[Green Cohort] Module 2

[Adam Qazi]

Please submit SOAPs below:

[Adam Qazi]

Submitted by Sally Azzo:

During residency I started to notice that most physicians including “me” spend more time in front of the computer than spending time with the patient, we always try to gather as much data as we can from the medical records and unfortunately sometimes we start judging the patients based on previous notes. I see the word “non compliant” a lot. In fact, this is the reality, we have a lot of non-compliant/ non-adherent patients, some of them have their own reasons to become non compliant while others don’t.
Unintentional bias can happen while encountering passive patients, patients who smoke, patients who abuse various substances, non-adherent patients, and passive-aggressive patients.
I had a patient with multiple co-morbidities and on several medications; she only shows up in the clinic when she needs refill for her pain medications, she doesn’t want to listen to me about her HbA1C of 14 and her BP of 180/100 but the only thing she want is her norco. As a consequence, I feel bad and useless; I would be biased towards her and sometimes towards her entire population group, but even if I feel that I would still educate her, prescribe the medications that she is not taking, and continue my care at standard level.
Finally, I like to refer to this quote “the three big pieces of how humans work together in a medical encounter: “What is happening to the patient before the doctor walks into the room, what is happening to the doctor before he walks into the room, and what happens in the room.”

[Adam Qazi]

Submitted by Yeohan Song:

Mr. L is a 37yo gentleman who suffers from chronic pain following a GSW in 2001, requiring R nephrectomy, added on to my clinic schedule for the afternoon. I reviewed his chart and saw that he had several recent visits within the past month, for various reasons. Knowing that he was likely on on-term prescription analgesics, I tabbed through to his list of prior UDS logs and pulled up his PMP-Aware data sheet. As I had expected, I was faced with an extensive list of prescription narcotics.

At first glance, the entire screen seemed covered with high-dose narcotics—not only morphine, but also oxycodone in the tens to hundreds of prescribed pills each month. A quick glance at the last prescription fill date made me realize that this was much too soon for his next prescription, and at that moment, the patient wheeled himself into the room.

I started the visit off with a greeting, asking open-ended questions and asking what brought him in. The conversation was quickly being redirected to his request for a refill of his opioid medications, so I asked him what other issues I could help address at the visit aside from his chronic pain, as it was still too early for prescription renewal. At that moment, there was a brief moment of silence, when he began to think, and slowly, he began to share about a friend who had been recently killed, and for whose death he felt partially responsible, with an immense sense of guilt. As it was our first meeting, he was hesitant to share any more than that, but that was enough to start the conversation about his grieving process, and eventually led to his request to be referred to a counselor.

In considering the approach I had regarding this patient and his initial reason for the visit, I readily admit that my perception of the patient was already being formed, if not set, before I ever laid eyes on him, which was in large part based on his anticipated reason for visit. However, as noted by Chapman et al. JGIM 2013, I was able to counter this initial impression through an act of perspective taking, considering the trouble he must have taken to make his way to the clinic on his wheelchair and thinking about him as a person, trying to make the most of the day in spite of his ever-present pain, and his dependence on the pills that give him the bitter-sweet moments of tangible, if fleeting, relief.

Through taking the moments to consider the other person in the room, to in fact recognize their humanity aside from their distilled chief complaint, I realize that I can recover the empathy needed to deliver care, rather than to merely resolve a problem.

[Adam Qazi]

Submitted by Adi Shemesh:

This week, I encountered an elderly professor who came in for a well-care visit. Though she was prediabetic, she was otherwise in good health and showed understanding and willingness regarding lifestyle modifications in order to prevent developing diabetes. It was obvious that she had a better understanding than the average patient regarding diabetes due to her education, and that at least some of her compliance stemmed from that understanding.

Educational gaps can be a major cause of health disparities due to the effect of understanding on a patient’s judgement of whether to adhere to proposed management. As a physician, I understand that with most of the patients I have encountered thus far as a resident, I don’t have the privilege of being a pure physician without first being an educator. To reach the patients and increase their compliance, especially relatively healthy patients that require preventive care, they have to be first taught in a manner that they understand the importance of the proposed treatment. Therefore, my goal is to achieve the same adherence from a professor and a less educated patient by being able to adjust my level of medical education to their understanding of the medical field.

