[Purple Cohort] Module 5

[Leslie Kao]

Please submit your SOAP Reflections below:

[Ahmed Yeddi]

My patient is 22 year old lady who was admitted many times for alcohol intoxication and alcohol withdrawl. She is homeless and does not have health insurance. She was denied entry to many rehabilitation institutions due to lack of insurance.
As Primary care providers, we play a key role in facilitating patient engagement in health-related behavioral change, such as smoking cessation or abstinence from alcohol or illicit substance use. Indeed, formal drug and alcohol treatment programs are not readily available in some settings, and other patients may decline to enter or cannot enter a formal program. In this role, primary care clinicians must not operate from the belief that providing information alone will change behavior, as provider-directed instruction for implementing behavior change has proven ineffective. A far more effective approach to facilitating behavioral change is based on two complementary frameworks: readiness-for-change, and self-efficacy. Following assessment of a patient’s readiness-for-change and self-efficacy, those working with patients around health-related behavioral change should provide brief, patient-centered interventions, referrals, and information.This should be individualized to the situation of every single patient.

[Wadah Ismael]

Psychosocial determinants of healthcare are very important cornerstone in our practice, however, sometime we tend to avoid going into details or uncover major psychosocial issues that is behind our capacity to fix, like for example, the patient choice to live in unsafe environment, or transportation to clinic for scheduled appointments. Personally, sometimes, I feel if I go over these issues without solving, will make me go into trouble, and even legal consequences. However, I learned in this module, that providers should feel comfortable addressing these issues, and immediate resolution is not expected always. Some issues need time, and/or referral to appropriate personnels (social workers, psychologists, psychiatrists).

[mowyad Khalid]

I met a pt with CVA and living with his brother, he was disshielved, I asked his kids about who lives with him, and how does he eat, and reported his brother us just living there eith no help, social worker contaced, he was moved to nursing home, he improved

[Jasleen Kaur]

It didn’t take long for me to discover that all this talk of social determinants actually matters more at the level of the individual and then for the population as a whole.

I have 2 patients with similar complaints of lower back pain but with different social factors affecting them. Just to make everyone understand better, I have tried to put like a story. My pts are two men in their late 30s both in good health. Mr X is an educated citizen, and his wife is a nurse. They enjoy a wide circle of friends as well as their respective families.

Mr Y rents the basement in the house, earns money as a laborer in a local warehouse and perform odd jobs. He is separated from his wife and children and stays afloat with their basic expenses but that’s about it.

It turns out they’ve both suffered herniation of the L4-L5 lumbar disc. The identical injury, with identical symptoms, nevertheless, they will end up having radically different paths through the health care system, with radically different outcomes, for reasons having nothing to do with medical science.

Mr X calls in sick, sees me and gets a consult with a physiotherapist. I prescribe some anti-inflammatories and refers for an MRI. His wife being a nurse helps him understand the condition better, takes care of him. He, being educated himself understands modification to his lifestyle and his duties. Some months later, he has improved with conservative management. His life and work are fine.

Mr Y cannot take time off, because he’s only paid when he shows up. He sees me and gets prescribed the same anti-inflammatories, but they don’t help much since his job is almost all lifting, carrying, and bending. He’s referred to PT which he states after few weeks is not benefitting him. Due to his educational status, he also doesn’t understand the do’s and dont’s well. He is referred to pain clinic and prescribed Tylenol 3 a few weeks later.

After a month of trying to muddle through, Mr Y is forced to quit work. He is referred for an MRI, which is cancelled by his insurance as they think symptoms are not enough. He is lost to follow up with his PCP. Mr Y grows increasingly stressed and depressed, starts to smoke Marijuana as his friends suggest that it helps from pain.
He is back to pain clinic and through several trials of medication, ultimately ending up on high-dose Oxycontin. He applies to a disability program and is waiting for an answer.

We’ve all been conditioned to believe that medical science is the answer to what ails us. Our health is impaired by some sort of disease, and whatever treatment we use will fix the problem. What I hoped to illustrate here is that It’s job security, income, education, social life (i.e., friends and family), language and ethnicity (very often seen in Detroit now) — all those social determinants — that matter most to a person’s health.

