[Purple Cohort] Module 1

[Adam Qazi]

Module 1 SOAPs:

Beyond Health Care, Heiman HJ et al.

Social Determinants, Marmot M.

[Adam Qazi]

Submitted by Mowyad Khalid:

Mr. D is a middle age gentleman. He was diagnosed with pulmonary hypertension, and multiple comorbidities including obesity. He came to the clinic for follow up.
He said he is not using his medications regularly.
After inquiring about his medication non-adherence, I found out the medications prescribed to him for pulmonary hypertension were extremely expensive, and that a single pill costs approximately 80 dollars. So, he bought a few as he could not afford more.
I asked our staff and we provided him with some samples, and prescribed a generic medication, with same efficacy but significantly lower price.
My point is, not every patient who is not taking his medications does that because he does not care. Most times, its financial or societal issues, and we should try as much as we can to help them

[Adam Qazi]

Submitted by Adel Elmoghrabi:

Coming from a developing country and practicing medicine in a predominantly under served population with widespread inequities I aspired to come to the US to seek broader knowledge and understanding the functionality of one of the most powerful healthcare systems in the world. Hence i had the belief that by becoming involved in the system and perhaps seeking an administrative experience in the health care system I would be able to grasp the necessary tools to participate in reshaping global healthcare in areas where health disparities and inequities result in the preventable death of less fortunate people. It wasn’t however until I started residency did I gain more insight that heath disparities and inequities are a global problem even in developed countries as the social determinants constitute one of the major obstacles in depicting this disparity.
During my first 2months of residency which were both on the floors I felt that I was studying for a master’s degree in sociology rather than being in a medical residency. Perhaps that was slightly disappointing for me during the early stages, especially when I felt that I was asked more questions during rounds relating to the patient’s social history than regarding their medical condition.
Although I asked myself every day, to what extent do we have to be involved in the social aspect of patient care I’ve come to realize that I myself could be a possible barrier to either blocking health care inequity or being one of the confounding factors that contribute to it. Understanding the statistics and the population we serve reshaped my understanding that spending as much time planning social logistics from transportation to durable medical equipment so patients can measure BP or Blood glucose at home, assisting in setting up home health care etc. is a new dimension which is no less important and perhaps is more challenging and arguably more significant than diagnosing the disease and treating it. Our social worker, case manager, PT/OT colleagues exposed me to a deeper perspective to help initiate and maintain an environment that helps eliminate these disparities illustrated by understanding the causes of the causes such as patients who have nowhere to sleep or lack of access to nutrition or are unable to independently rely on themselves yet have no social support.
To reiterate, prior to starting residency, my interpretation was based on the understanding that the only solution to healthcare disparities can come at an institutional level and that the political leadership and policy makers play the leading role solving this challenge. However, I ask myself how much could we as individuals contribute to help fixing this problem. Although not entirely correct, many of the social determinants of health inequity somehow relate to financial deficits and that poverty is a major cornerstone that correlates with health inequity. As a Tax payer I do expect that the government provides us the necessary infrastructure and basic needs to live in a civilized society however on the individualized level how much could we intervene or contribute or give to the less fortunate. I have grown to understand there must be justice in nature and that no one can or will ever have everything. Humans have an equal distribution of blessings, just distributed in different shape or forms. Some are stronger, others are wealthier, and others are healthier, some are happier or funnier than others but we all share one goal which is to live a good life. We are all reliant on each other and we all need each other in one way or another.
After reading this week’s article, I have been asking myself and thinking of possible solutions some of which are short term and others long term. My immediate action is to be able to understand the social determinants that may affect the patients I serve. It is however concerning that during the short encounters and time constraints during clinic or hospital encounters, it may be less feasible to address these issues in depth. Hence, I propose that we synthesize a questionnaire to be distributed to all our patients at clinic or hospital which helps us understand the background conditions that our patients are exposed to and the lack of access to the most basic needs of life such as water, a problem that we may take for granted however one that people are facing in the very same city we live in!
It strikes me that in many developing countries or even developed countries nonprofit and charitable organizations are taking the leading role in serving to abolish hunger, health inequities and addressing both national and global health catastrophes. Learning that there are clinics which serve the uninsured and treating at no expense inspires me that a long term goal once I am an attending would be to dedicate a fraction of my time and financial income to support the maintenance and establishment of such freestanding clinics that can ensure that high quality healthcare, medication and support is present in every city around the country. It is as such that small contributions from the more financially capable can help in abolishing one of the major lethal aspects of social determinants of health inequity which is Poverty!

