):

Mr. W is a 57-year-old gentleman with medical history of hypertension, stroke, osteoarthritis, peripheral vascular disease and severe systolic heart failure with an AICD. He came to clinic for follow-up after hospital discharge where he was admitted for syncope. At the hospital, he wanted to leave AMA but agreed to stay overnight, however left as soon as the primary attending had seen him the next morning, with some work-up still pending. In clinic, his first response to greeting was that he wanted to see his PCP for several years but whom he saw for the first time only at the previous hospital stay.

Mr. W was visibly irritated but as we got to talking he presented as a very reasonable man. His syncopial symptoms had resolved. He was supposed to follow-up with his cardiologist as well as pulmonologist for an incidentally discovered lung nodule on imaging for which appointments had been made at discharge. He said that it will not be possible for him to keep the appointments. Of note Mr. W has had history of not following up with his physicians. During the conversation may factors were discovered that explain has brash and seemingly irresponsible attitude to his health. Mr. W was found to have osteoarthritis of knees, he was using a cane for ambulation. He is unemployed as he is unable to work due to his several comorbidities, has no means of transportation – unable to afford one, he continues to walk to most places despite the pain – walking up to 40 minutes with rests. He lives in Detroit, and although taking the bus is an option, due to the frequent delays he often gets late to appointments and hence walking turns out to be faster than short trips on the bus. He even walked to the clinic 30 minutes for this appointment.

Reflecting on social determinants of health inequalities Mr. W’s case made me realize the social barriers that limit him access to quality care. He has real issues, which are non-medical but have significant bearing on his health and are at least as important as any medication I can prescribe. His fundamental problem was inability to even make it to his appointments in a timely manner. Being a physician under the Hippocratic oath we are responsible to do all that we possibly can for our patients. In our case, although we cannot help with all his issues we certainly can do our part by advocating for our patient to enable him to continue follow-up medical care. We reached out to our Pulmonary colleagues and rescheduled his appointment to coincide with his Cardiologist’s appointment to save him one more trip to the hospital. We are also working on setting up transportation for him so at least his medical needs are met. Mr. W was extremely appreciative of us and left very satisfied with his visit to the office.
As a physician, I will look more deeply into factors outside of medicine that affect health of my patients and try to find ways within my means to address those issues.

[Adam Qazi]

Submitted by Irfan Shafi (8/20/17):

Miss E is a 44 year old women who with PMH of DM Type 2, HTN, HLD who presented with c/o dysuria, b/l flank pain and urgency for 4 days, she denied any fever, chills, bloody urine and N/V. Her USG abdomen showed 4mm renal calculi. Based on size of stone we recommended a trial of mild diuresis and after high volume water intake, analgesics and also arranged Urology referral. After addressing her chief complaint upon further investigation into patients history she reported an HBA1C of 11.9 done 2 weeks ago and her fasting blood sugar ranges from 250-300. When I tried to ask her reasons for elevated blood sugars she admitted taking high carb and high fat diet. Although she has received numerous dietitian referrals and counselling , she said something which really made me immediately reflect on the article. She said its easier and cheaper to eat junk than to eat healthy, she said ” Fried chicken is cheaper than salad at most places.”

Objective

As its mentioned in the article “Social Determinants of Health Inequalities,” we need to examine the cause of causes. The social conditions that give rise to high risk of non communicable diseases wether acting through unhealthy behaviors or through the effects of impossible stressful lives.I couldn’t disagree with my patient, as results of study CARDIA showed higher number of neighborhood fast food restaurants and lower number sit down restaurants were associated with higher consumption of obesogenic fast food type diet.

Assesment

I strongly believe that determining social factors which impact the health of our patients is most crucial step while evaluating our patients. There are factors we can control or change as health care providers through coordinated care with social workers, nursing staff and others,and there are factors we can’t control like in my patients case her easy accessibility to fast food than healthy food and its cost but I believe what we can do is at least educate our patients about the ill effects of unhealthy diet and positive effects of exercise.

Plan

My plan is to thoroughly evaluate “CAUSE OF CAUSES” and also educate the patient about ill effects of unhealthy diet and life style even if we have to be repetitive.

• This reply was modified 6 years, 7 months ago by Adam Qazi.

[Adam Qazi]

Submitted by Ahmed Yassin (8/20/17):

S: Ms. B. is a 49 y/o woman with past medical history of Hepatitis C and Hypothyroidism, who presented for follow up and health maintenance. Of concern, the patient has an active Hepatitis C with high viral load and she never received any sort of management. She has been diagnosed years ago with this virus. She was very motivated and welling to follow the medical advised and recommendations. During this visit she was very afraid that a time might come when she will be to late to get the treatment she need.