[Pranav Shah]

This past week I have been swamped in clinic with very complicated and time demanding patients. The whole week I have been racing against time to finish seeing patients on a timely fashion and in doing, I have probably missed so much.

One of the patients I saw this week came in for a medical work form that would help him get out of work. Patient had a previous history of osteoarthritis in his knees and just recently had an elbow surgery done due to nerve compression. When looking at the patient’s chart I saw multiple excuses I could give for the patient not to work. I was getting ready to simply write something down saying that the patient needs to be switched to a non-intensive work position; however at that time I thought about my education and going through a systematic method in assessing a patient. I asked, “why don’t you want to work this position anymore?”

The patient replied, “To be honest, I can do the job just fine. My elbow is actually much better than before and my knees, although I get tired, they don’t affect my ability to work. The real issue is that I can’t read.” The patient is a worker in our hospital and brings food to patients. The reason the patient wanted to have a medical disability form was really because he couldn’t read the diets each patient had. Because of this deficiency, the patient was mixing up people’s diets throughout the hospital.

How many of our patients are illiterate? Do we ask them this when prescribing medications or giving them print outs of deferrals? How many people do we give educational material to without knowing their educational level? I guess, I still need to come up with a better methodology of assessing patients that includes this train of thought.

Actionable item: Assess patients’ literacy in clinic.

[Ahmad Abu-Heija]

Reflection:

Biopsychosocial assessment of patient’s situations was used this week in my interaction with patients. I had the chance to witness firsthand how social support, in terms of friends and family, can affect a patient’s well-being. My patient blatantly answered my question to her not taking her medications, with “I have no friends or family, do you expect me to do all of this on my own”, and she was right. I should not expect her to do all of that on her own, she is alone. Ther lack of social support in her case is a determinant that reflects more upon her condition than the condition itself, as she already had measurable complications from the disease she is suffering from. After looking deeper into her situation we both realized that she has people that care about her, but she has isolated herself from them. We spoke about reaching out to these dear ones and further assessment will be done on our next visit, in the same manner that I would check someone’s A1c at follow up or repeat blood pressure.

[Emmanuel Akintoye]

Understanding the financial capability and/or insurance coverage of our patients is very vital in making treatment decisions. As a CCR resident this week, I had to return a call of a diabetic patient who has not had her insulin for days because the brand of insulin that was prescribed at last visit has a lot of copay which the patient cannot afford. While we care a lot about our patients and do a diligent job to provide them the best available medication, paying a little more attention to what we prescribe with respect to insurance coverage/copay may go a long way to achieve our aim of providing the best care for the patients. Understanding and appreciating the psychosocial determinants of health help physician to see beyond just the physical patient that sit in front of them. It provide insights into what other factors physicians need to consider when making treatment decision.

[Hala Nas]

This clinic week I had a unique patient experience: I saw an adult patient with autism spectrum disorder…

She was brought in by her mom, apparently she has not been her usual cheerful self for the past days, her mom was saying that she is not “talking as much as she used to, to her self or imaginary friends”. I sat there, for a split second I was puzzled, what causes an autistic patient to be more quiet?!

As my mind jumped to the regulars for an internist: infections, inflammation, stroke… I couldn’t help but think, what if there is something psychological going on? I had no idea how to effectively gauge that! As I discussed the case with my attending, who had some good knowledge about autism spectrum disorders, he opened my eyes to the fact that in such cases, many underlying psychological problems go unaddressed: depression, anxiety, loss of a close person, emotional and psychological abuse. I leaned a good lesson this week: not to be reserved in addressing these problems whenever I am confronted with such a tricky situation, and to be able to refer to a specialist that can better help out my patient

[Muhanad Taha]

I used to access the patients for any psychiatric and substance use disorders, but I barely address the patients social support and resources at each visit. This week I started to incorporate the social support and resources into my assessment . I had an elderly lady with 3 comorbidities and ~12 medications, I reviewed all her medications and I found that she recently started on a new CHF medication called entresto, the patient got one sample from her cardiologist and she didn’t know if the medication is covered by the insurance or not. I called the pharmacy and they need me to fill a specific form and fax it which I did. At the same time I called her sister and I asked her to check her mother medications every week to make sure she has enough. This is an example of how important to know about the patient social support and the resources including the medical insurance. Any delay in this patients medications will result in CHF exacerbation and hospital admission. Considering patients social determinants of health have a strong influence on care plan adherence.