[Adam Qazi]

Submitted by Msutafa Ajam:

Mr. R a pleasant 62-year-old male patient with a medical history of DM type 2 and hypertension; diagnosed more than 5 years ago. His last visit to the clinic was in January/2017. His diabetes and blood pressure were far from being well controlled; he was not compliant with his medications, necessary life style changes or his clinic visits.
At first, I thought maybe this gentle man does not understand the burden and possible consequences of his medical conditions if they were not appropriately treated. However, as I tried to assess that level of awareness it turned out he knew almost everything needed to better control his conditions. “Why this patient is so ignorant of his health?” I asked myself. Upon further questioning, the patient was meeting the criteria for depression and he was lacking the motivation to follow any advice from his doctors or to take the initiative to care for himself. He also felt overwhelmed by the many complicated advices he gets from his doctors which he finds difficult to follow.
As a physician who has just started his career, I understand that poverty has substantial impact on individual’s health, and I also understand that physicians are shorthanded when it comes to changing the inequality in health care delivery, but I feel committed to find solutions and use whatever resources available in the community that can help me deal with my patient’s conditions.
Thinking of poverty as a sole determinant of health status can lead us to overlook the importance of other major factors. For example, statistics show that worldwide, the second highest cause of disease burden among adults age 15–59 years is unipolar depressive disorder. Furthermore, we need to keep in mind that both poor and wealthy patients have unhealthy habits; smoking, lack of exercise and eating unhealthy food can be even more prevalent among higher socioeconomic status.
My plan is to entail health care delivery according to the patient’s needs and capabilities and avoid biased decisions like blaming poverty for poor health outcomes. I will screen for depression especially those patients who have chronic medical conditions. I will also try my best to simplify my medical advice; a patient who has 4 unhealthy habits will definitely feel overwhelmed and frustrated if we ask him to change them all at once, but if we help him focus on changing one at a time will improve his willpower and adherence to lifestyle changes and general well-being.

[Adam Qazi]

Submitted by Yahya Ibrahim:

Mr. M. presented to the clinic to follow up on a relentless left wrist pain and hand swelling that has been going on for 3 weeks despite starting him on appropriate management with Colchicine and Ibuprofen. After addressing his major complaint we also discussed screening for colon cancer. It was marked in the chart that the patient is not interested in it. When I inquired as to why he has this opinion, he explained that given his insurance plan it will be cheeper for him to do the test rather involve his medical insurance and pay the deductible. Unfortunately, colonoscopy was also not something he could afford and he added “there is blood in stool test that could do the same thing for me and it is much cheaper.” I explained that that test modality though more affordable would not substitute the technique used in colonoscopy to screen for colon cancer. He stated that he now understands better and he might consider doing it given what he learned during this visit.

Our patients’ population in Detroit is of low economic status. That is no new news. But they have a budget where if explained adequately could help them in prioritizing their medical needs putting more important lines of management first. Asking more details about their lives would take more time but ignoring it could be detrimental.

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

[Adam Qazi]

Submitted by Carli Denholm:

