[Red Cohort] Module 3

[Adam Qazi]

Please submit your SOAP Reflections below:

[Mohammad Rauf]

S:
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[Ali Saker]

Primary care medicine is the first line of defense in the health system. When people don’t have access to primacy care, they tend to have increased numbers of hospital admissions and progression of the disease. On the other hand, patients who have regular Primary care f/u and good adherence tend to live longer, feel better, avoid disability, avoid absence from work and overall a better quality of life.
When I started seeing patients on the outpatient practice, I have noticed a considerable amount of: loss of f/u, non-adherence to medications, drug-seeking behavior and advanced stage of the disease. All might have been halted if a proper follow up with early diagnoses and intervention were implicated. That made me wonder, where is the problem and how it might be possibly fixed.

It’s crucially important to identify and intervene on the behavioral variables that might be responsible for non-adherence. It can be frustrating for healthcare professionals, especially at times of stress, fatigue, and burnout to deal with non-adherent patients. Which unfortunately can reflect on patient care with negative consequences if compassion based strategies were not implemented. Implement behavioral theories in your daily practice to try to do a meaningful intervention. One key element is to assume ownership of the patient. Involve your patient in your treatment plan, clarify the diagnoses in a simple language, ask your patient how often he/she was taking their medication in a non-judgmental way and build a partnership with them. Imagine yourself in their shoes and try to convey your information in the way you want to hear if you were the patient. It’s a fact that people have variable degrees of intelligence and receptivity. However, you must always try to educate your patients, find them reliable resources of information, provide them with feedback and ask them to provide you with feedback too. We as residents have multiple reliable resources that is patient-oriented and can be used to increase adherence.
Once I have seen a physician in one of the outpatient clinics who had perfectly adherent patients, I asked him: do you choose your patients? He answered: No, I train my patients.
Key points I have learned this week: always use motivational manner to support adherence, people won’t come see you again if you criticize them. It’s my mistake if a patient is non-adherent unless proven otherwise. Always ask about living situation and food accessibility as a potential modifiable difference in health in less privileged patients.

[Hibah Ismail]

One of the most important prognostic factors in a patient’s health is adherence to medications as it has a large impact on the morbidity, mortality, hospitalizations, ect caused by the disease. However, as simple as it can seem for a patient to have to take a scheduled daily medication, multiple underlying factors that affect patient adherence are usually overlooked. I will give a few examples from the patients that I have seen in my clinic.

Patient 1 presented to clinic to follow up on DMII and HTN. However during the encounter it was noted that the patient’s DMII and BP was not controlled and thus multiple adjustments were made to her medications including discontinuation of 2 medications; increasing the dose of two other medications and starting 1 new. In addition patient had requested screening mammography to be done and that was given to her during the encounter. Although I had written down all the patient’s medications on a separate paper for her, with notes on which meds were to be started, discontinued or adjusted, the patient called the clinic back the next day in order to ensure the correct regimen as she reports she was not sure of the adjustments made anymore.

Patient 2 had presented after being lost to follow up for more than a year. She had a large thyroid gland that was been investigated last year and patient had lost to follow up due to travel to another state. Patient 3 had lost to follow up due to loss of insurance

Patient 4 had presented once in the past for PAP smear but during her encounter she had complaints of multiple symptoms that were addressed, lab requests were sent that were not done by the patient and medications will filled but patient did not obtain them. Upon seeing the patient again this week, extended talk about her underlying anxiety was taken, which resulted in diagnosis of domestic violence.

As seen by the examples above, all of which were patients seen in 1 clinic week, adherence to medications is a much broader topic than what we think of it to be. Underlying factors including insurance, access to healthcare, socioeconomic status, understanding of disease implications, ect have to be considered during patient encounters to optimize patient care and adherence.

[Amjad Kanj]

Physicians and patients should work hand in hand to ensure the best outcomes. I strongly believe that our role as physicians is to share our medical knowledge with our patients. Understanding the disease is an essential step for adherence to therapy. I came to learn this when I started taking time to explain to my patients “what” is happening in their body, “why” it is happening, and “what” the treatment will do to them.

My patient is a 56 year-old woman with heart disease who stopped taking her Statin since 2 years. Upon inquiring about the reason, the patient stated that her cholesterol levels have always been low and that she doesn’t see any need to take a Statin. After explaining to the patient in depth that the reason we prescribe statins to patients with heart disease is their anti-inflammatory effect and their mortality benefits, the patient wanted to start taking a statin again. Not only that, but after few appointments, the patient was asking for refills to her statin!

[Mohammad Rauf]

We should always work together with our patients and involve them in decision making, however this is difficult when pressed for time in clinic. One thing I realized this Friday is that there is no real good indicator for practitioners to evaluate whether a patient will be compliant or not. Now that I look back, I remember times where I thought a paitnet would be adherent and they turned out not following up at all, others whom I never suspected of even picking up their medications became regular in continuity clinic. I hope I will be able to add warmth to every encounter to ensure the best chance for my patients.

[Nadine Abdallah]

Medication adherence is one of the most common problems we face in primary care and is something we fail to address a lot of times. Personally, I used to devote minimal time to asking about medication adherence, mostly in the form of the question:” Are you taking this medication?”. Most of the time, patients answered “Yes”. After the session we had and the discussion, I started asking inquiring about adherence in different ways, asking more targeted and specific questions, like: “How many times in a week would you miss a dose?”, and it was striking how many times I got 2 different answers from the same patient to what I thought were similar questions. This led to more questions and discussions with the patient about reasons for missing medications, including inconvenient scheduling, transportation problems, and not being aware of the indication of the medication. Some patients did not even know they were supposed to be taking it. Taking the time to address the causes showed improvement in adherence and avoided adding different medications. I also liked Dr NNodim’s idea of a dedicated visit to discuss medications, their indications, and scheduling with the patients and make them more involved in their own care.

[Scott Smith]

Medication Adherence is a frustrating topic for all parties involved. I prescribe medications to patients but can’t guarantee that they will take it correctly, or even at all. Even more difficult is modifying lifestyle based on a physician’s advice. Have any of us tried to take a TID medication reliably or tried to eliminate 2 grams of salt from our diet? That’s a tough pill to swallow. Many patients don’t understand the need for certain treatments or interventions. There are patients who will do what you say no matter what, but many will just ignore advice if they don’t understand it’s necessity or they will end up doing it completely wrong.
My strategy for compliance is to explain why I think the intervention will help, and I ask if they agree with me. Simplifying complex regimens is also a great way to improve adherence. This is far from perfect but I’ve especially had success with the ladder.
Patients want to be well and they come to us for help, they aren’t aiming to be nonadherent.

[Abdelaziz Mohamed]

The use of the term adherence is a new concept to me. I have always used compliance and was never aware of the difference. The concept of my patient being adherent to his medication has always been an important one, and I am most likely to include it on my HPI whether as inpatient or outpatient.I am an honest believer that we have to work with our patients as a team to remove all obstacles to make sure they have the medication and are able to take it.

I have an example of two patients who presented to clinic over the past few month. The 1st was a diabetic patient on insulin who always has high blood sugar and needs repeated hosp admissions with DKA. Establishing that she was not able to take her medication regularly due to her work schedule was the 1st step to establish th reason behind her non-adherence. I always documented lack of adherence for her, but never took the time to dig into the reasons of why because I did not have a well established relationship with the patient. After a few visits we where able to have a good conversation about it and hopefully this will change her outcome in the long term.

With better understanding of adherence I will hopefully be able to adhere to the concept.

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