[Adam Qazi]

Submitted by Hadeel Sahar:

As part of my self believes, I am trying to do my best to provide an equal and unbiased care to all patients regardless of their racial difference, age or sex difference, insurance difference, etc.
My philosophy is that every patient should receive an equal attention and care, taking in consideration his/her internal believes, educational level and other factors. Sometimes things go out of our hands as in this patient.
A 55 year old African American gentleman with history of HIV (on HAART with 100% adherence to medications) and recurrent DVTs and PE (all unprovoked). He was seen by the hematologist and planned to get a lifelong anticoagulation therapy (due to unprovoked nature of his DVT/PE) in the form pf Apixaban. The reason why apixaban recommended over warfarin due to HIV status (HIV medications can interact with warfarin causing labile INR, In addition HIV medications tend to change and HIV patients at time may require prophylactic antibiotic therapy, which may also interfere with warfarin ie.it would be difficult to maintain a safe and therapeutic INR). We have send pre-authorization twice to acquire an approval for Apixaban, but till now we couldn’t get a feedback. Luckily the patient is getting a free samples of apixaban from the hematology clinic.
In my patient’s story, I am happy that he is getting free samples from the hematology clinic, but at the same time I feel very sad that we couldn’t get a prior authorization for such an important therapy for him.
I think such problem should be addressed and discussed thoroughly to reach a solution to my patient and similar other cases.

[Adam Qazi]

Submitted by Maninder kaur:

It is only 3rd month of my residency period, but in these three months I have observed that we all have unintentional bias in regarding different groups of patients. For example, we assume that most of patient with high risk behaviors like I/V drug abuse, smoking they are not compliant with their treatment and doctor’s advice and have more drug seeking behavior. But we don’t remember that every patient has his/her own identity and thought process, not all patient with addiction are non- compliant and non-serious to their doctor advice
Last week I met in clinic with 2 patients, they both were I/V drug users. One patient came with complaint of URTI leading productive cough. We gave him trial of oral antibiotics as cough was productive. On 4th day of his antibiotic course, I called him to make sure antibiotics are working for him, but he told me that he did not take his antibiotics and he was not having any clear reason not to take his treatment. I advised him again that antibiotics are very important for his throat infection , but I am not sure he will take his treatment .1 day before that I met with other patient, he was also I/V drug user and he was having T2DM, he was fully compliant with his treatment, use to follow up with podiatry and ophthalmology yearly for complications work up and was having a thorough knowledge of his diabetes and even the risk of I/V drug use and was willing to join methadone clinic also. In short, he was a good patient for me.
So, we should not assume that all the patients with high risk behavior are noncompliant, non- serious, who are not having any understanding of their disease process. We should treat them as other normal patient, because they have equal I Q as others, they will get our point about their disease if we explain them in same way as to other patients and if we are able to convince them, they can make up their mind to stop that high-risk behavior. So, it all depends on doctor-patient relationship.
I will try to be non- judgmental about any group of patients and will make good relationship with my patient to guide them and treat them in an effective way.

[Adam Qazi]

Submitted by Yuliya Sharakova:

Ms.S is 44-year-old female with past medical history of HIV on anti-retroviral therapy. She has been patient of mine for more than a year, and every time she comes to the clinic, she complains of symptoms of mild upper respiratory infection and requests disability for several days due to illness. So every time I see her name in my schedule, I already have an idea why she is here and what to be ready for. In other words, I have been already biased. Last week during visit she was complaining of diarrhea of 3 days duration, which prevents her from leaving her house, since she goes to the bathroom 5-6 times a day. And as usually she was asking for disability for several days. Upon thorough history taking and examination, I found out that recently she had urinary tract infection and was treated with antibiotics, given by Urgent Care next to her house. I suspected diarrhea due to C.difficile, and tests I ordered confirmed that. Appropriate treatment provided. But as physician I felt uncomfortable, because I was not ready to take this patient seriously when she came to see me.
Analyzing this experience I can now say with confidence: even patients, that physician thinks he/she knows everything about, deserve thorough and unbiased approach in order to provide good timely patient care.