S: Social Determinants are a key area of study for physicians as our patients are often faced with struggles that are due to these social determinant factors. We MUST address these issues in order to provide the most effective health care possible. I am glad that we are tackling this issue head on with this new curriculum. I think that many of us have already dealt with some of these issues by virtue of the patient population that we serve in Detroit and we are inherently poised to learn a great deal more.
O: As this week’s article pointed out, there are a wide variety of social factors that contribute differences in health care outcomes. Some of the most frequently seen social determinant challenges in our clinics include low income, lack of transportation/access to healthcare, poor education, addiction, and lack of social support. As an example, Ms L. is a patient I saw this week who was lost to follow up with rheumatology and has advanced rheumatoid arthritis. She did not wish to be referred to the clinics nearby, stating that she has had poor care experiences at them. However, she depends on public transportation, which is not a reliable or practical option for getting to other clinics in the suburbs due to her limited income and distance needed to travel. In the end, that patient agreed to be referred to a downtown clinic because it was important for her RA to be treated by a specialist. But, the interaction did illustrate a few of the challenges that she, and may others, face.
A: I feel that I have a fair understanding of how social determinants affect my patients. As I mentioned before, residents in our program have an advantage in studying many of these issues because of the population that we serve. While we are often able to identify and understand may of the challenges that our patients face, what we frequently lack is the knowledge of how to help our patients overcome these challenges
P: I think that the Social Determinants curriculum has the potential to be very useful to us all. I look forward to learning more about social determinants and how to address them (when possible) to provide the best care that I can for my patients. And, maybe, to narrow health care disparities in general in the community.

[Adam Qazi]

Submitted by Pranav Shah:

S: I was fulfilling my CCR tasks during the week and I ran across a patient who was requesting insulin. When I went through the chart I noticed that the patient had recently had her insulin refilled during her office visit. I decided to call the patient. The patient told me that her young daughter got a hold of her insulin vial and threw it off the table. On top of that the patient was in Florida visiting family and had only brought one vial. Originally I would have simply just filled the prescription and moved on, but due to this course I wanted to learn more about this patient.

O: I found the pharmacy that was closest to where the patient was currently visiting in Florida and sent a prescription to the pharmacy, instead of refilling the prescription blindly and sending it to her normal pharmacy in the system and having the patient call for a transfer.

A: Although this time I was curious of possible social determinants I felt like normally I am as perceptive. On top of asking about which pharmacy would be best for the patient, I talked to the patient about safety concerns as Hurricane Irma is about to reach her region. Patient stated that they were going to fly back, however all flights were cancelled due to the storm.

P: I would like to see more consistent efforts when thinking about social determinants of patients. Questions such as how will they get their medications, can they afford them, or do they have children at home who might break their medications are important to my overall understanding of a patient’s needed. The idea of providing EQUITY and not EQUALITY really resonated with me. Each patient is different, even though they may mostly be “AAM” or “AAF”. Possibly I will need to change how I begin my SOAP notes to address this issue at a more psychological level.

[Adam Qazi]

Submitted by Ali Alateya:

Ms. S.P is 58 yrs old AA F pt with multiple comorbidities including DMII & morbid obesity, because of her obesity pt is tried to loss weight to improve her A1c levels with no success, pt was refereed to our dietitian & pt initially did loss some weight but eventually pt rebounded & gained all the weight she lost although she trying to follow her dietitian instructions, our next step was to refer to weight loss clinic but unfortunately because of her insurance she has to pay a lot of deductions which she can’t afford, it was a major set back for the pt that there are many options to treat her condition but because of her poverty she can’t access it.
as a team unfortunately we don’t have many other options to offer to the pt other than to discuss these events with our dietitian so she can come up with new & more aggressive plan so pt can loss weight again.

[Adam Qazi]

Submitted by Raya Kutaimy:

Taking care of a patient involve multilevel process, that needs special relationship between the patient and physician with the main component is trust and understanding. Mrs. X she is 58 year old lady with PMH of DM and HTN, when she started to follow up with me she was complaining of non-specific joint pain that is worsening gradually, she was already referred to pain clinic and she follows with them for pain management which also did not improve her pain. All her rhematological work up with rheumatology clinic evaluation which was done later was negative. She complained of whole body pain and unable to cooperate with physical therapy. Of a note from 2 -3 clinic visit with the patient that she was silent most of the time, has very little knowledge of her medical problems or her medications, though she is complaint. When discussed her social issues, she lives by herself, has friends from church and one son who lives in far city. PHQ9 was done and it is positive. She was referred to psychotherapy, after 2 months she came for follow up visit, with significant improvement, in her pain level to the point that her pain clinic decreased her pain medications and though she was ok with it. She looked different, even the way she dressed and the smile on her face. She reported much improvement
It is crucial component of patient care is to address social issues and environmental circumstances, though sometimes it becomes challenging to address these issues with busy schedule but that can be managed better with continuity of care for patients.

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