[Red Cohort] Module 1

[Adam Qazi]

Module 1 SOAPs

Beyond Health Care, Heiman HJ et al.

Social Determinants, Marmot M.

[Adam Qazi]

Submitted by Amjad Kanj:

I still remember very well the cultural shock I had one year ago when I moved to Detroit 48201. After my first clinic week, I was left with many questions: Who are the patients that we serve and why are they all “black”? Where do they live and how come they are so poor? Are they insured, under-insured or un-insured and who pays for their medications, clinic visits,hospitalizations…?

To be honest, till now, I still don’t have answers to most of my questions. But I came to realize that understanding the demographics of the population we serve is essential for us as physicians to properly serve that population. We need to understand WHAT is going on in 48201. Seeing patients at the hospital and in the clinic for a year now, made me realize few simple things:

-Patients miss appointments because they can’t find or afford a ride to the appointment
-Patients eat fast/processed food because we have very few grocery stores in 48201
-Uninsured patients go to the ED for simple stuff, because we have very few clinics for the uninsured in 48201
-Free clinics can significantly decrease the financial burden on the healthcare system by decreasing unnecessary visits to the ED
-Many patients in 48201 who couldn’t afford care few years ago are now able to because of the affordable care act
-ETC…

I wish I can fight poverty, improve transportation in the city, or open new grocery stores, or provide care for to all the uninsured and underinsured… but there is one thing I can do to help, and I have been trying to work on this since day 1 of my residency and that is to KNOW MY PATIENTS to be able to help them as much as possible. I hope this new “reflection Friday” program will help me achieve my goal.

[Adam Qazi]

Submitted by Nadine Abdallah:

When I first started seeing patients in clinic, I was excited to apply what I had learned about the recently updated guidelines on the management of hypertension, diabetes, dyslipidemia…, to preach about the DASH diet, exercise, and weight loss, but soon I learned that the task what not so simple. It was frustrating to see the blood pressure and HbA1c were not dropping, despite prescribing the right medications. I couldn’t understand why patients “can’t just take the medication”, “stop eating fatty food”, “schedule that mammogram”, or simply “not miss their appointments”. Unconsciously, I started labeling patients: “The lady who never takes her medications”, “the guy who never shows up”…, and became less zealous about treating them. However, several months into residency, inpatient rotations, and encounters, I came to realize that prescribing the right medication was not enough, and that the reasons behind non-adherence were not “laziness”. I started to investigate, and was met with answers that made me ashamed of the labels I had attached, and judgements I made. Of the answers I got, were: Lack of transportation to pick up the medication, loosing insurance, working full time and not having time to go to physical therapy or schedule the mammogram, not affording to join the gym, not affording the blood pressure machine, eating fatty food instead of healthy food because it was cheaper… Although this helped me “realize” what the problem was, a more difficult task arose, which is the: action. I was not taught in medical school what to do in such cases. I learned from my seniors and supervisors how to get creative. Asking patients to check their blood pressure at nearby pharmacies if they can’t afford a machine, cheap generic drugs at local drugstores… However, I still feel helpless in many scenarios that are beyond any creative solutions.
What I have learned to so far is to ask, inquire, and investigate, and tailor the management to the resources available, which can only be achieved by establishing a relationship with the patient and collaborating with them. Sometimes, they can give you the answer that books and websites cannot. What I hope to acquire throughout the rest of my residency is more solutions, and ways to work around the social, economic and transportation hurdles, to achieve the desired health goals.

[Adam Qazi]

Submitted by Scott Smith:

The American healthcare system at its best provides underserved populations with a very basic safety net but is not great at giving comprehensive care. At its worst it ignores the needs of the underserved and they slip through the cracks until they come to the hospital with a health crisis. The unfortunate reality is that the system in its present form gives the best and most comprehensive care to those who can afford it, and safety net programs cannot match the funds that premium plans have available. Even if this injustice were remedied, the at-risk populations would still have difficulty attaining good care. Other factors prevent them including lack of reliable transport.

One of my patients Mr. S is an elderly gentleman who has multiple comorbidities including hypertension, COPD, and ankylosing spondylitis. Luckily his diseases are not very advanced and he has been very adherent with recommended therapy, but he does not have reliable transport to and from his office visits. He doesn’t have his own vehicle but can arrange transport through Medicaid. However it takes a lot of planning I order to plan these rides. You must arrange the transport few days in advance and then must set aside a block of time to wait for the transport. Sometimes the rides are not available that day. It is definitely not the optimal situation like a person who has their own vehicle, but Mr. S is unemployed and cannot afford a vehicle.