[Adam Qazi]

Submitted by Neelambuj Regmi:

I like many of our residents here at DMC must have taken care of sickle cell patients. There are few sickle cell patients that visit us almost on a monthly and sometimes weekly basis for a pain crisis. I was also taking care of a patient who had been admitted to the hospital 6-7 in the last 4 months or so. His rate of admission was suspicious to me and I assumed unconsciously that the patient is in the hospital for “pain medications”. But with further workup, we found out that his hemoglobin was dropping. I hadn’t realized until I saw his lab reports I was not empathic towards his pain problem.
I realized that assumption in medicine can be very detrimental. Medicine is such a dynamic field that any assumption would eventually be proven otherwise. Esp with regards to patient and pain, assumption that the patient is addicted to pain medication without actively taking history and examining the patient can mean more pain and suffering to the patient.
After this encounter, I have tried to see patients in a non-judgemental manner. I promised myself that I would be more careful about the history and physical findings before I label someone as “pain meds seeker”.

[Adam Qazi]

Submitted by Sindhuri Benjaram:

During my clinic week I had an encounter with a patient who had a follow up visit but came primarily for medication refills. In the clinic patient had high BP and mentioned he has not taken his medications for a week because he ran out off his meds. He brought with him empty bottles of anti hypertensive meds. When I looked into his records same problem have arose on his previous clinic encounters and on scrolling through his medication list he had enough number of refills, but he stated that he called the pharmacy and they never got back to him. He is not homeless but not educated and has little understanding of his health status and how multiple comorbities affect each other.

Given our hospital’s patient demographics we often have such patients. When I looked at the chart a few questions came into my mind firstly is he complaint with his medications, looking at the empty bottles what is he doing with his meds, always has same issues so is there something else going on. He was on an appropriate regimen for his anti hypertensive meds. So I called the pharmacy and enquired into the refills issue. I figured that there was a communication gap between the patient and the pharmacy. I realized that there are often other issues like patient’s education status, understanding ability which are also important. He has a home and is insured but is not educated enough to contemplate the communication gaps, does not ‘google’ about his health problems. After this encounter I told myself always consider the patient’s social status, education level before using the words non-compliant or coming to the clinic for others meds.

[Adam Qazi]

Submitted by Kenisha Evans:

Ms. M is 63 y/o woman 3 cigarettes/day smoker with unknown 5 year hx of muscle spasms and radiculopathy, who had previously changed PCP due to issues with obtain physical therapy with previous physician, presented to clinic for medication therapy for muscle spasm and radiculopathy. Ms. M was not my own patient but was returning for refills on flexuril that had been prescribed for 10 days PRN and Lyrica to which she was not own. Patient was completely sold on Lyrica and flexeril to managed her symptoms and was not open to hear about any other medications or other forms of treatment options. She was most recently prescribed Gabapentin 400mg BID but per patient she was not taking this medication has it doesn’t relieve her symptoms. Patient was convinced Lyrica was the answer to her problem. Patient stated she had an EMG but initial was unsure when. On EMR review, Ms. M had known history of chronic pain management s/p L knee replacement and osteoarthritis. I was quick to MAPS patient to rule out substance abuse and dependence than investigating the nature of EMG study, which was later found and reviewed and recommend follow up with neurology.

Objectively
Although referral for reevaluation was made for neurology, I was not looking for any acute changes in Ms. M underlying condition as my top differential for patient with chronic pain management but my thoughts were how can I treat her dependence or let me rule out substance abuse. As stated in the article “Physicians and Implicit Bias: How Doctors may unwittingly perpetuate Health Care Disparities,” we base our perceptions of reality on received info and experiences reinforced until they become automatic. Even at this early stage of my medical career I have learned as part of culture of patients of this community I see I must be particularly skeptical of patients that are chronic pain med seekers, which is true. However it creates an underlying bias for all patients who request certain meds as oppose to looking for a new etiology of the pain vs chronic uncontrolled/ inappropriately managed pain.

