SDH 2/2018

[Kalyan Sreeram]

S: During this clinic week I had a 45 yo patient come in who has a history of moderate AR and nonspecific syncope, purported to have used cocaine on occasion in the recent past. He is currently wearing a loop recorder to see if there are any arrhythmic episodes, and if so there is a possibility they are completely a result of cocaine usage. The use of certain substances describes potentially avoidable harmful behaviors, and cocaine use would constitute a behavioral/psychosocial determinant of health.

O: Objectively, I took time to educate the patient on the dangers of cocaine to the heart, especially considering the low threshold for coronary ischemia and vasospasm while using the drug. In doing so I found out that the patient had a very fractured and inconsistent social support system, and that it led him to start using cocaine at all in the first place. He also has a history of antipsychotic medication use, though for unknown reasons following unemployment from his previous occupation.

A: Therefore, as an assessment I believe that this patient has brought on clinical problems to himself in part because of his own behaviors. Yet it is not prudent to fault him fully for committing his detrimental behaviors, and this is where the 5-domain psychosocial/behavioral model of health comes in.

P: With this patient I identified a social support lacking, psychiatric stressors (depression/anxiety), lack of adequate community resource (lack of occupation), leading to compromised “functional status” and biomedical markers of inadequate health as seen by his recurrent syncope. I addressed how all of these factors tie together, and the patient expressed understanding regarding how he should proceed to give himself the best chance at good health.

[Dr. Nnodim]

Dear Kalyan,
Thank you for your excellent reflection. Great use of the biopsychosocial model of care to assess your patient. I am curious to your phrase “…I believe that this patient has brought on clinical problems to himself in part because of his own behaviors.” This could be interpreted as “blaming”. I think that the biopsychosocial model liberates us from the “blaming” approach to patients such as yours, because it helps us understand that addiction and mental health are diseases that cause physical and neurological changes which render these patients less able to make better life decisions than others. This understanding allows us to, therefore, explore more effective approaches to helping these patients and making a real difference in their lives. What are your thoughts on this, or perhaps I misunderstood you? Thanks for responding and bringing up such a good point.

[Author]

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