The problem of reliable transport is one that certainly affects at-risk populations more. It is a question of available cash and many at-risk individuals cannot devote that kind of money when they need to spend it on more important things. Bus systems can be used but take much longer than driving directly, and those who are working need to take off entire days just to go to an appointment. Medicaid rides are a great resource but not everyone has Medicaid and those who do may not know how to access these services.

One thing I will incorporate into my clinic practice is to assess how my patients plan to come to their appointments and recommend such resources if they need them.

[Adam Qazi]

Submitted by Khaled Janom:

I will start with a plan for myself. I will try to the best of my capability to understand what my patients are going through or went through socially and economically and try to incorporate that into the way I plan to help them. When you think about it, “minor” details in the patient’s story get overlooked when we as physicians try to know the medical history. We rush to the facts relating to the medical knowledge we learned at school. Why wouldn’t we? We spent the last four years, immersed in the vast medical knowledge and we had little time to contemplate the sociological aspect of medicine. When we study a disease, like heart failure, we never find in books “inadequate transportation” or “low income” as a cause of heart failure exacerbation, we conclude that adherence to treatment was lacking. I am optimistic however because I am acknowledging the “minor details” more often since I started my residency. It could be because I am living and training in Detroit, and thus I am seeing more examples, but I am sure it is because I am exposed to these obstacles more these days.

[Adam Qazi]

Submitted by Vivek Reddy:

This reflection will be regarding a clinic patient of mine since I was an intern early in residency. I remember this patient who is a very pleasant elderly lady who came in with an elevated blood pressure. She has multiple other medical problems including diastolic congestive heart failure, Osteoarthritis, COPD and allergic rhinitis. At the day of her visit her blood pressure was elevated despite being on oral anti-hypertensive medications and my line of questioning started with her overall well being and eventually directed to her chronic medical conditions.

The patient told me that while she was given a diagnosis of hypertension, she did not like taking her medication as it caused her to urinate excessively making her daily activities difficult. I was well aware of untoward effects of medications, even if these were expected from the medication ( i.e. excess urination after starting a diuretic ) and I discussed with her the idea of switching to another medication to increase adherence. After further discussion the patient told me she believed that her elevated blood pressure was secondary to being stung by a bee and she did not believe that medication was needed.

At this point I realized that while this patient was very understanding and had no intention of being non-compliant with her medication, there was a clear lack of understanding of her disease process/processes. This patient believed that her diagnosis of hypertension was reversible and genuinely felt that these medications were not needed and the presence of this medication was causing unfavorable symptoms ( excess urination ).

I then started explaining to her such that she could understand her underlying conditions and not only was she grateful she understood the importance of medication adherence and also understood that whenever she had doubts with our medical practice she could verbalize her concerns.

It occurred to me that when a patient does not take medications or missess appointments, it is important to assess for the presence of a knowledge or communication gap. I hope that I am able to identify more patients with such barriers in the future.

[Adam Qazi]

Submitted by Kunwardeep Dhillon:

When we see patients in clinic it is often very challenging to manage pain. Possibly because it is a truly multifactorial process with anatomic changes, physiologic changes and possibly a concomitant psychologic or psychosocial component. During this clinic visit I saw a patient chronic lumbar back pain. She had a recent ED visit at which time imaging of the lumbar spine showed no acute pathology. She presented to our clinic and was requesting norco for pain management.

On physical examination I did not note any alarm symptoms and I proceeded to discuss with this patient regarding her symptoms and request for pain medication. After discussing the risk and benefit of chronic pain medication it occurred to me that this patient did not truly understand the risk of chronic opioid medication.

This patient believed that pain medication would make her feel better and that she could stop at any time. While this is true in many patients I explained to her that there is a significant risk of opioid dependence and that if her pain is tolerable in this case avoidance of opioids and early activity are key. Furthermore I printed a monograph of Norco for this patient and went into detail on the negative side effects of the patient. She was truly grateful and appreciated the time taken to explain why pain medication is not ideal as opposed to a simple rejection.

