[Red Cohort] Module 7

[Adam Qazi]

Please submit your SOAP Reflection below:

[Mohammad Rauf]

This week I focused on asking patients about their occupations and financial status. I found out from one patient that she is hoping on getting her disability approved so that she may get Social Security money. She currently depends completely on her boyfriend. I asked about whether she has access to food and she mentioned how she has been eating only Ramen noodles for the past few days and that this would continue till her boyfriends paycheck comes in. Now imagine whether this relationship does not work out or the boyfriend becomes abusive. The patient would have to choose between tolerating abuse or financial instability/homelessness. This just stresses the importance of bringing up biopsychological issues to better recognize our patient’s and what factors are contributing to their health/illnesses.

[Khaled Janom]

Patients coming to DCC clinic having many elements contributing to in-adherence to the treatment plan. I would like to discuss one patient in particular. She is a 57 year old lady living with her fiancé and two kids in a two bedroom apartment. She has HTN, DM and PAD. She does not take her Amlodipine or her Atorvastatin and even though she had a fem fem surgery few years ago, she is now re-experiencing her claudication symptoms. Ten minutes into the discussion, the patient breaks down in tears and informs me that her fiancé just cheated on her and they are in the process of leaving each other. She then says she feels very down lately and has no energy to perform basic tasks like caring for her kids. She does not have family around. This patient has no social support, has limited resources considering she is on social security and has depression. Dealing with depression and lack of resources in this patient would probably improve her compliance with her BP control and her statin medication. I decided to start the patient on an SSRI and made sure she goes and take an appointment with the therapist in the same building. I explained to her that depression is a medical problem that can cause this energy loss and could lead to indifference to caring about one’s health needs. Patient was asked if she had any suicidal ideation and we decided that she needs to be seen weekly till her moods improve because the SSRI requires at least 1 month to take effect.

[Hibah Ismail]

This week I have focused on my patient’s resources and social support in terms of psychosocial and behavioral determinants of health.
My patient is 30 year old female who has previously presented several times to our clinic seeking medical advise regarding various different somatic complaints, including fear of having cancer, PCOS, SLE, ect. She has underwent several workup in the past with no definite diagnosis. Upon seeing the patient, I asked about her previous visits and the source of her concerns for these various diseases. Upon further history taking, I asked her about her living situation. She reported having been in a previous abusive relationship with current fear of her coworker harming her and her children due to other unresolved problems in her personal life. She reported living alone with her four children with no nearby family. She has not spoken about her abusive relationship to her friends or family due to fear of her children being harmed. She had not felt safe at home and is always watching her way home due to her concern of being followed and black-mailed. I focused my encounter on asking the patient about her current social support and network and her information about available resources that can help her with her current situation. We continued to bring social work to give the patient additional resources that she can seek which are available in her community as well as encouraging her to seek legal help from police. After our visit I re-enforced that the patient can call our clinic at any time if further help is needed.
Learning about our patient’s social support and living conditions can be an imperative part of learning more about their diseases and to obtain better ways that we can help them in their everyday medical, social and psychological battles.

[Ali Saker]

This patient had a positive social support system from his family, however, living with his mother and depending on her at the age of 47 had a significant negative impact on his self-esteem leading to feelings of worthlessness and feelings of being “ less than a man”.
He was previously able to work as a roofer before his MVA 3 years ago, and now he is not able to due to constant pain. His MRI 1 week ago didn’t show significant findings that can explain his pain. His insurance doesn’t cover naproxen for his musculoskeletal pains, he is not able to afford 13 $ and was eliminated from the pain clinic for unknown reasons.
There has been an inconsistency with the location of his muscle weakness and paresthesia’s when compared to previous encounter, raising suspicion for somatization secondary to the significant stress of daily life. He denied histories of personality or behavioral disorders which is commonly associated with somatization. He is currently experiencing anhedonia, low mood, irritability, sleep disturbance, and low energy. He bursts into tears during the exam and states that he doesn’t want to be on antidepressants since he tried fluoxetine before and was not effective.
The patient generally had a negative view of his condition and was not expecting any improvement or any benefits from treatment solutions we have offered. I tried explaining that it’s a responsibility of both of us as well as him to work to improve his health. Luckily he agreed to psychological, cutting down on alcohol intake, and taking his atorvastatin which he decided to stop on his own.
This encounter emphasized how social support can have both positive and negative impact, the importance of investigating underlying problems when facing somatization, and the importance of supporting a patient to get over the feeling of being victimized by their health condition.

