[Red Cohort] Module 1, 2018-19

[Adam Qazi]

Please respond with your SOAP for the week of Sept 10-14, 2018 below.

[Adam Qazi]

From Ali Saker:

If we take the effort to ask our patients about their access to food. People feel ashamed to share unless they get asked. SDH has a multigenerational impact. Our job is to work teaching patients about different resources put in by the state for the community, educating patients especially who has Medicaid and Medicare about free transportation offered by their insurance, and possibly grouping their appointments on the same day, and grouping family’s appointments on the same day. That will help achieve a better show up rate and better overall health. IF we are moving forward to recognize these health problems, that would increase the overall population health. If children are born to low socioeconomic status families, the lack of education will have significant correlation to health outcomes which is frightening.
I believe to improve healthcare in general, we should ship healthcare funds to increase the social support in order to address the invisible link of SDH.

[Hibah Ismail]

During our years of residency, we have come across a large variety of social factor that hinder our patient’s health. We wonder why patients do not show up in clinics, do not take their medications, do not adhere to diet and exercise, and get constantly readmitted to the hospital. However as we progressed in residency we learned about the barriers that affect our patients on daily basis; no access to transportation, medications not covered by insurance, cost of healthy food as opposed to fast food, unemployment, lack of social support and many more which we learn to uncover daily. It is empirical that we learn to encorporate these factors in our history taking and be able to provide resources and aid to our patients in order to ensure the utmost healthcare that we can provide.

[Khaled Janom]

We should learn to acknowledge the factors that affect patients’ response to medical care or even access to it. These include basic education, access to food and clean water, shelter, basic healthcare insurance, mental health, and having a social support. These are interconnected. Having a comprehensive approach to each patient and addressing these factors will undoubtedly help the overall purpose of our job: improving the lives of our patients.

[Arslan Mahmood]

Social inequality creates a greater divide in healthcare than is acknowledged. We should connect with our patients at their level. If there isn’t a clear understanding of the factors that lead individuals to make health-risk decisions, one cannot implement interventions to improve their health. Telling our patients to walk everyday for 30 minutes, does not mean that our job is done. Someone not able to afford housing in a secure neighborhood will not be comfortable walking outside. This environment leads to a state of chronic stress. To change the health outcomes of these individuals, we must first understand how economic opportunities shape their decisions.

[Brett Trzcinski]

Subjectively, it is clear after a few months of medicine training anywhere, but especially in our community, how significant social factors are in determining if patients will be able to receive care, and if so, how effective our interventions will be. Our discussion in the introduction to social determinants of health provided objective data that supports our subjective sense that social/culture/economic factors are shaping our patient’s health and experience receiving care in our current medical system. The brief case example of the Philadelphia Healthy Corner Store Initiative as a way to improve access to healthy food was inspiring; I believe many similar initiatives to improve access to fresh produce are also underway in this community. I plan to educate myself on the available food assistance programs in the community and incorporate questions on diet and food availability into my regular practice as a way to better serve and care for my patients.

[Aamer Javed]

It is important to be aware of the multiple factors that contribute to a patient’s health including education, socio-economic status, access to healthy foods amongst other factors. It is eye opening for me as a physician to see the stark contrast in zip codes that allow some to unlimited access to resources vs. others who have limited resources. As a physician I have to be cognizant that I can’t simply tell diabetic patients to exercise more or to eat healthier when they don’t have the means. For example, some patients live in neighborhoods where they don’t have parks where they can safely walk and others live in areas where the grocery stores with fresh foods are not available. In addition, buying fresh produces is often more expensive than getting unhealthy processed food from convenience stores or from fast food restaurants. I plan to learn more about resources available that will benefit my patients and help improve their overall health and well being.

[Raja Rabadi]

Many Physician including me were getting frustrated when the patient do not show up to their appointments or when they do not fill their prescriptions and take medications as prescribed. But now I know better. I learned that many patients have to arrange transportation a head of time ~ 3 days before their appointments and sometimes the bus/ car don’t show up. Some Have to take multiple buses and travel for about as hour in order to make their appointments. Another issue is the medications we prescribe are not always covered by the insurances or the Copay is very expensive that the patient cannot afford. After learning about Social determinants I have changed many things when I talk to my patients or address their issues. I first explain their diseases to them in a language they can understand and comprehend, then I explain to them how their medications in order to prevent progression of a disease, and finally I explain how they should take their medications. I ask my patients about their jobs and how they are supporting themselves and if they are able to get their medications. I also make sure that I prescribe medications that are covered by their insurance. I remind them to make transportation arrangements for the next clinic, to ask a friend or family member or see if they can take the bus or afford any other means of travel. I think spending an extra 10min with each patient is needed in order to see how they live, what are they capable of doing, how are they surviving, and if they have the necessary means for survival. Once we attempt to help and get to know them better, i believe they become more adherent to medications and followups

[Omar Chehab]

This is my third clinic week and my first year practicing in the United States and I just started to realize that factors that affect patients’ response to medical care or even access to it are mainly social. These include basic education, access to food and clean water, shelter, basic healthcare insurance, mental health, having a social support, and most importantly transport. These are interconnected. Having a comprehensive approach to each patient and addressing these factors will undoubtedly help the overall purpose of our job: improving the lives of our patients. This week I was scheduled 4 patients for diabetes follow up and non of them showed up. These patients might eventually present to our hospitals with diabetic complications such as Diabetic foot infections and other complications. If we listen to the complaints of our patients they all state that getting to the clinic is the hardest task for them. A greater effort should be made in providing certain transports to major refer centers to ensure adequate follow up and prevention.

