[Purple Cohort] Module 2

[Adam Qazi]

Please submit your SOAP Reflections below:

[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.

[Kendall Bell]

My patient was a 61 year old male w/ pmh of hyperlipidemia, chronic sinusitis, and heroin abuse. Patient presented to clinic as he had recently entered into a treatment program for his heroin abuse and was seeking relief for his sinusitis, and wanted to reestablish care. The patient expressed that he was very embarrassed that he recently began using heroin again, he stated prior to 6 months ago he had been off heroin for almost 5 years. Patient also stated that part of the reason he has not followed up at the clinic was that he was ashamed he had started using heroin again.

This stuck out to me because the patient shouldn’t be made to feel ashamed of their medical conditions. I see drug abuse as any other medical condition that can be helped with medical therapy, as well as counseling. If as doctors we make patient’s feel more comfortable, that they will not be judged then patients like mine will come for treatment sooner. This patient didn’t feel comfortable getting care for his other medical conditions until he was off drugs, instead patient’s like these should come to us for help getting off drugs, with our help he could have been enrolled in a methadone clinic, or supplied with other resources to help him regain control of his addiction sooner. This also made me realize if he had come to me personally during his addiction I wouldn’t have been much help to him because I am not familiar with the local resources for methadone clinics and the process to enroll patients, so this helped me see a deficiency in my knowledge base.

I hope to learn how to communicate with patients to make them feel comfortable opening up to me about their problems, and not feel like judged. I also will familiarize myself with different resources for patients so if in the future a patient did come with me for help in this regard I will be able to offer some assistance.

[Carli Denholm]

To say that we all have bias seems obvious at first. It is also easy to say that your own bias does not affect your care of patients. However, I think that this week’s article did a great job of pointing out that we also have implicit biases that are subconscious and DO affect the way act. We need to be aware of what those biases are so that we can be mindful of how we practice. So far, I have used the Harvard Project Implicit to take an IAT about weight which found that I have a moderate preference for thin people. I plan to take more IATs in order to better understand what my implicit biases are. Going forward, I hope to use this information when I practice individuation and perspective-taking. Hopefully, this will reduce the affect that my implicit biases have on the care of my patients.

[Antonio Smith]

It felt humanizing to discuss things we can do to minimize the impact intrinsic biases have on our clinical practice. Individuating and perspective taking.

My Patient I remember most vividly is a 30 year old male with poorly controlled hypertension and HIV due to missing fourth months of doses. He explained that he recently moved to another side of town and did not have transportation available to pick up his medications from his old pharmacy. When I asked him why he didn’t call the office for assistance, he admitted that he was too embarrassed to come in and that he didn’t want to be a burden to the Doctors. He was extensively counseled on the importance of calling the clinic for any need he has regarding his HIV.

At first glance, one may assume that he was a cavalier or apathetic patient given his charted history of non adherence. However, this patient also has an underlying mental disability which occasionally disrupts his medication routine. Individuating is particularly important because focusing on the facts regarding his medical and developmental illnesses will help prevent this patient from having further disruptions in his daily med regimen. It can be easy to stop investing a root cause of a patients illness if when non adherence is involved. In this case, the conversation may not have steered itself toward changing pharmacies if more questions weren’t asked about his issues with taking his medication. After individuating the case, it his equally important to take on the patients perspective. HIV is a complex illness with management schemes that may not always make sense to our patients. It is important for us to put ourselves in our patients shoes, especially when counseling our patients on their illnesses.

In the Future I plan to utilize individuation and perspective taking when addressing compliance and poor follow up in order to close the gap between myself and my patients when addressing their complex socio-economic/medical issues.

[Pranav Shah]

S: There are so many scenarios where I am personally bias on a day-to-day basis. In clinic many of are bias of those patient’s who ask for narcotic pain medications.

O: This clinic week I had a female patient with morbid obesity who was a NEW patient to the clinic. She came w/ mild spinal stenosis and severe lower back pain. Patient has had difficulty walking and has been on Xanax in the past along with Norco 10mg. When I assess the patient, she had a bulging disk in her lower back and was in severe back pain with any movement of her back. Patient had numbness and tingling down to her toes.