[Scott Smith]

I focused on home environment and social support this week. One of my patients is an 88 year old lady, in relatively good health but with poor functional status due to arthritis, yet she still lives by herself. She was hoping to obtain a housekeeper or home health aide. While interviewing her, she told me that she has many children that live in the area but that most of them are in worse health than she is. They are unable to provide daily help for her, but do drive her to appointments and cook for her somewhat regularly, which is what enabled her to live alone for so long. My patient could perform ADL’s satisfactorily but had more trouble with IADL’s, which her children could partially compensate for. The reason the patient wanted a home health aide or housekeeper was to help with IADL’s like cooking and cleaning. Her children helped with these currently but my impression was that she didn’t want to be a burden on her children who were in poor health. This patient had family support but it was waning. I think this is partly why she remained in relatively good health at an advanced age. She was able to attend appointments, pick up prescriptions and eat a decent diet because of her children’s help. I worry as her children’s health worsens, hers may reciprocate the pattern.

[Asil Daoud]

This week, focus was on my patient’s home environment and social support along with associted psychiatric disorders. My patient is a 41 year old male, who was incarcerated for 27 years for murder before his release few months back. He is limited with his daily functional status due to associated psychiatric illness of severe form of schizoaffective disorder. Discussion about first few months of his release pointed to many difficulties faced to find, not only a house to live, but an assissted living with allowance as patient is dependent in many of his IDLs. Patient described being back and forth with several housing and insufficient financial aids up until last month where he was moved to Emmanuel house, in which he got what he described as ‘DOUBLE the allowance he ever wished for’, he was also asigned to us as PCP along with continuous psychiatric care.

[Amir Laktineh]

My patient is a 38 year old female coming to the clinic only to ‘talk’ about her living situation. She lives in a two bedroom apartment with her four daughters. Her sister and her unemployed boyfriend have recently moved in with her along with their two children due to recent finicial problems. Patient described trouble adapting to her new living situation along with limited finicial aids which can not be sufficient to cover all members living recently in her house. She says she has been drinking daily, double the amount she used to drink to deal with her stress. I focused on my patient’s living situation in which has likely reflected on her well-being and pushed her to alcohol abuse to adapt to her situation. In this encounter, I reinforced the need for psychological councel and social work for help along with the dicussion of several other ways to adapt to stress.
This emphasized the role of Psychosocial aspects on our patients’ wellbeing and general health.

[Hussam Tabaja]

This week I spent more time during my encounters to discuss psychosocial factors with my patients. The case I would like to discuss is that of a 67 year old lady who was coming for routine checkup. She is an established patient known to our service but it was my first time seeing her. We were seeing her for uncontrolled DM. The patient had persistent reads of 10% HbA1c despite being followed for almost 3 years. She has CKD secondary to DM and had previous history of diabetic foot ulcer leading to hospitalization. Previous visit notes labeled patient as “noncompliant” with insulin but no reason was specified. When I screened the patient for psychosocial determinants of health using the 2-question approach the patient answered yes to having “low mood” and “lack of interest.” With further questioning, she reported having problems falling asleep, drained energy, problems concentrating, and low appetite. She also reported forgetfulness. She denied suicidal ideations but claimed that her hopelessness in this life makes her not care about her health. The patient has been living alone in Detroit for almost 15 years now. She is a mother to two sons and both are living abroad. Her sons talk to her over the phone every now and then but she has not seen them for years. Her husband passed away years back due to heart attack. The patient reported feeling “lonely” most of the time.

According to the patient, her lack of compliance with her medications is because this “hopeless” feeling that she has. She also forgets to take her medications sometimes. Therefore, her depression seemed to be the main reason behind her lack of compliance. This was surprising to me as the patient seemed to have a pleasant mood during the encounter and was often laughing and telling jokes. I would have probably failed to screen this patient for depression if it was not part of our exercise. Hence, screening patients for psychosocial determinants should be applied in every encounter we have with a patient regardless of their appearance or behavior in the clinic.

[Nadine Abdallah]

This clinic week, I focused on the social support aspect of the psycho-social model of clinical care. I asked most of the patients I saw: “who lives with you?” and “Do you have fiends or family who help out when you have difficulties?”. I noticed that most of the time, patients who had good support were more likely to be adherent to medications, and appointments. I saw a patient at the Tolan park clinic who represented the other extreme. It was 52 year old gentleman with alcoholic and hep C related liver cirrhosis, uncontrolled HIV and hypertension, who presented for routine follow up. I noticed most of his clinic notes mentioned medication non-adherence, and he often left prior to plan was discussed. When I asked him about social support, and he answered that he lived alone, and no family members or friends lived around in case he needed help. This contrast between the patients made me realize the importance of social support not only in patients who are physically dependent, but even in fully functional patients. I tried to motivate the patient, decrease the number of medication he takes to enhance compliance. I felt that we as physicians can in some way provide support to our patients by showing that we care about them, and by devoting some time to listen to them, and be involved in other social aspects of their lives.

