[Yellow Cohort] Module 1, 2018-19

[Nabil Al-Kourainy]

Reflections here

[Nabil Al-Kourainy]

After reading the two articles for this week, I am struck by the fact that Social and Environmental Factors account for 20% of total health and wellbeing. We know that SDH have a significant impact on health outcomes including morbidity and mortality as well as functional limitations. In the past I was aware of these SDH’s and the effect that they have on the lives of my patients, but after reading these articles, I have a greater appreciation for my role in a patient’s SDH. While I cannot change the health coverage for a patient, if he/she does not have insurance. I can do things like prescribe medications that are low cost or no cost to patients. While I have been doing just that over the past year, I did not realize that those efforts were apart of a pt’s SDH. I have made great use of the Walmart $4 formulary and other formulary offers for prescription meds which among other things allows me to treat several of my diabetic patients with low cost $28.00/month of Insulin 70-30. Meijer provides Metformin and Atorvastatin for free. And, more recently, I have started using GoodRx to show my patients who are without insurance, or in some cases with insurance but with higher copays, a way that they can afford their medications. In addition, I try to provide high quality of care to all of my patients, by listening to their concerns, and triaging the most pressing medical issues. I also have recently been phoning patients that I have started on new medications, to check on their progress, lifestyle modifications and potential side effects. In this way I have been increasing the provided availability.

I have learned that the individual physician can play a big role in improving the health outcomes of patients, through employment of the above strategies. I will continue to use these whenever possible, remembering to ask my patients about their finances and transportation available to them, because they may not freely offer this information. By being attentive to my patient’s needs in this manner, I hope to positively improve their overall health and quality of life.

[Abubaker Hassan]

Thank you, Nabil for sharing these important practical tips.

[Shivani Agrawal]

I just finished reading the book DopeSick by author Beth Macy. The book talks about the opioid endemic in America. It details the use of oxycontin and how the drug manufactures targeted physicians to prescribe their drug through gifts/advertising. The drug company was not honest about the abuse potential and risks of this medication. The author writes about how lives were changed due to opioids. Often, the prescription started legally after a procedure or medical issue. Once the doctor stopped prescribing the medications, due to addiction- people started turning to illegal sources to obtain pills or heroin. The book was very heartbreaking and reminds us to “do no harm”. This week, as often happens in clinic, I had to deny a controlled substance to a patient. Reviewing the MAPS report of this patient, there were prescriptions from multiple providers. Although the patient wanted the prescription, that was not in their best interest.
We now have to difficult and crucial conversations with patients about controlled substances. As part of social determinants of health, I know many of our patients have extreme stress in their lives (financial, access to resources, housing, transportation). They may feel that the use of opioids and benzodiazepines is helpful but that may not help them in the long run. Overall, the book reminded me of the situations many patients are in and the reminder to always do what’s best for the patient.

[James Bathe]

Social determinants of health have huge impacts on our patients. While SDH affect everyone, we see particularly affected patient populations where intersections of different factors crash together and create huge waves of inequity in our patient’s health. I recall that a colleague who had left the DMC came to me begging me to leave. They reported that other systems are much more well funded, the patients have more resources, and everything seems to go much smoother. She told me that it was so much easier to work elsewhere. And that really struck a chord with me; it’s much easier to leave the problem behind for easier populations. How many physicians leave the Detroit area or even inner cities in general for patient populations that have fewer SDH complicating their care? Is it right to do so? Or is it a morally dubious choice that physicians make for their own comfort? I don’t know the answer for everyone, but in the past year, I personally would rather work in this patient population due to the large disparities our patients face. I feel like I can help more here. And with eyes towards the impact of the SDH on our patients, perhaps we can all work together to change the situation here for thousands of people. To minimize the impact of SDH while optimizing care is a worthy goal we can all strive for.

[Adam Qazi]

Social and environmental factors account for 20% of risk of premature death. When broken down, there are some sub-factors within this category that we as physicians cannot control (eg, economic stability) and some that we can, notably in the health care system and community/social context subcategories. Studies have continually shown that minorities have poorer health outcomes even after adjusting for social economic levels and education. Infant mortality for black babies is still twice that for whites (1, 2). A black baby born to a black mother with an advanced/professional degree still has similar rates of death as a white baby born to a mother with an 8th grade or less education. A black mother has over twice the risk of dying post-partum than any other race (3) even when their life’s research is focused on the study of racial disparities (4). Why is this? Does living as a racial minority, especially a black minority, increase rates of basal stress? Are we as health care physicians treating black versus white patients differently? If so how? And why?

While I cannot change the color of my skin, I can become more aware of the implicit and explicit biases I project to my patients. Being more aware of these outcome disparities in the future will make me atune to how I may be treating my patients differently.