[Bayan]

I have a type one diabetic patient with developmental delay who came in multiple times with uncontrolled diabetes and had multiple amputations. His a1c was consistently above 10. Patient was on insulin and it seemed that there was an issue with administering insulin because of his delay. Met with his family to discuss taking care of the patient and to better control his diabetes.

[Raya Kutaimy]

I have an experience with one of my patient this week,
He is 59 with PMH of DM, HTN, HIV and neuropathy
Patient is has hx of non adherence to medications, He knows his medications and what they are used for but he has tendency to stop medications on his own when he feels well or when he feels something abnormal ( headache, nausea) and he stops medications on his own instead of calling or visiting pcp. Patient was evaluated last visit which was 20 days before his colonoscopy and I explained to him that he needs to stop aspirin 7 days before colonoscopy and to restart the medication next day after the procedure. He did not restart the medications after the procedure as he did not like it. BY more detailed discussion with him to know the reasons, he stated that he was healthy and taking 1 pill for HIV 2 years ago but once he started to follow with PCP he found himself on 6 pills and he thinks that makes him sick .

I realized that the patient is scared of the idea of being sick and does not want to take many medications. Explained to him that he takes these medications for protection from heart attack or stoke and to control his BP which was not controlled before that. Explained to him that he had HTN and DM , he was not on medications but he had the diseases.

I realized from this patient that when we have a patient who does not take medications, we have to find out what causes him not to take medications specially in the setting of a patient who knows his medications, Honest and understands his medical disease.

[Ghaith]

When it comes to the social determinants of the patient situation, This might be by far the most critical thing that needs to be assessed. Most providers are doing a great job in the ambulatory setting counseling their patients, reconciling their medications and addressing their health needs, but without assessing their patients’ social circumstances, this hard work might be useless. Imagine spending half an hour on a busy clinic day, talking to one of your patients about diabetic food education and insulin use, and at the end, your patient understands everything. Now he comes for the 2nd visit and you see your patient took no effort to establish your plan. Then you talk to him/her and you figure out he/she has a very good knowledge and understanding of the plan, but he/she just feels so depressed to do any work. Depression was one example and the list keeps getting longer.
Our job as internists, whether primary care providers or hospitalists, is to be proactive in recognizing barriers that compromise patient care from the patient own side and working appropriately on them, not just following our treatment guidelines without considering the appropriateness of care plan implementation.

[Haider Aldiwani]

I am posting my experience this week with one of my new patients

I had a patient which is homeless but lives with a group of friends. He also had multiple comorbidities. Upon evaluation the patient was depressed and showed dissatisfaction with his current life situation. After we had the discussion this week about social determinants I started exploring patient current social situation. His social issues greatly contributed to his depression but fortunately he recently got his insurance. Me and dr. Nnodim were able to print him a list of places which provide social work services. Patient was happy about it. Apart from the medical management which involved prescribing anti-depressant we also referred the patient to a psychologist to evaluate his depression.

I was able to connect more with the patient and he was genuinely satisfied with our service. He scheduled another appointment with me although he was seen occasionally one year apart and no continuation of his care was noticed.

I believe we were able to convince him to start taking care of himself and feels better about himself. I also think his social status played an important factor in establishing relationship with me as a clinician.

[Carli Denholm]