[Said El Zein]

As physicians, we often become focused on treating diseases rather than treating patients. We tend to be very busy and sometimes overwhelmed that we forget to ask our patients very basic questions that could make a lot of difference such as : How do you usually get here ? do you encounter any difficulties coming to our clinic ? how are things at home ? are you able to get all your medications ? etc…
During my clinic weeks, I have come to appreciate the importance of the social determinants in affecting the management of my patients. This will change the way that I interact with my patients in the future and would allow me to address some of the social difficulties that they may be facing hoping to improve their overall health and compliance.

[Alaa Akhras]

A very important aspect of medication management is education. A patient arrived to clinic today after being discharged from the hospital. She has a history of DMII and her hba1c has continued to decrease. She was initially on insulin but it was discontinued during her last visit 3 months ago. She was told that she was doing much better and that her hba1c level was almost back to normal. She was told that she needed to stay on metformin during that time. Apparently, she wen to the ED earlier this week and had abdominal pain and urinary frequency. She was diagnosed with DKA. Her blood glucose level was in the 800s and her hba1c in clinic was >15%. When asked if she was still taking the metformin she stated that she felt a lot better after clinic and she felt that she did not need to take it. I feel that if we had told her that she must remain on it no matter what she would have been adherent to it. It is very important to explain that no matter how they feel, or how well their numbers or symptoms look, they must remain on their proper medication regimen.

[Hussam Tabaja]

As I progress in my medical training I’m starting to better understand the link between social factors and patient’s healthcare. I believe that USA is a perfect setting to observe the close relationship between both entities. Patient’s care and their outcomes are shaped by their wealth, education, and available resources. Today I came across a patient with uncontrolled diabetes who has been following up with us in the clinic. Her HbA1c was significantly elevated. The term non-compliance was mentioned in her medical chart. She was prescribed Lantus during past encounters but she was not taking the medication. When I contacted her pharmacy they informed me that the patient has no prescription coverage and so she is not able to fill out any of her medications. For so long we have been sending scripts to her pharmacy without noticing that she is not even able to make use of these scripts. This is a great example that shows how understanding patient’s social factors can change our approach with the patient’s. We might be able to help with whatever resources we have available. After discussing this case with the nursing staff at the clinic, I discovered that we have stocks of free lantus samples stored in the fridge. We contacted the patient and provided her with supplies. Another important aspect that I learned today is to familiarize myself with all the available resources we have in our clinics in order to help our patients more.

[Nabeel Rizvi]

Often times as Physicians we focus strictly on diagnosing and treating medical illness. This group discussion has been an excellent reminder to help us become better well-rounded Physicians. We should utilize this opportunity to make an initiative to spend a couple extra minutes with our patients to find out more about their social situations and determine any challenges that may be affecting their health. This will allow us to establish better rapport and hopefully we can work together with them to tackle these barriers. My future care plans will now be more structured to entail health care delivery according to the patient’s needs and capabilities. I will do my best to avoid biased decisions for poor health outcomes. I will screen for many of the social determinants we discussed; especially in those patients who have repeated hospital admissions. I will also try my best to educate my patients to help simplify my medical recommendations and treatment plans, and to make an extra effort to provide outside resources to those with difficulty. A patient with multiple medical issues will definitely feel overwhelmed and frustrated if we ask them to make changes all at once, but if we focus on addressing one issue at a time we will improve their effort to adhering to treatment plans and medication regimens. By implementing some of these ideas, overall health benefits will be achieved one day at a time. I believe that preventive medicine is the key to living a healthy life and to the many issues that plague our health care system today. Much of the pain and suffering and a majority of hospitalizations we encounter could have been prevented with routine regular medical care, leading to my desire to practice proactive medicine versus reactive medicine. After this discussion, I have now come to realize the importance of achieving valuable care goals with my patients instead of attempting to do it for them.