[Alaa Akhras]

For this clinic week, I will focus on some of the medical bias that might occur to younger & healthier patients. I encountered a young gentleman of the age of 33 with no significant past medical history who presented with dislocation of his right thumb. The patient had severe tenderness and very limited range of motion with passive and active movement. He stated that he dislocated and tried to “pop it back in” however, the pain had began to worsen and his motions became very limited. He subsequently went to the emergency department at St. Johns hospital. He stated that they never looked at his thumb let alone performed any imaging studies. He also mentioned that he was only seen by the nursing staff and that a physician never even spoke to him. I saw a great deal of frustration in his eyes. His case is similar to many out there where younger individuals are not given proper medical attention due to their age. Many of the times we look at these patients and believe that they are young and healthy enough that they can heal themselves, or that they can get over it. I believe that when we are approached by any patient we should present to them similar degrees of caring and compassion regardless of age, sex, race, or sexual preference. It is not our place to judge people based off things that are beyond their control and to treat each individual equally.

[Abdelaziz Mohamed]

The use of this weeks topic to focus on a specific domain about my patients has been an interesting one. At baseline I usually ask my patients about their living situation. A habit that I picked up when I did pediatrics rotation in Sudan, as the availability of electricity and refrigerators is not always guaranteed, and when dealing with type I diabetics we had to ensure that the patients where taught well on how to store the insulin. So on top of that I took a new question to ask about source of income and support. It was a pleasant surprise that several of my patients have had stable jobs, and in fact 3 where asking for notes to return to work.
I feel this weeks topic is one of the best we had as it shed the light on the importance the components of functional status of our patients. I intend to ask about the support system along with the above questions starting next clinic week.

[Hamza Salam]

This clinic week I focused more on the social support aspect of the clinic patients that I saw and tried to determine if there is a correlation between improved medical awareness, compliance to medications and follow up with people who had more social support. I observed that there was a major difference between people who had more social support than those who did not especially when it came to follow ups. Interestingly I also learnt that this did not only apply to elderly patients who are more dependent on close relatives/friends for care but even relatively younger and healthier individuals. I would like to quote an example of a patient who I saw this week. There was a 38 year old male patient with a history of gout. The patient had at least 1-2 gout flares per year attributed to poor compliance with medications and food. He agreed to non-adherence due to the fact that he didn’t think it was important. He was overweight, smoked and drank alcohol on a daily basis. The patient did not have any social support and was not in touch with anyone from his family. Poor compliance and an unhealthy lifestyle seemed to be more prevalent in patients who did not have anyone to check on them on a daily basis.

[Amjad Kanj]

Jamie was coming in for regular follow-up at the clinic. She was looking sad and anxious. Upon inquiring about what is happening in her life, I discover that Jamie lost two family members during the Christmas Holliday: her niece Linda and her sister Joanne. She is still shocked and didn’t yet come to terms with what has happened to her. She has been busy with the funerals and now with her nephews moving in to live with her after they lost their mother. When I asked Jamie who supports her the most, her answer was: the Church. “I go to the Church every Sunday, pray to God above to give me strength to accept things in life. The people at the Church are my other family, they are always there when I need them”.

It is crucial for patients to have some sort of support when fighting a certain disease. Jamie appeared to have strong spiritual support helping her overcome this period of grief. I had an honest conversation with Jamie about what I can do as a physician to support her even more during those difficult times. In addition to the time I spent counseling and consoling her, I prescribed a medication for her to take during stressful times. She will see me again in one month.

[Raja Rabadi]

My patient was an 80y/o female who came to the clinic for an annual physical. She wanted to make sure all her medications were refilled and that she was taking her blood pressure reading correctly. Her blood pressure was slightly elevated, so naturally, I asked her if she was taking her medications regularly. The patient said yes and she mentioned that she is pretty active with her church and eats healthy. Then, I asked her if she has any family members that check up on her. She said no, that she lives alone in an apartment building. Then, she went on saying that her lease status is what causing her blood pressure to rise. I asked her if she has enough food and if she is eating well. She told me that she was an AT&T manger for 36yrs and had retired years ago. When the market crashed she has lost most of her pension, and the current place that she lives at keeps increasing the prices and charging her for random services. She said that she has little money for food that she ended up applying for food stamps, which was also reduced. She finally told me that she decided to move and leave the place that she lived in for more than 30yrs. The patient looked a little hopeless and has no family members to take care of her. I provided her with phone numbers to decent buildings that can save her few hundreds of dollars a month, which will give her more money for food. The patient left the room happy and appreciative, and she asked me to be her regular doctor.