[Marvin Kajy]

The field of the social determinants of health is very complex as it is concerned with key aspects of people living conditions, working circumstances and their overall lifestyle. No where is this perhaps more evident that than in the city of Detroit. Patients are often forced to make decisions between paying for a medication or paying for food to provide for the family. After working in Detroit for over a year, it is very apparent to me that the health literacy of the population is very low. Patients often arrive to the ED having no clue what they are diagnosed with or what medications they are on. When the patient arrives to the hospital in critical condition, we do an amazing job at making the patient better. We use very expensive medications and perform advanced procedures to preserve life. Yet we spend little time educating the patient (the cheapest intervention). It is no secret that the US ranks as the highest nation in terms of health care expenditures. However, our health care outcomes are modest at best when compared to other first world countries. This alone should have been a wake up call a long time ago that something is wrong in the American Health Care System structure.

The best and most cost effective action that a physician can do is educate the patient regarding his/her medical condition. For example, if a patient comes to the hospital for a STEMI, s/he can be expected to be discharge on at least new 5 medications. This can especially a big change especially in a patient who was in perfect state of health before and never saw a doctor. As I have progressed through my training, I have noticed that more and more time with patient to educate them about their medical condition and the purpose of each medication. I have realized that the patients get more comfortable with what they are diagnosed with and how to self manage their own exacerbation. For example, I tell a heart failure patient to weigh themselves every day and if they gain too much weight, then they should take an extra lasix. Or for the COPD patient, if they are cough and bringing up sputum, then they should immediately go to their PCP for evaluation. These are attempts to avoid hospitalizations and lessen the burden on the health care system

In conclusion, the goal of the 21st century physician is to beyond just “treating the patient”. It is more and more apparent that a physician has to promote awareness, debate and action, with the goal of developing laws and policies that specifically address the root causes of illness, healthcare disparities and the needs of the patients affected by poverty and social disadvantage.

[Eskara Pervez]

I had a patient yesterday, 26 year old female, with uncontrolled Diabetes mellitus and hypertension on the verge of obtaining disability because she was almost blind from diabetic retinopathy. She also had CKD IV and she had never seen a nephrologist.She has been taking care of herself since she was diagnosed at the age of fifteen. At this visit she wanted a referral to to Social worker as she was homeless and was sleeping on the floor of her mothers home.
How did she develop microvascular complications of her diabetes at such a young age? 26? Poverty. Lack of education.
Essentially, the social determinants of health are all of the external factors that affect health outside of the doctor’s office. These factors are critical to understanding patient health and care considering that nearly all of a patient’s life is lived outside of the clinic’s four walls.
Understanding certain social factors will help providers better target their patient outreach and engagement efforts. From identifying patients who need more community support to overcoming obstacles keeping patients from receiving the care they need, a comprehension of the social determinants of health will help providers deliver better person-centered healthcare.

[Hammad Ali]

SDH come in to play in all socioeconomic groups. Given the population we cater for we not only have the low socioeconomic class but also the group of people who have been racially maligned for centuries. This has resulted in fostering distrust in the patient population towards those in positions of power (doctors in our case), and the Tuskegee syphilis study fall out only reaffirmed their suspicions.

So every time I have a patient who, is lucky enough to have insurance which covers their prescriptions and has easy access to pharmacy to get their medications, if still they stop taking their medications then this points to one either lack of insight in to their disease process and treatment or an underlying mistrust that we (doctors) are giving medications that they don’t need.

Establishing a repertoire with the patient would go a long way in alleviating this distrust. However, since it has fostered over so many years it will take time for it to die out, till then all we can do is not get frustrated by it but try to understand where our patients are coming from and patiently advocate the treatment plans to our patient.

[Deya Obaidat]

In a fast changing world only few things seems to be shared between people from all races, socioeconomical status and genders. and despite that there are no people alike in this world, that doesn’t mean that people should be treated differently just because they different. In a world where the amount of money that you have in your bank account decides what kind of car you drive, house you live in, education you get we shouldn’t let that affect the health care that people from different races, genders and socioeconomical statuses get.

for me personally, I think education plays the biggest part when it comes to getting the health care needed, as initially it may prevent disease as educated people tend to exercise and have better diet than uneducated people, they also have less smokers and drug abusers rates and they seek medical attention to get preventive medicine such as vaccines. education also affect your health by making you more likely to have a job, and despite that means that educated people might have more exposure to hazards and stress, it also means that they are able to get health insurance, more income and even can obtain sick-leaves when they need them, and by the end of the day educated people have more social support from their social network which helps them out through times of stress and illness.