This encounter made me realize that when patients come to see a doctor, they have so many questions and such little time to discuss them. As a physician I realized that explaining to someone the risks and benefits of medications and our thought process makes them understand our treatment plan. This reflection put into perspective that patents want to be involved in their own treatment and want to be made aware of their medical conditions. It made me realize the importance of medical education and the importance of closing the knowledge gap. I hope to identify more gaps in the future and address them!

[Adam Qazi]

Submitted by Hibah Ismail:

As I transitioned from my medical school in Lebanon to residency in Detroit, I was not aware of the tremendous amount of knowledge I would gain. Sure, we all expect to gain experience and knowledge during our training, however what I expected was expanding my knowledge on medical guidelines, treatment plans, ect. During my first week in clinic was the introduction to the new culture of Detroit. Patients would present with the same chief complains, the history taking and physical examination would be the same as those we learned in medical school, however little did I know that the management of the diseases we learned about would differ greatly.
Keeping HbA1c less than 6.5, counselling on DASH diet, and prescribing medications seemed to be an easy task. However, once clinic weeks progressed, we learned more about our patients. Asking deeper questions and learning about their living situations expanded my knowledge of the management of their illnesses. As I learned more about my 24 year old female patient who was looking for a job and attempting to feed her children, waiting for transportation to be able to show up to her appointment in clinic gave me a deeper sense to the struggle different cultures have and to the resources we should know about to help facilitate a better lifestyle, and thus a better health for her and her children. Thus, our experience began; acquiring information about Medicare and Medicaid, about different insurance plans, generic drugs, STD clinics, social-work and resources all became an integrated part of our practice.
Learning about the social determinants of health is in fact an integral part of our practice because it is an inevitable fact that learning about our patient’s struggles, obstacles, and available resources is key to identifying and optimizing the best plans for management of their illnesses, whether it is diabetes, heart failure, or dialysis. Although the utmost solution to healthcare might seem far-fetched as it involves improving patient’s finances, education, access to clean water supply, nutrition, and other factors that involves tremendous amount of time, effort, planning and monetary means from governmental institutions, however this does not remove our responsibility to really LEARN and KNOW the people we are treating and encountering. In the end of the day, medicine is a practice of art, and there is nothing more satisfying that using the art of language and words to learn about the core struggles of the people we try to help.

[Adam Qazi]

Submitted by Hussam Tabaja:

Subjective:
Miriam-Webster’s dictionary gives a relatively simple definition of the word health by defining it as the condition of being sound in body, mind, or spirit. Notice how this definition is very “individualistic”. However, health is anything but simple or individualistic. Health is a function of economic and social conditions that people interact with. Factors such as educational level, profession, place of living, the people we interact with have a direct impact on our health. This was illustrated by the article titled Social Determinants of health Inequalities.

I saw the impact of social determinants on one of my patients during my floor month at Detroit Receiving Hospital. To illustrate, I was assigned to the care of a 66-year-old Hispanic female who was admitted for diabetic ketoacidosis with blood glucose in the 600s and HbA1c of 11. She is status post right below the knee amputation and has a history of poorly controlled diabetes with multiple admissions for DKA. She was initially managed by the MICU and then transferred to my care. Prior to meeting the patient, I thought that this is going to be one of the many nonadherent morbidly obese diabetics that pay little attention to what she eats or drinks. As soon as we get her blood sugar under control, she is going to resume her usual lifestyle. Wow, was I wrong.

Objective:
When I met the patient, she was frail and spoke little English. She said that she did not know much about managing her diabetes. She lives with her daughter and she is the one that manages her medications and her diet. Ms. CS stated that her daughter would measure her blood sugar every day and gives her insulin. Furthermore, she reported that she tries to eat healthy by eating salads and fruits. However, she does say that she often eats the same foods as the rest of the household. She ambulates with a prosthetic, but she does not like using it because it makes her feel unsteady.

I contacted the patient’s daughter to gain a better understanding of the patient’s diabetic history. Her daughter told me that she would measure her mom’s blood sugar daily. Based on the reading, she would subsequently give an insulin shot in the belly. Her daughter explained to me that when the glucometer would read “high”, she would administer 30 units of glargine insulin. However, if her blood sugars were between 200-350 mg/ dl, then she would administer 15 units of glargine insulin.