O: She exhibits multiple factors that may negatively affect her health care and its accessibility. Some of these are modifiable and some are not. These include poverty, inaccessibility and insurance coverage issues as well as medical documentation clarity. One of the main issues we discussed that she has been denied acceptance for Hepatitis C treatment due to her insurance company coverage and how her issue has been addressed as she turned away. Other points I raised to her were basic measures to control her health and welfare.

A: In order to formally assess the patient condition, I had to go though different aspect of her life and trying to navigate multiple options. Her records weren’t complete as well. For instance, she had different work ups previously for Hepatitis C assessment but she never finished the final step to start the treatment. There is always a gap of information and lack of some tests results. Based on that she had some different repeated tests. I realized that she received health care from different health systems, and there is a significant gap in the transition of care between these systems. Eventually she has no complete records in our system.

P: It is hard for us to actually eliminate some social barriers and inequities, but at least we can modify some factors. In order to provide this patient with the needed standard care, I tried to contact different units and asked the patient to consent for records release in order to obtain the full picture, in aim to formulate clear plan for the next step of care. I realized that inappropriate transition of care might come with its own huge burden on the population health, including this patient. I need to read about methods and ways to enhance this important step of every patient health care, starting from the simple daily sign out during wards days to the more sophisticated records and documentation notes sharing between different health systems. The aim next visit will be to get all the records ready, and order what we need in order to refer the patient for Hepatitis C clinic for proper treatment. Insurance coverage will be arranged with social worker and/or charity organizations.

The question for everyone to answer is: Are we really willing to take the next step in patient care by investigating the areas of vulnerability and areas of failure whether medical or not, or are we just want to keep provide pure medical care although we know that this will not be applicable and/or affordable for many of our patients due to social and economical reasons?. What the benefits of ordering a test or treatment and we are not trying to see the real obstacle and barrier implied here. Health care and welfare concept should totally replace the narrative and concrete sole medical care, if we really willing to make the change we looking for, or for some, who pretend they looking for.

[Adam Qazi]

Submitted by Manmohan Singh (8/20/17):

Ms. X is a 65 year old lady with PMH of HTN, DM who was recently discharged from the hospital after treatment for acute stroke. The patient was discharged from the hospital 2 days ago and she came to me for post hospital discharge follow up visit. When she presented to me she had a box of medications with her containing all the medications. She was carrying all the medications that she was prescribed even 2 years ago (one of her medication was also an antibiotic that she was prescribed for pneumonia 2 years ago and she was not aware of it). Her BP on presentation to me was 224/114. When asked about her BP medications she could neither name them or could recognize from her box of medications which ones are for her BP. She was on 4 different BP medications per the discharge summary when I looked up in the CIS. Her hospital course required 2 times admission to the MICU for iv BP meds. And on imaging of her head she had an acute stroke for which she was started on plavix (allergic to asa) and statin.

On my physical she had no focal neurological deificits, her lungs were clear to auscultation, no macular edema was seen on fundoscopy, CVS exam was benign.

She was immediately sent to the HUH ER with her Bf and I called the HUH ER with necessary patient information.

The fact that this patient’s BP was uncontrolled is her mismanagement of her medications. My plan is that when she comes to me on the next visit, I will make sure that she gets a pill box clearly mentioning the name of medications, their indications and their dose and frequency separately so that she does not get confused or skip her medications. I will also make sure that she gets a written handout from me regarding the name, indication, dose and frequency of all her medications. I also organized her medications in a separate bag that she is supposed to be taking currenty and asked her to return all the other un-necessary medications too authorized collection centers.
From now on in my practice I will make sure that all my patients should have knowledge about all of their medications especially the elderly patients.

• This reply was modified 6 years, 7 months ago by Adam Qazi.

[Adam Qazi]

Submitted by Suman Khicher (8/20/17):

Ms. X is a 37 years old woman with past medical history of Bipolar disorder, Class 3 obesity(BMI 47), Ovarian Cyst with Hirsutism came in with complaint of frequent and heavy menstruation. I was very concerned about her and her high BMI actually surprised me. I wanted to help her losing weight to prevent from having Diabetes Mellitus and Cardiovascular diseases. Regarding her current chief complaint, it was obvious that her body fat is playing a significant role.