This week I had one patient who particularly illustrated the 5 domains of the psychosocial model of healthcare. The patient, we’ll call her Ms. S, was a middle aged woman presenting to establish a PCP. She had been healthy and working in home health care until about 1 year ago when she had a rotator cuff injury which required surgery. Shortly after the surgery she was diagnosed with cervical spinal stenosis. She is unable to lift more than 10 pounds or drive and so she has not been able to work for 1 year. Consequently she lost her job and her home and has had to move in with her mother, who is elderly and unable assist her. She is currently applying for disability. To make matters worse, she was contacted 2 weeks ago by police working on the untested rape kits recently found in Detroit. This brought up the trauma of having been raped decades ago; memories which she had repressed until now.
Her social support includes mainly her elderly mother and adult daughter who lives in another state. She has friends, but does not feel that she can share her troubles with them.
Her resources have become limited with the loss of her job and home. She is living with her mother until she can get back on her feet. She is applying for disability and is currently collecting unemployment to make ends meet. She was told by her orthopedic surgeon that she should not drive and so she relies on her friends and public transportation to get to medical visits.
She does not display any hallmark characteristics of personality disorders. She denies having any challenges due to drug or alcohol use. She rarely drinks alcohol but uses marijuana daily to help her cope with her stress.
She had never been diagnosed with a mental health disorder. However, she has symptoms suggestive of depression and acute stress disorder.
She has pain and numbness in her R arm and leg due to cervical spinal stenosis. She has pain and reduced ROM in her R shoulder.
Her functional status is, of course, a culmination of all these factors. Her functional status has changed significantly in the past year. She is no longer able to perform her occupation and she has difficulty with ADLs such as grooming and dressing, as well as driving. We have started to tackle her problems by referring her to psychiatry. And, she is going to be following with ortho for possible spinal surgery. This is just the beginning of a long road. All 5 domains of the psychosocial model will need to be addressed before we can make any major changes in functional status.

[ABDELRAHMAN M AHMED]

My 43-year old female patient with a BMI of 43, awaiting bariatric surgery, bilateral OA with Hx of right knee arthroplasty showed up 45 minutes late to her appointment. I was naturally bemused. She was all apologetic when she entered the room and explained to me that her daughter, who usually drives her to her appointment, was not available today and she had to take public transportation. “I had to walk from warren ave to the clinic” she explained. I told her no problem and that I was glad that she was able to make it. To conclude, if your patient arrives 445 minutes late, find an excuse for them and be certain that it is out of their hands.

[Yahya Ibrahim]

I had a patient this week who was relatively young and had a trouble controlling her DM. Her HbA1c got worse from 10 to 11 she had gained weight too. She is always accompanied by her husband. When I spoke with her she mentioned that they have been homeless due to malfunctioning heating system in their house that they had to move out and stay with friends for the past 3 months.

Needless to say that this imposed a series of difficulties for her as she had no control over her diet. She ate whatever food that was provided to her. Then she mentioned that the families who had them over did not agree that she stores her insulin in their refrigerator. This in addition to inability to fill her Metformin and BP medications got me suspicious. We asked her husband to step out of the room. I explained that insulin does not need refrigeration after being opened and that she could have continued to take it regardless. I asked about abuse and lack of support at home. She denied it and mentioned that her husband has been supportive and helpful though he did not seem like it to me as he was disengaged in our conversation until we asked him to leave the room.

I still don’t know for sure whether that was in the case in this patient’s poor compliance. I truly hope that that is the case. Part of me is still worried about her. It is not easy to open up. This becomes especially challenging to open up for a stranger doctor one meets every few months. We might shut down our miseries by continuing to strongly ignore or deny them. Moral of the story; we should always ask or touch base on psycho-social determinants because sometimes even if we do, we might be able to unravel the true circumstances that translate the picture we see before our eyes.

[Antonio smith]

I admitted a 30 year old patient with history of steroid and cocaine abuse presenting with tachycardia and dyspnea. A UDS was done in the ED and it was positive for cocaine. His diagnosis was summed up as a cocaine induced tachycardia. I was told before seeing him that he was a liar and that he probably does coke all the time and he expects the hospital to take care of his drug issues when he can’t even be honest with the doctors. After appropriate workup he was found to have thyrotoxicosis and hadn’t used cocaine at all the entire week.

Had our team fell into the trap of labeling this patient as a drug addict and missed this easily treatable there would have been grave consequences for this individual. It pays to be thorough even when what appears to be the most likely answer stares one in the face. These folks come to be helped not to be judged

[Ali Alateya]

I had this pt who is diabetic & had morbid obesity, pt keeps gaining weight & A1c in 3 months increased from 6.6 to 9, pt was refereed to dietitian a visit before but pt was not able to see her because he has no transportation & he depends on his sister to bring him to his appointments, also he is willing to go to gym but again can’t go because of transportation issue, luckily he has some support so his sister can bring him to the most important appointments, although i won’t be able to teach him about diet change like a dietitian but will meet frequently so we can bring his weight down so we can control his diabetes.

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