Assessment
I should see each patient as a separate individual encounter, not use my thoughts of one or more patients with similar stores to determine the reasoning/ assumptions of their visit. As with most patient with history of chronic pain there has to be line between new acute event and their management need of their tolerance compared to pain management dependence, and substance abuse, no matter who is presented.

[Adam Qazi]

Submitted by Lubna Fatiwala:

Subjective:
This week during Friday reflections we identified an interesting factor influencing health disparity within our patient population. Education. We discussed the impact of education on the health literacy of our patients. The question we had at the end of this was the degree of influence of education over a patients understanding of their health factors and the level of compliance associated with this understanding.

Objective:
An interesting study in Pubmed analyzes “The relationship between health, education, and health literacy: results from the Dutch Adult Literacy and Life Skills Survey.” (https://www.ncbi.nlm.nih.gov/pubmed/24093354) The study aimed to study whether health literacy could be a pathway by which level of education affects health status. Health literacy was measured by the Health Activities and Literacy Scale, using data from a subsample of 5,136 adults between the ages of 25 and 65 years, gathered within the context of the 2007 Dutch Adult Literacy and Life Skills Survey. Linear regression analyses were used in separate models to estimate the extent to which health literacy mediates educational disparities in self-reported general health, physical health status, and mental health status as measured by the Short Form-12.

In conclusion Health literacy was found to partially mediate the association between low education and low self-reported health status. As such, improving health literacy may be a useful strategy for reducing disparities in health related to education, as health literacy appears to play a role in explaining the underlying mechanism driving the relationship between low level of education and poor health.

Assessment:
The external validity of this study to our patient population maybe limited as it was conducted in a different socioeconomic environment, with a primarily European patient population. However it did point out a positive association between Education and level of personal well-being.

Plan:
As a practicing physician in the metro Detroit area, when evaluating my patients, I can gain a cognition of the level of education of my patients and ensure a clear understanding, clinical reasoning and communication pathway exists between us, so that the patients can feel comfortable to bring up all of their questions and concerns.

[Adam Qazi]

Submitted by jahid:

Ms. J is a 54y/o obese woman with HTN who presented for health maintenance. She lives in AFC home, and has been adherent to bp medications. She presented with no acute events, she is not a smoker nor does she drink alcohol. Social Hx consist of former smoker, illicit drug abuser and has been drug free since Dec. 2015. To date Ms. J has had a difficult time maintaining normotensive levels in bp just above 140/90s. Unaware of the dynamics of her housing, I discussed DASH diet and importance of daily exercise. When she being to explain the meals that are prepared for her, I realized how can I educated a woman who currently doesn’t have control of the food that is provided and prepared for her. Additionally, the daily activities that are schedule for her as a member of the AFC home, cleaning the house and her job working as a janitor cleaning a concert stadium contributed to my lack of appreciation for her living dynamics. Prior to being place in AFC home she had been unemployed living in shelter.

Objective
As the article entitle “Social Determinants of Health Inequalities,” stated “a focus on material conditions and control of infectious disease must not be to exclusion of social determinants. The circumstances in which people live and work are important for communicable as they are for non-communicable disease.” In Ms. J case I thought of ways she could improve are activities of daily living that could benefit her health. I told her to ask for more of the green leafy foods in proportion to small size of other items on her plate. While working take breaks walking up and down some of the stadium stairs every other day in addition to routine work. My plan with next clinic visit to find health affordable snacks she my request or even purchase.

Assessment
I realize I don’t have an idea of what is provided in an AFC home or any transition housing system that may have a positive or negative effect on the health of my patients.
To effectively address my patient issue it is necessary to gain knowledge about limitations that may alter course of patient care. As stated in the article “Social Determinants of Health Inequalities, “treating existing disease is urgent and will always receive high priority but should not be to the exclusion of taking action on the underlying social determinants of health.”

Plan
My plan is to learn more about the settings of AFC homes and how they help manage heal thing living for their occupants.

[Author]

Posts