On taking her detailed weight history I found that she was in normal weight range for her height until she started having anxiety attacks at the age of 21. She was being treated on Zoloft and Zyprexa. According to her, these medications along with increased stress in her life are responsible for her weight gain, which started significantly at the age of 25. At the age of 30 , her periods started to become heavy and prolonged. She mentioned that she is having difficulties in her personal life and she “stress-eats” whenever she feels overwhelmed. On assessing the readiness of the patient to make active lifestyle changes towards losing weight, she said she is trying for the last month regarding her diet, only eating salad from a fast food chain and she switched from tap water to bottled water. She says that in last month too, she cheated multiple times and ate fried fast food. And for exercise she says she walks as she does not own a car and runs on treadmill for an hour 1-2 times/week. She acknowledges that this is not sufficient but she is trying.
At that time, I did understand that this is a very crucial moment in that conversation that can help her to be more enthusiastic. I encouraged her for the efforts she is making and start progressing from the stage she is now. I advised her to refrain from stress eating and be away from the avoidable stressors, do relaxation exercise to make her feel calm. Next thing I asked her to monitor her diet, maintain a food diary and write whatever she eats so that she can control her caloric intake. For exercise I asked her to maintain the activity she is doing and gradually increase the frequency and intensity of exercise. And the last thing I asked her to measure her weight daily to be aware of any weight increment. I explained her the morbidity and mortality of the diseases associated with obesity and scheduled a appointment with a Nutritionist for having a appropriate diet planning.
But this is not enough, it is very important on my behalf to encourage her on every visit and assess if progress is being made or not. If not, I will try to find out what is the cause and will counsel the patient again.

[Adam Qazi]

Submitted by Bakht Nishan (8/20/17):

A 54 years old male with recently diagnosed diabetes mellitus and HTN came to the clinic for follow up visit. Patient stated that he is non compliant with his medications as he does not have health insurance to cover his insulin/medications. After consulting some colleagues, came to know that in this case we can give information about resources/social worker to help patient with getting insurance and required medications. Social determinants of health came to my mind and the role it can play in well being of each patient. I wished we had some clinic setup to help such patients on the spot with getting health insurance. I wished politicians could spend more money to address these issues more effectively instead of spending billions on wars. I still felt I could play my role through proper counselling about medication compliance, DASH/diabetic diet, exercise and resources to help him with his insurance/medication. I did that and gave patient the information about resources to help him get his medications (but still part of me felt that I wish I was politician or a billionaire and could do more for such patients not only in USA but around the world). I still believe there is lot that can be done on a larger scale by involving not only doctors but politicians, governments, communities, everyone to give everyone the care that they deserve.

[Adam Qazi]

Submitted by Anita Choudhary (8/20/17):

S: Ms. X, a 23 y/o young healthy female with PMH of hepatitis C came to DCC clinic for healthcare maintenance. She was concerned for her hepatitis C infection in the past as she never received treatment for it and wanted to get rechecked. Her social history included illicit drug use, needle sharing and high-risk behavior for multiple drug use. She was in rehab. On her following visit, she came to discuss her repeat hepatitis C test results. On further conversation, she stated that only 2 weeks of her rehab is remaining and following which she is interested in working but she admitted that neither she has a place to stay nor any social and economic support to help her in restarting her life after rehab.

O: It was my second week of the ambulatory, did not have adequate knowledge about type of services one can offer in such scenarios. But with the help of clinic staff, I was able to gather information about various shelters and residential placements, social and economic support and I provided that information to my patient. She appreciated the support.

A: Rehab motivated her to restart her life, she was enthusiastic to work and have her own home. At this stage, it is very crucial to have a social and economic support. I believe social determinants can have a very positive influence in such scenarios and eventually promoting our patient well-being on a larger scale. I realized other than tackling medicine issues, I need to broaden my knowledge about social factors which can affect my patient health directly or indirectly.

P: My plan is to learn more about those services which can be offered to my patients when they need such as dental services, and shelters and residential placements. On Friday lecture about social determinants, I learned about integrated care free services which includes free healthcare services, shelters and various other social support. I intend to offer these services to my patient when they are in need.

As the article “social determinants of health inequalities” states that one of the major thrust that is complementary to development of health systems and relief of poverty is to take action on the social determinants of health. Hence, with the application of social determinant factors every time I encounter a patient, will eventually promote optimal care to my patient and build a good physician-patient relationship.

[Adam Qazi]

Submitted by Hossam Abubakar (8/20/17):