[Scott smith]

A patient of mine has recently found himself trapped by a situation he can’t control. Although born into a poor family and having little means himself, he managed to do everything right and get a steady job as a nurse aide and stay healthy. But he recently had a back injury causing spondylilisthesis. He is now out of work with no means of paying for physical therapy that he needs because he is being denied workman’s compensation. It will be very difficult for him to work in the same field until he can strengthen his back with PT, but cost is precluding him. Unfortunately he doesn’t have an education that could help him secure a less physical job. I now fear he will be stuck living on disability. In any other developed country cost would not preclude a patient’s recovery. This patients lack of financial security will likely lead to chronic pain and debility and I have felt helpless when treating him.

[Nadine Abdallah]

I experienced a situation where I found myself helpless as a physician. One of my patients had bed bugs ad could not go to work, so she had no income for months. She came to clinic short of breath, wheezing, and had lost at least 10 lbs over 1 month. She had stopped using her inhalers, and was not eating because she could not afford it, and asked for help. I did not know what type of help I could offer as a physician. There was no social worker available in clinic to provide the assistance I would otherwise get on an inpatient ward. I was not aware of the resources available. I was introduced to the resources by the faculty in clinic, and discussed with food stamps, and gave her inhaler samples. We also gave her the number of a social worker. I still felt helpless, and could not address any of her health issues that visit, and realized that simply prescribing a medication, and knowing a patient’s blood pressure and HbA1c were not enough to deliver good care. A physician should be aware of the social, economic background of their patients. This information is rarely volunteered, so a physician should take the initiative and ask.

[Amjad Kanj]

In order to achieve health equity, we need to be aware of the social determinants of health (SDH). I came to realize that SDH are all around us. Whether it’s your zipcode, neighborhood, socioeconomic status, level of education, access to transportation and availability of outpatient clinics, all of these will affect your health outcomes in way or antoher.

My patient was admitted to the hospital recently because he missed dialysis. He missed dialysis because he lives in an area with no public transportation and he missed his ride.

My second patient has been gaining more weight despite continuously educating him about the risks of his obesity on his health. He is gaining weight because there are no grocery shops in his neighborhood and he gets his caloric intake from fast food restaurants.

My third patient has not been eating well because he lost his teeth. His insurance plan has no dental coverage. He dropped out of school at the age of 10 and has a very rudimentary understanding of Medicare Advantage coverages.

Ways of addressing SDH:
-Patient 1: SW, bus tickets..
-Patient 2: Food coupons…
-Patient 3: SW

[M Rauf]

We need to be aware of social determinants of health, as everyone should receive care based on the severity of their health condition and not on the basis of income, race, neighborhood, family, level of education, etc. We should be consciously make an effort to acknowledge our patients social issues. I have multiple patients that have these issues, one patient was not able to get glucagon injections as she had not met her out of pocket maximum and she was not able to afford coinsurance/copay. She has had multiple episodes of hypoglycemia as she has hypoglycemia unawareness and every time she needs to be rushed to the ED for care/reversal.

[Lakshmi]

It does not come as surprise when we see some patients missing follow up appointments or not able to seek preventive care just because they don’t have insurance coverage or cant afford costs. Every person irrespective of their socioeconomic status deserves equal opportunity to reach the maximum health that they can achieve. Some patients even miss their appointments just because they cant afford the cost of transportation or the inconvenience caused by travelling via 2-3 buses to make it to the doctor’s appointment. SDH broadens our knowledge and help us understand the barriers and how can we help to overcome some of them by knowing available resources and educating ourselves and our patients about it. For example; We can arrange bus passes for the patient to make to the appointment or for their way back home.

Also it’s very important to understand, how the lower SES shapes individual’s eating behaviors. For example, if I want to counsel my hypertensive pt. for low salt diet, the first thing I ask is if he/she is able to take 3 meals in a day. I remember having a patient who was relying on church for groceries twice weekly. Knowing this background information helped me make more sense to the patient as now I was talking how to be selective on whatever limited grocery options that pt. had . Overall taking sometime to understand patient’s socioeconomic circumstances has always helped me connect better to my patients and thus improve patient compliance and reach better health outcomes.

[asil daoud]

Despite the tremendous advances in knowledge in medicine , there is always little room for doubt that social factors are powerful determinants of health. However, Given that SDH—including socioeconomic conditions such as income, wealth, and education—are by definition outside the realm of standard medical care, SDH can be overlooked by health care providers. As a medical resident, my experience has been growing with my patients whom I encounter in clinic, teaching me that social factors, whether affecting diseases or seeking health care can be a major factor. I do believe that SDH should be collaborated with the standard medical care and should be part of collaborative work between all health workers.

[Amir Laktineh]

If we thought of the social determinants of health as the conditions in which people are “born, grow, live, work, and age,” , this would lead us to how their health status was shaped. This would definitely indicate the importance of all social aspects of our patients coming to clinic. In my clinic week, I was able to assess social aspects of many of my patients, by simply assessing their home situation, transportation and even access to food. Surprisingly, many of the ‘ non-adherent’ patients were found to have one of the previous as an obstacle. Addressing those issues, by giving transportation aids or referral to social workers, was some simple ideas and a start point.

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