Even minimal support can have the biggest impact on a patient. It can lift up the patient’s spirit, provide strength and determination, help the patient’s to be more compliant with medications/appointments, and better control a disease.

[Michael Hill]

Any discussion of treatment without consideration of these other aspects of the biopsychosocial model is incomplete. A patient this week was a newly diagnosed diabetic. After discussing the diagnosis and the consequences of diabetes, I went to formulate a plan with the patient starting with diet and lifestyle. The patient had a somewhat poor diet with room for improvement, but is not in control of it much. He is currently in a group support home for treatment of addiction. At this place, meals are centralized and not under his control, so he has difficulty limiting carbs and processed foods with high added sugar.

Treatment of his substance abuse problem therefore interfered with diabetes management. I discussed the patient’s diet and the resources available with him. We figured out what was actually modifiable in his diet, and how he could store and administer insulin at this facility since all medications are under lock and key at times.

When I called the patient to follow up on some test results, we discussed how his initial treatment was going, and he talked about receiving dietary and general advice on how to deal with his diabetes from other residents at the group home who had also diabetes. They represented a resource to help him I had not considered, apart from established aspects we already have such as a dietary referral. These acquaintances can also provide emotional support as they have been dealing with similar health issues.

[Pradeep Kathi]

This week I had an opportunity to see a 57-year-old pleasant female presented to the clinic for medication refills. She has a medical history of breast cancer s/p treatment, hypertension, diabetes, diastolic heart failure, recently diagnosed stage 4 uterine cancer currently on chemotherapy, neuropathy from chemo and recently diagnosed PE/DVT. After addressing the medical issues, I focused on her social support system. She told me that she stays alone at home and she has a home health aid that comes to help her with some activities. She has a lot of issues to deal with every day and she needs to regularly follow with her Oncologist (twice a month) to obtain care. I asked her if there is any family member available to help her and emotionally support her while she is going through the treatment. When I asked her, she felt happy to talk about the family support. She told me that she has a grandson who loves her a lot, comes to see her everyday and helps her with most of the work at home that is left to do. He does not leave her until she forces him to go to his place to take care of his daily stuff. I think having a person who loves her unconditionally is keeping her happy despite going through a lot of health related issues and social support definitely plays a big role in overall health of a person.

[Lakshmi Pathai]

This week, I asked most of my patients at least 1-2 questions from each domain of psychosocial model of clinical care. It was nice to see how some of my patients have good social support and they were more compliant with their medical appointments and aware of their health issues and had the motivation to fight with their disease whereas, on the other hand, people with less social support tried to take care of their health but lack enough motivation to make day to day decision like taking medicines, eating healthy, etc.

One of my patient, that I would like to discuss is a 72-year-old woman with medical history significant for Diabetes (on Insulin), I had changed her insulin dosage in the last visit but she did not take it from the pharmacy because she had paid 36$ last month for the insulin before I changed it so she was not able to afford it to get it the second time. When asked in detail, I came to know that she lives with an adopted child (12 years old) and gets 750$ from social security. She pays 500$ for the rent and manages with 250$ for the whole months. When I asked is she able to manage to eat 3 times a day, she informed that she gets food from church every week and manages to feed on that. She goes to church twice a week to get food. Different churches have different days for distribution of food.
And how about coming for her appointments, she informed that she takes 2 buses to come to the clinic but today she took help from a friend to drop her as she was not feeling well to take the bus. She did not have any family, only friends who helped her at the time of need.
After talking to her, I asked if I can be of any help to her, she said no. I counselled her to try to get her insulin this month and gave her other prescriptions. After talking about her social condition and listening to her, it helped me to develop a bond with her which I believe is necessary for a patient-doctor relationship.

In summary, I believe we as the clinician have more responsibility than just giving medicine to a patient and treating their numbers. Asking a patient about his social issues and having a compassionate listening makes a lot of difference and gives the patient a feeling that his doctor does not only take care of his disease but takes care of him as a person. Which bring us back to our core that we are treating humans not subjects and taking care of their health, which does not merely mean an absence of disease but complete physical mental and social well-being.

[Author]

Posts