Miss E is a 62 y/o who with PMH of DM Type 2, HTN, HLD and recurrent cellulitis who presents to the hospital in 2 times in 2 weeks with complaints of unilateral LE swelling, pain and erythema. On his first admission he was started started on IV vancomycin for a diagnosis of cellulitis and was seen by podiatry in the hospital. His cellulitis improved and was discharged home with an oral course of Bactrim and instructions to keep legs elevated to facilitate cure of infection. He then re-presented with the same complaints of LE redness and swelling. On detailed questioning the patient reported that his heating is was not working and that he sleeps in his car all night which does not allow him to elevate his legs. He states that he does not have enough money to fix his furnace. He was again treated with IV antibiotics but this time a multidisciplinary approach was perused where social work was involved and the patient was placed in SAR facility until the time he received his monthly income where he could fix his heating system
Objective
It was obvious that the cause of Mr. J’s recurrent admission was not his cellulitis but rather his social situation. This is proof that focus on medical management with negligence of social determinants will not serve our core goal, which is helping our patients and not just providing them with the correct guideline base management. Although Mr. J received the correct treatment the net result was him not being treated and suffering more morbidity.
Assesment
It is crucial that at every encounter we be mindful of our patients’ social determinants of health. This will enable us to take many factors into account while treating our patients. Although some factors we will not control or fix there are some that we will be able to change as physicians. The only way that we will be able do our part is learning more than just the symptoms and signs.
Plan
My plan is to try to not only prescribe the correct treatment but also attempt to anticipate any social/economic barriers that will prevent my patients from taking the treatment or limit the effect of the treatment. I plan to execute this by talking more with my patients’ and getting more information on place of living/ diet/ transportation etc.

[Adam Qazi]

Submitted by Tushar Mishra (8/20/17):

Subjective: Mr. V is a 50 year old gentleman with PMH significant for diabetes mellitus type 2, Hypertension and Asthma who came to the clinic for his follow up visit on a Monday. 2 weeks prior to this visit, he came to the clinic for his regular scheduled follow up, was found to have HbA1C level of 10.5. The reason for the poor glycemic control was his inability to comply with the medication regimen he has been prescribed, due to various personal issues going on in his life. Mr.V is currently homeless, and is not able to take his medications on time. He was provided with prescription of all the medications he would need, and was suggested to maintain a glucose journal for the next 2 weeks, to assess for any need of adjusting his medications.

On the current visit, he reported not being able to procure the medications again. He also presented with pruritic lesions of bedbugs this time, which he got from staying at another person’s place, which was not ‘well kept’. He reported symptoms of polyurea with nocturea, numbness and tingling in both feets along with occasional shortness of breath. Mr. V was again adviced to resume his medications to prevent the irreversible complications from establishing.

Objective: It clearly looked like getting his medications on time was not on top of Mr. V’s priority list at the moment. After discussion, he was able to gauge the potential consequences of not being adherent to the medication regimen. He was motivated to comply this time, but did not have a clear plan for the next few weeks. The most important issues for him during the clinic visit was the constant itching from bedbugs and living in a decent place.

Assessment: Mr. V seemed like a logical and rationale man, who understood the importance of taking care of his health, but was not able to do so due to various issues going on in his life. The social work assisstance required for Mr. V was crucial, and had to be initiated as earliest as possible to prevent the irreversible consequences of his chronic conditions from establishing. It becomes clear from this case, that all the time and effort put in the biomedical research to provide the best treatment modalities for the patients would be in effective, if other aspects of patient’s life, outside of his disease, are not addressed properly.

Plan: The next time I see a case like Mr. V, I would make sure to ask my patient, what would be the barriers that he/she might anticipate that would prevent him/her from taking care of his health. If a remediable cause is identified ahead of time, critical time could be saved for patients, which in most cases, if once lost, can never be regained.

[Adam Qazi]

Submitted by Ahmed Yeddi:

My patient was a 32-year-old pleasant lady with type 1 diabetes mellitus (uncontrolled and complicated by diabetic peripheral neuropathy). She came to the clinic for medication refill as some of her insulin ampoules were broken and she was not able to have all her insulin shots the week before.
As you probably expected her blood sugar was > 400 and her urine was positive for ketones. We explained the significance of these findings to the patient and we advised her that she needs further evaluation and treatment at the emergency department.
Her response was the most shocking thing I have heard in a while: “ My job is at stake and I need to report back to work after my clinic appointment. I have to keep my job so that I don’t lose my health insurance because I have chronic diseases and I can not afford all these medications without insurance. Moreover, I need to work more hours so that I get some money to pay the rent. Today is my deadline for paying the rent (it was 09/06) and they will kick me out if I don’t pay by today”.

As a physician, your role is not just to give medical advice and prescribe medications. You should assess if your patient will be able to follow your advice regarding the diet and the medications (or any other instructions) you would like them to be on. Because If you didn’t, your instructions will be unattainable to most of the patients we deal with in our community. Unfortunately, a significant number of our patients may miss their clinic appointments because they can not afford a ride to and from the clinic (which is unbelievably sad but that is the truth). Here comes the importance of the social determinants of health which allows us to take many factors into consideration when we treat patients. Although some factors are beyond our control, there will always be things we can contribute for our patients. We need to see the patients as humans we are trying to help, not only a medical case that we are attempting to solve.
“It is better to light a candle than curse the darkness”. Eleanor Roosevelt.

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