Topic #5 PSYCHOSOCIAL AND BEHAVIORAL DETERMINANTS OF HEALTH AND HEALTH CARE

[Brett Trzcinski]

SOAP Reflection:
Although we were unable to have our discussion this week on account of inclement weather I still found the learning case on psychosocial determinants of health to be a helpful framework to think about many of my patient encounters. Frequently while admitting patients to the hospital for a primary cardiovascular or pulmonary issue I find myself performing a medicine reconciliation which includes an antipsychotic or antidepressant. These issues usually end up toward the bottom of my problem list with language along the lines of “not in acute exacerbation = continue home …” However, often it is these issues that led to the patient being admitted in the first place or keep patients hospitalized longer. After going through this case, I intend to improve my patient care by prioritizing the mental health questions when performing an H&P, identifying the key components of a patient’s social support, and finding ways to involve them early (and more actively) in the patient’s care.

[Nabeel Rizvi]

Often times as clinicians we put more emphasis on addressing medical issues and can tend to overlook a patients social or mental health concerns. This caring with compassion case was an excellent reminder on identifying key components of a patient’s psychosocial network. The 5 domain model is an excellent method to use to help manage the complete health of our patients. I look forward to implementing this framework by asking the 1-2 screening questions in each domain to provide high quality care to my future patients.

[Hibah Ismail]

Every patient’s psychosocial environment is by far one of the most important factors affecting our patient’s adherence to medications. Often times we prescribe medications thinking that would solve our patient’s problems, however if we had not discussed and if we do not dig deeper into the whole psychosocial situation that our patients live in, it is more likely that the prescription will not be filled, the patient will not take the medication as prescribed, or the patient might not follow up. Therefore screening for mental illness should be part of our everyday encounters to make sure our patients receive the best care we can provide.

[Arslan Mahmood]

Psychosocial aspects of a patient’s life are equally important in maintaining his health. We as clinicians often don’t pay much attention to this aspect of the patient’s disease. Mental health should be addressed at every encounter by asking screening questions.

[Nadine Abdallah]

The contribution of psychosocial factors to a patient’s health was reflected in a patient I saw in clinic this week. He had consistently elevated blood sugars of 500s and he insists on being compliant with his prescribed regimen. However, on questioning it turned out that he was only using the short acting insulin and thought it was a mixed formulation. The patient lived alone, had no family or support system, and dependent on food stamps. This is in contrast to other patients I saw that week who came accompanied by their family members and had excellent control of their medications and health problems. After this encounter, I will try to ask more questions about the social situatiation and support system as this information is rarely volunteered. I hope that K will be able to help this subset of patients by simplifying medication regimens, decrease the number of meds to avoid polypharmacy and create more realistic goals.

[M Rauf]

Was not able to participate in the session due to clinic being cancelled. My experience with the US healthcare system is that, the system is costly and inefficient. We need to learn from countries with better healthcare. I believe insurance companies are an unnecessary middle man and need to be removed in order to make our system more efficient.

[Amjad]

Sam 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. Sam appeared to have strong spiritual support helping her overcome this period of grief. I had an honest conversation with Sam 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.

[Scott Smith]

Psychiatric health is a primary determinant of a person’s health. One patient of mine has schizoaffective disorder, which unfortunately has estranged him from his family. When he couldn’t keep a job he recently became homeless. Normally when people lose their home, they have family able to take them in but mental illness can burn bridges. He recently saw me in clinic and I signed paperwork so he could become the payee for social security, he will now be able to afford housing soon. He has luckily stayed very healthy. He told me that things are constantly being stolen from him in his shelter, if was had chronic medications to take which were always stolen from home, it would be very difficult to keep them secure. There are many people who advocate for the “housing first” model for aiding homeless people. By providing housing to a patient, their other issues become easier to fix.

[Lakshmi Pathai]

Psychosocial expect is one of the very important part of the general health. We, as a physician can play a minor but significant role by giving some time to understand the psychosocial expects and the barriers.
I had a patient with type 1 diabetes, multiple admissions with DKA, the patient was very hard to speak and she was rude to other medical staff including nurses, life stress practitioners, social workers as well as physicians. On her second admission in the same month for DKA, I spend an hour with her and discussed her social support and she mentioned that she does not have any social support and her family has abandoned her, she does not have enough money to fix her insulin pump which was broken a few months ago. She has to work to pay her bills and manage her medical expenses. As a physician, I counselled her about blood glucose control and the complication of diabetes and how we can avoid it. And I requested social worker support for fixing her insulin pump.
By giving time and understanding her situation, I believe, I was able to address the barrier and provide better care.

[Haris Younas]

The physician should be aware of the psychosocial issues of the patients. Sometimes patients might have some personality trait but they do not fit into any particular personality disorder. For example, your patient might be expressing “splitting” i.e one physician is completely wrong and the other physician is completely right. Similarly some patients show passive-aggressive behavior. Other patients might have a dependent personality and completely relying on the physician for every decision.
The most important thing for the physician is that he/she should not take these things personally. The physician should identify these traits and deal with them accordingly.

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