A: Obviously at this time I referred the patient to Neurosurgery for spinal stenosis due to the functional limitations that she was enduring; however, the patient also wanted pain medications. In my mind, all I thought was – “another Norco patient”. Then the article came into my mind. My job as a physician is to help and aide patients. I did not write a script for pain medications at that time. I got a UDS and checked MAPS. I had patient follow up next week when she will be prescribed narcotics.

P: Many times we can group patients into categories: “chronic back pain/pain seekers”, narcissistic, uncontrolled/non-adherent. My goal over the next few weeks is to understand the inherent bias I have when assessing these patients and try and treat them with health equity. I ended up telling my patient that if she did not meet with the neurosurgeon and PT within 5 weeks I would not refill the pain medication. Patient understood and stated that she just wanted to get her life back on tract. I hope I did the right thing and didn’t just get another patient with chronic back pain – addicted.

[Mowyad Khalid]

52 yo female with PMHx of HTN and DMT2. She presented for a follow up. Her home glucose readings in the last month ranged from 120-220, and she reported she is non compliant with the diet or meds.
At first it seemed she is a non compliant pt who does not care about her health. But, her HBA1c was 6.2 which was good. Also, her other labs were good.
I asked her why she was bot compliant recently, and she told me her only grandson has died in a car accident, that depressed her, and caused her non compliance and stress eating.

We should always ask the patient the question WHY.

[Jasleen Kaur]

To deny that I hold any bias would be incorrect, naïve at best.

On floors, I tend to care for so many patients with frequent admissions to the hospitals, elaborate work up done previously with unspecified chronic pain diagnosis and asking for narcotic pain medications.

The reality is that even when we are not aware of our biases against certain people, we all inevitably hold implicit biases. These biases “can leak out through non-verbal behaviors, such as eye contact, speech errors and other subtle avoidance behaviors that convey dislike or unease.” Implicit biases, as they tend to escape our consciousness and are more difficult to address.
Indeed, medical institutions across the country are increasingly recognizing the need to address how provider bias can adversely impact patient health outcomes. One paper details “how individuals might move from absolute denial and defensiveness about [unconscious bias] to acceptance of [unconscious bias] and the ability to recognize it on oneself and then to mitigate its influence on behavior with patients.” Growing pains are unavoidable. Exposing clinicians and others to the notion of bias and increasing their awareness of their own biases is a crucial first step for “debiasing.”

By consciously realizing the possibility of bias, I try to review every time I make a medical decision. I tried to remind myself that as a physician I have to help and aide patients at the best of my professional ethical standards. I get a UDS and check MAPS for the pt. I try for an alternative source to avoid pain medications by giving referral for physical therapy, you tube video to Yoga and relaxation techniques. I try to provide opinion evidence that is fair, and related only to matters within the area of expertise like pain clinic.

I plan to take Harvard Project IATs in order to better understand what my implicit biases are. My goal would be to use this information when I practice individuation and perspective-taking.

Hopefully, this will reduce the affect that my implicit biases, and hence care of my patients.

[Raya Kutaimy]

My patient is 26 y/o female who presented for general physical exam and forms for her job, she is a return patient but she was not seen in the clinic for more than 2years.She never had pap smear exam, she even could not recall if she had it in the past or not. When we discussed with the patient taht she needs pap smear exam, initially she refused and wanted to defer the exam till she follows with OBGNY, initially she made her mind that she wont get pap smear, after discussion with her, I explained to her that she can follow with OBGYN but pap smear alone does not necessarily be done by OBGYN and we do it very ofetn to our patient ( specially she had no other indication to be refered to OBGYN), started explaining to the patient what is pap smear and how important it is for screening cervical cancer, specially she did not have one in years. When my patient initially refused to get pap smear, I felt taht she just did not want to do it as she is scared and she most likely will not follow with OBGYN. At the end, I realized that this patient refused pap smear simply because she did not know much about it and was never educated about it, she was scared from the test itself. Bottom line, when a patient refuse a test or a medication, we need to make sure they totally underatnd what is the test and what its is done for, what are the risks if ot is not done, we simply need to make sure they are well educated regarding test, medication and any other medical decision before we ask them to choose, and if a patient refuse to get a test or medication we need to go further and try to answer all their concerns and questions

My patient successfully had the papsmear test

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