I believe that everyone should have an equal opportunity to achieve their best health-care possible, and despite it being extremely difficult to provide everyone with health insurance and higher education along with with sufficient monthly income, I suggest start educating people in those unfortunate areas about the importance of living a healthy life to prevent diseases and be in a good state of health, we can do that by doing multiple free seminars on multiple healthcare topics which they will relate to, and despite that not being enough to achieve the full equality by getting equality in healthcare between different groups in country but it is surely a start there, as these kind of seminars might drop the rates of drug abuse and smoking and increase the rate for seeking preventive medicine.

[John Dawdy]

Although we spend many hours during our training learning medical facts and guidelines in order to best treat our patients, we often skim over the many other factors that are involved in order to deliver optimal medical care. Those other factors, the social determinants of health, impact the delivery of medical care to all of our patients in some fashion. Whether it be socioeconomic, political, racial factors that limit a patient’s ability to receive care, these need to play in our decisions as providers. This course seeks to either make us aware of or remind us to check our decisions and keep these factors in the forefront of our mind while we are in clinic or on the wards. We can all think of one patient that was particularly difficult in some fashion due to their social factors, but it’s also important to remember that each of our patients has some form of barrier that must be overcome in order to optimize care.

[Muhammad Usama]

It’s startling how strongly someone’s health and longevity can be influenced by where he or she lives – a person’s ZIP code is a stronger predictor of his or her overall health than other factors, including race and genetics. And it’s not just life expectancy – access to care, access to health information, and quality of life are all affected by where one lives. You don’t need to travel far, or at all, to see the neighborhoods that have been left in the past. Some of our largest hospital systems are in the same urban communities that are burdened by these staggering mortality statistics – you can literally stand in the hospital lobby, open the doors, and gaze outside upon a neighborhood that experiences 1950s-quality health outcomes. You can travel even further backward on the health quality timeline by walking a few neighborhood blocks.
I recently read about the term “Delmar divide” on an article published on Harvard School of Public health website.
https://cdn1.sph.harvard.edu/wp-content/uploads/sites/21/2014/07/Delmar_divide470x313-470×313.jpg
“In St. Louis, Missouri, Delmar Boulevard marks a sharp dividing line between the poor, predominately African American neighborhood to the north and a more affluent, largely white neighborhood to the south. Education and health also follow the “Delmar Divide,” with residents to the north less likely to have a bachelor’s degree and more likely to have heart disease or cancer.”
It was only after I started working in Detroit that I started understanding the Social determinants of Health and how important are they in determining one’s health. But I am just at the beginning of this journey where my understanding of this subject has started to positively affect the patients I serve.

[Lea monday]

Clinic was really hard this week. I had one patient who’s son and daughter in law were shot in cold blood on their front lawn. His grandchildren witnessed the event and ran for their lives. He had a nervous break down and was in a psych hospital for 2 weeks. All his medications got changed around so we worked to make sure they were safe. He really didn’t need to come back in 5 weeks but I decided to have him come back so we can talk more and just to be a source of support and stability for him.

[Justin Gatt]

One of the biggest reasons I chose to stay in Detroit for residency was the opportunity to continue working with the population in our city. Unfortunately, access to things most of us don’t think twice about like transportation, payment for medications, or family support is often difficult to come by for many in Detroit. Patients oftentimes have not seen a physician in many years and have not maintained compliance to medication regimens leading to disease progression not seen in many areas of the country. As doctors in Detroit, we have a chance to make an enormous impact in patients’ lives, more so than many residents in other states. While we cannot change certain problematic aspects of the healthcare system of our country, we can do our best to support patients in our city and take the time to work with them on establishing a clear plan for each medical problem they have. It is essential to dedicate a few minutes of each patient visit in clinic to discuss the patient’s social situation and whether they have anything preventing them from obtaining the best care possible.

[Dana Kabbani]

A few Detroit statistics:
-In 2015, Detroit’s infant mortality rate was 13.6% compared to 6.1% in Wayne Country, excluding Detroit, and 6.8% in Michigan
-The obesity rate in that same year was 37%, compared to 31% in Michigan
-The diabetes rate was 14.6%, compared to 10.4% in Michigan
-Lastly, 18 percent of Detroiters reported poor mental health on at least 14 of the past 30 days, compared to 12.6% in Michigan

Some of the factors that impact these statistics are lack of education, health insurance, as well as socioeconomic factors. The first article discussed the social and environmental factors that impact health care.