After collecting the history from the patient and her daughter, it became obvious that both individuals have a limited understanding of the disease. I spoke with the daughter extensively about her mother’s medical condition and the need for better management of blood sugars. I told her at what times she is supposed to check the blood sugar and when to administer glargine insulin and aspart insulin. I gave the patient and her daughter handouts in Spanish about diabetes. In addition, the team consulted a Spanish speaking dietitian to talk with the patient and her daughter about managing diabetes.

Review of previous records revealed that the patient was discharged on long acting and short acting insulin. However, when I spoke with the patient’s pharmacy they told me that the patient had never picked up her short acting insulin. When the patient was discharged, I called the pharmacy and asked the pharmacist to please dispense the long acting and short acting insulins to the patient.

Assessment:
In order to fully assess this case, we have to go back to a concept that I was taught in my first year of medical school and that is the biopsychosocial model. The biopsychosocial approach systematically considers biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery.

From a biological viewpoint, the patient has been admitted multiple times for DKA’s. Given her elevated HbA1c, it is evident that her body is persistently exposed to elevated blood sugars. This predisposes her to micro-vascular and macro-vascular complications. Therefore, she needs close follow-up with her PCP. Each time the patient was discharged from the hospital she was given a specific set of instructions for her insulin regimen. For unknown reasons, it appeared that she was only getting the long acting insulin only to manage her diabetes.

From a psychological viewpoint, it is well known that depression is among the most common neuropsychiatric disorders in patients with type 2 diabetes. The patient’s PHQ-2 questionnaire was negative. When I spoke to the patient about her repeated hospitalizations for her diabetes, she was admittedly upset. She was upset because she felt it was not something she could control. Understandably, she did not like the repeated finger stick glucose testing and the repeated insulin injections. The patient stated that living with the disease was difficult, but her daughter was a tremendous support.

From a social viewpoint, my patient had several risk factors that make her especially vulnerable to falling ill. For instance, the patient was elderly (poor physiologic reserve), non-English speaking, she was dependent on others and the patient was mostly wheel chair bound. One important protective factor is that she lives with her daughter. This is her strong social support. She can constantly keep an eye on her mother and get her medications filled. It is important to identify the daughter our ally because she has the most contact with the patient.

Furthermore, during my interactions with the patient, she told me that she is an immigrant from Puerto Rico. Although, I did not know her insurance or citizenship statues, it is important to have the following discussion. The high costs of health care and the erosion of insurance coverage are significant challenges that confront all Americans. These problems are especially hard on immigrants to the United States, who have extremely low rates of health insurance coverage and poor access to health care services. Immigrants, both legal and undocumented, often rely on a patchwork system of safety-net clinics and hospitals for free or reduced-price medical care. Their reliance on this system has led many states and communities to be concerned about uncompensated health care costs for uninsured immigrants and the state and local fiscal burdens that result. This situation really complicates health care delivery to the immigrant population.

Plan:
My job as a health care provider is not just making sick people healthy again. My job also entails preventing healthy people from succumbing to an illness. If there is one thing that this case taught me is that I must identify people who are at risk of falling ill and to not be afraid to ask why. If a patient’s HbA1c comes back elevated, then ask why. If a patient is unable to come to the scheduled appointment, then ask why. If a patient was laid off, ask how they are doing at home and how are they coping with the stress. As physicians, we can use the biopsychosocial model to identify patients who are at risk of falling ill and intervene appropriately before their condition deteriorates. Equally important is the identification of allies in the treatment of the patient. Someone who can monitor the patient or assist them with their medical needs.

In addition, I think that the hospital system should identify locations where people who are under privileged can be referred. For example, referring them to clinics that provide free health care and prescriptions. I was a Wayne State University medical student and I had the pleasure of working at many free clinics, most notably is Cass Clinic. These clinics are managed by physicians and medical students who volunteer their time. Referring the patient to such clinic allows them to get some form of healthcare that prevents them from coming back to the hospital. Although, there is a flaw in this idea. If a hospital would refer a patient to a clinic that is managed by medical students, it could lead to liability problems.

Within our medical system, it is often difficult to stop and think about the tremendous social hurdles that our patients face day in and day out. After this week, I have realized that it is very easy for a physician to set a health goal for the patient. However, it takes an extraordinary physician to help a patient reach that goal.

