[Purple Cohort] Module 1, 2018-19

[Leslie Kao]

Module 1 reflections here

[Antonio Smith]

This week I learned that we spend more on health care than we do on social programs. This wasn’t new to me, but it does add perspective as one rounds in the hospital. one case stood out to me as I reflected on this throughout the week. This gentleman is in his 30s and uses IV drugs. He developed endocarditis secondary to his poor syringe hygiene. He underwent TTEs, Echos, IV antibiotics, fluids, prolonged hospital stay etc. I would not be surprised if his care doenst surpass one million dollars. It just amazes me how prodigal American health care is. A lot of it is waste, but there is a large portion of care that would be otherwise preventable if there was more emphasis on social programs and the audacity to try something unconventional.

[Jasleen Kaur]

I believe that social determinants series affecting the patients is a reinforcement to me to care for my patient better as a whole.
A patient came to the clinic with HbA1c was 11.4 with no follow up since many months. She felt fine otherwise and stated that she did not like the idea of taking medications. Anyone would conclude that non adherence is the concern and a huge problem, but doctors failing to educate their patients was not only a major cause.
I believe, there are many reasons for non adherence —a desire to do things “naturally,” pills represent reminders of their sickness, depression, social issues within families, self-experimentation with stopping medications and noticing no change in perceived health, and most important drug costs.
I try to have a continuous multi modal approach to it. I continue to provide a 2-minute talk of risks vs benefits of medications to all my patients and help some ancillary burden lift off them. I also advised patients to get their medications at the clinic and I try to go over each, with cost and side effect profile. Social worker could provide reinforcement as person to person visit to discuss insurance or travel issues, have dedicated psychologist to understand their mindset, etc to make it better for patient care.

[Ahmed Yeddi]

S: This week discussion was how lack of health coverage or inadequate health coverage affects the quality of health in our patient population. The discussion was centered on the need for basic medical coverage and how it impacts health of our patients compared with that of other developed countries like the US.

O: Considering the fact that health coverage will never been evenly distributed across our patient population, it is imperative to keep in mind the types of insurance available and what they are able to cover. Prescriptions should be carefully tailored to meet the insurance coverage of each patient.

A/P: Find out what insurance each patient has and determine what they are able to cover for each patient. Consult with the pharmacy when appropriate to ensure that each prescription will be covered by the patient’s insurance company.

[Carli Denholm]

One of the the themes of the articles that we read this week which stood out to me was the idea that the health status of a country was a better indicator of success than other measures such as income or productivity. Without effective strategies to promote population health through social determinants, success of the whole cannot be achieved; or at least, maintained. When people’s basic needs are not met, they are not able to achieve their full potential. This is true on a global scale and goes beyond national borders. Any yet, as individual providers, we can help make a difference through each interaction with patients by considering their barriers to health and by supporting social efforts to promote health equity on national and global levels.

[Hajra Khan]

During our discussion this week, I was struck by one particular strategy that somebody had reported using in order to assess a patient’s social determinants quickly; the physician asked a simple question, “How are things at home?”. If the patient paused, the physician knew that he had to spend more than 20 minutes in the examination room in order to assess possible social barriers to the patient’s healthcare. I felt that was a smooth and effective way to tap into a complex and essential element of a patient’s care and I intend to implement this strategy in my own interviews going forward.

[Pranav Shah]

My first patient this week was a diabetic who could not afford her test strips. The patient had insurance, paid for all her medications, used many different coupons and spoke with a social worker to get her medications for the cheapest amount. Even after all the rebates and discounts, the patient’s copay took a huge tole on her finances. The one thing the patient had to cut down on, was her test strips. Patient couldn’t check her daily sugars, nor could she participate in a sliding scale due to the cost of her test strips. I thought to myself, how can help her? Before I thought that sending the patient to a consult service would cost the patient more – due to travel expenses and another appointment co-pay; however when I sat down with the patient and discussed how much her medications cost her I realized that free samples are actually REALLY HELPFUL.

I referred the patient to Endocrinology to get free sample of Lantus and Novolog so she could spend the money she does have on her test strips. I don’t know if this will work or if this is even a reasonable management for this patient, but I took a chance. I was happy I took the time to tackle how compliance/adherence issues and not just told the patient she needed to check her sugars. I did feel like I addressed social determinants with this patient.

[Ahmad Abu-Heija]

During a regular follow up visit in clinic this week, I was caring for a young gentleman who was involved in a motor vehicle accident a few years ago, that left him with chronic back pain. This patient carried a flag with him that labeled him as pain seeking (i.e avoid narcotics). During the interview, I learned from the patient that he works in a factory as a car part assembler. His occupation not only exacerbated his medical condition but likely will never allow him to fully heal. He maintained all of his appointments, he saw a pain specialist, he underwent all the imaging and testing asked of him, with yet no relief to his back pain. On further questioning about the possibility of switching jobs or even a lesser demanding position at the same factory, he wept. He wept and went on about how he searched for over 10 months for the job he currently occupies, and how fortunate he was to even have a job, yet deep inside I knew his job will only lead to further worsening of his condition. We went through the appropriate paperwork to attempt to possibly enable him to make the switch and crossed our fingers. However, how many other patients we see regularly are “victims” of their own occupations, with detrimental work conditions and demands that will leave them in worse condition than without a job. I can only ask these questions and hope I can alleviate this patient’s back pain, through avoiding placing any labels on him, and hopefully, one day securing him a position that will support his “back” rather than impair him further.

[ABDELRAHMAN M AHMED]

As we reflect on the impact of social determinants of health on our practice , I intend to try and measure the BPs of attendants of a local barbershop. I will update you with the outcome. Recent studies have shown that this approach has led to better BP control particularly in african american population.

https://www.nejm.org/doi/full/10.1056/NEJMoa1717250

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