[Mahvish Khalid]

Education and socioeconomic standing are two of the biggest factors that may help explain the health disparity among different demographics within the Detroit Metropolitan area.
Education has an enormous impact on our lifestyle and the choices that we make on a day to day basis. Exercising regularly, getting a good night’s sleep and eating a healthy, nutritious diet are habits we adopt as we are educated about the human body and as a direct consequence of our surroundings.
Socioeconomic standing plays a vital role as well. For example, organic food is so much more expensive when compared with fast food which is also so readily available. Secondly, people falling at the lower end of the socioeconomic spectrum lack proper health coverage and often delay treatment until the problem gets significantly worse.
Extreme income disparity and not having access to quality education therefore, have far reaching consequences when we look at their impact on a person’s health and mental well being. While these challenges are extensive, we can do our part by taking the initiative to promote healthy living. Whether it’s taking a stand on political issues of living wages and income inequality or creating awareness about health consequences of one’s lifestyle, ours can be a voice that makes a difference.

[Sahrish Ilyas]

Just as the article details inequalities in health amongst different nations of the world, such inequalities similarly exist within the state of Michigan, largely due to the common social disparities that exist ubiquitously (i.e lack of education, lack of financial resources). On a daily basis, we, as training physicians, see the challenges faced by the people of Detroit and thus it is imperative that we improve the communication gap with our patients. Often times our patients will not elaborate or go into more detail than they feel is necessary and most of what isn’t said is lost in translation- and the majority gets interpreted as “non-complaint patient.” As I have learned to engage with my patients more about their social environment and available health resources, it has become more evident that the social disparities play a tremendous role in overall health. Simply stated – we need to be better listeners and we need to come up with a dynamic health plan for our patients that takes into account the disparities. The commonly recurring issues : 1. Lost insurance for some time, following up after several years – now discovering completely uncontrolled non-communicable diseases 2. Lack of transportation! plays large role in our patients missing many of the subspecialty appts we set them up with. 3. Lack of income/financial resources

[Aliza Rizwan]

Social determinants of health are the conditions in which people are born, grow, live, work and age. Addressing social determinants of health is important for improving health and reducing health disparities. There has been increased recognition that improving health and achieving health equity will require broader approaches that address social, economic, and environmental factors that influence health. Although health care is essential to health, it is a relatively weak health determinant. As a physician we are responsible to care for our patients not just to an extent to treat their diseases but to be there as a counselor whenever they need us.
There is growing recognition that social and economic factors shape individuals ability to engage in healthy behaviors. For example, children born to parents who have not completed high school are more likely to live in an environment that poses barriers to health such as lack of safety, exposed garbage, and substandard housing. They also are less likely to have sidewalks, parks or playgrounds, recreation centers, or a library. Further, evidence shows that stress negatively affects health across the lifespan and that environmental factors may have multi-generational impacts. Addressing social determinants of health is not only important for improving overall health, but also for reducing health disparities that are often rooted in social and economic disadvantages.

[Syed Umer Mohsin]

Social determinants of health play a very vital role in the healthcare system. It can determine if a patient can get to healthcare, receive medical attention, adhere to medications and follow-ups. This is especially true for a population such as ours in the city of Detroit. There are many factors that play a role in the choices our patients make regarding the healthcare. Recently I was taking care of a patient who made some concerning choices regarding his health due to circumstances he was placed in.

My patient was a 26-year-old Caucasian male who was in the hospital 8 months ago due to infective endocarditis secondary to IV drug use. He also developed septic arthritis due to bacteremia. He ended up having a tricuspid valve replacement and prolonged IV antibiotic course. He was discharged to a rehab facility for his IV drug habits. He ended up completing a few months in rehab but had to be discharged from the facility due to insurance issues. Because he was homeless, he ended up on the streets again. His circumstances made him vulnerable to IV drug use. He took up drugs as well as had unprotected sexual encounters. He, unfortunately, readmitted to the hospital with endocarditis involving the same heart valve. He was reevaluated by cardiothoracic surgery and deemed high risk for a second valvular replacement. In this admission, he was also diagnosed with HIV. The complexity of his health problems made his mortality 50% without valvular replacement and 30% with valvular replacement.

This patient is a prime example of how social disparities can play a major role in a patient’s health decisions. This is one of the many unfortunate individuals we encounter on daily basis. As healthcare professionals, we should be vigilant towards social determinants of our patients.

[Jared Goldberg]

One thing that stands out to me regarding social determinants of health is how easily they can be misconstrued. Clearly, many, if not most of these factors are systemic. While some of the biggest barriers originate in individual behavior, our articles are quick to point out that individual behaviors themselves are heavily influenced by external factors. I cannot speak for any of my co-residents, but throughout my life and certainly throughout my medical training I have encountered medical students, residents, attendings, nurses, and others who seek to blame patients 100% for their own health problems and who seem to be unable to consider other factors that might influence behavior. Sadly, these people vote for politicians that put forth and support policies that make addressing social determinants of health that much more difficult. Internal medicine residents should not be the only ones that should be having these discussions and reading these articles; multiple providers from multiple disciplines should as well.

[wsumed]

The Collapsing Empire – John Scalzi – 9780765388902

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