[Adam Qazi]

Submitted by Hamza Salam:

It was a rainy and unexpectedly cold afternoon in midtown when Mr. T came to the clinic. On a clinic day like that I am usually expecting a low patient turnover at the clinic, appointments are usually rescheduled and patients with relatively poorer health outlook are the ones who maintain close follow up. Mr. T had no medical comorbidities. 35 year old guy, works at a tire shop in Midtown, Detroit. His presenting complaint was “I don’t want to talk to anyone.” Now, he had my full attention! “So, what can I do for you Sir?” I asked. “I don’t know, you’re the doc” he replied. I went straight to the review of systems to allow him time and space to open up to me. He is a pack per day current smoker, drinks excessive quantities of alcohol on the weekends, denies drugs. His BMI was 32, did not exercise as he worked 10-12 hours a day and would be too tired to do anything afterwards. Recently, his diet had worsened, he had been smoking more and also drinking alcohol on the weekdays. The patient had a divorce 2 weeks ago and now was fighting for the custody of his kids. His mother was recently diagnosed with a terminal illness and he was finding a placement for her. His HR was 110 and BP 175/110 with no prior history of hypertension. He had his hands around his head and was looking downwards with his eye’s closed. There was objective evidence of emotional and social stress affecting a healthy young adult. If this continued, he most likely would develop HTN and/or DM within a few years. A permanent modification to his lifestyle was needed on top of this acute episode of stress.

Objective
As mentioned in the article, Greece had a per capita income approximately 1/4th of the US, but had a similar life expectancy when compared to the US population. On the other hand the Aboriginal and Torres Strait Islander peoples in Australia have a life expectancy less than that of India, but when it comes to income and availability of resources they belong to one of the most privileged societies on earth. Even the infant mortality rate in these people was closer to that of developed countries. So what determined a 10-20 year difference in life expectancy than the normal population? There is no doubt that societies that are economically underprivileged lack the basic necessities governing health; including the availability of clean drinking water, healthcare, education, hygienic living conditions etc. But the Aboriginal and Torres Strait Islander peoples didn’t lack these facilities, the issue most likely was that these were socially isolated communities. The reason I decided to choose this particular example is because I don’t see the entire population of Detroit as one that is devoid of food, water and basic facilities. Yes, there is a large homeless population and people who have never seen a doctor before. But, this does not account for Detroit’s one of the lowest life expectancy in the US and an infant mortality rate similar to that of Nigeria, which is a middle to low income country. Detroit does have one of the lowest income per capita in the US, but it is still 5 times more than that of Nigeria. What are we missing here? We have hyper-focussed on the economic aspect of a society’s correlation to its health. Although important, but this had made us miss the bigger picture. The social determinant of health is as important. Mr. T had a home, a living income, health insurance, access to healthcare, education etc. His lifestyle was the cause of her morbidity. I need to focus on his lifestyle and how to slowly modify it for a better health outcome.

Assessment
How do I approach this in my patient encounter? How do I tell him to exercise and control diet when I know even I could not have done it if in her position? What would be the right approach to counsel him into giving up alcohol when that is all he looks forward to every week? What can I do to convince him, that health care above else, will also determine her mental health. Mental health in turn governs physical health; when I know what social trauma he has gone through?

Plan
These are the aspects I feel that need to be worked on. It is easy to guide a patient on health lifestyle practices, but when it’s tough to understand what disables them to follow our guidelines and how to tackle it from patient to patient.

[Adam Qazi]

Reply by Eugene:

Thoughtful post Hamza. I agree with you that we are all too focused on external problems (money/resources or someone providing access to health) that we forget about a person’s individual situation. The example about Greece in the article was wonderful and shows how a relatively healthy culture (I use the term loosely) and good genetics are no less important than whatever medicine we can provide. I hope that your patient comes from a place and upbringing that will allow him to have the psychosocial support and coping mechanisms that needs at this time above all else so that he can focus on his overall health.

[Mohammad Rauf]

On this past Friday I realized how many factors we are not addressing with our patients, that are the main reason for their poor health outcomes. There are so many things I can’t change with just counseling, ordering a test, or prescribing a medication. There are so many socioeconomical factors that I cannot modify. As physicians however we can help by realizing these issues and catering our care to inculcate understanding and to involve multiple disciplines and services when caring for our patients.

[Author]

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