[Yellow Cohort] Module 3

[Adam Qazi]

Please submit SOAPs for Module 3:

[Muhammad Usama]

S:
I believe this week’s topic about determinants of adherence was very educational but often overlooked. I learned by reading the article and through discussion with my colleagues different factors impacting patient adherence. During my med school and before I started the residency, when I learned about medications which reduce mortality in CHF and CAD, I did not realize that despite mortality benefits of these drugs the literature shows that only 50 percent of patients discharged from hospital with these problems are prescribed/taking these medications, which reflects poorly on us being physicians and out health care system

O:
As I started this clinic week after reviewing the article my goal was to at the end of the encounter spend at least 10 minutes discussing with patients the importance of the medications they are taking, their side effects and particularly go through with them the medications which reduce mortality. Particularly for patients at risk for Atherosclerotic Cardiovascular disease taking statins I used to open ASCVD risk calculator and asked them to put the values themselves so that they calculate the risk themselves and then I used to interpret the results to them. Many of the patients told me that they never knew this information and now they feel like being partners in the treatment process and it has instilled in them the sense of being in charge of their health and more responsibility towards medication adherence.

A:
My assessment is that if physicians incorporate more patient engaging methods as mentioned above in their practice it would promote patients sense of partnership in the treatment and hence better adherence and compliance which in turn would result in better health of the community and decrease health-related costs.

Plan:
I will continue working on and looking for such methods which promote patient adherence to medications and spend at least 5-10 minutes in every encounter to ensure that.

[John Dawdy]

S: Patient adherence to treatment plans has been a challenge to physicians and an important part of the art of medicine for as long as it has been practiced. Our articles this week touch on patient adherence to medical therapies in terms of what barriers can be in place and how we can attempt to work around those barriers. This is a topic that is vastly important in our practice of medicine and something that we likely don’t pay enough attention to on a day to day basis. The best laid plans for medical care simply fall apart if they are not carried out. This responsibility falls most often on the patient to shoulder and unfortunately we do not always optimize their chance of success from our end. Rather, this often becomes an antagonistic relationship, leaving us thinking, “why didn’t they just do what I had asked.” Framing the problem as such has many faults and often perpetuates the underlying cause of the non-adherence that we see.

O: Keeping the different forms of non-adherence that are discussed in this week’s article by Jimmy & Jose, I sought to classify and understand why my patients in clinic this week were unable to adhere to their care plans. One such example was an elderly woman that was returning for “a blood pressure check”. I had not previously met this patient but she had very few serious medical concerns, the most prominent from her previous notes being her hypertension. Previous notes identified that she was prescribed two antihypertensive medications, first a calcium channel blocker and subsequently Chlorthalidone. The previous note gave me the idea that the resident was perplexed about why Chlorthalidone had failed to lower her blood pressure any further given the patient’s report that she was taking her blood pressure medication regularly. At her clinic visit with me her blood pressure was once again elevated to the same level as the previous two visits, and she said she was sure that she was taking her blood pressure medication. Luckily, she had brought all of her medications to the office. We reviewed each of these medications one by one and talked about their purpose. When it came to the Chlorthalidone she said that she was not taking this pill, which I inquired why not. She explained that it was a “water pill”, that she drank plenty of water and didn’t need any more. Her non-adherence was non-fulfillment and stemmed from a lack of understanding of the medication and treatment plan that she was prescribed. At this time I explained what “water pill” meant, that this medication was to assist in blood pressure reduction, and we came to an understanding about what it was that the previous resident had been expecting her to do. This knowledge will hopefully assist her in future adherence to this medication and help fulfill that initial treatment plan.

A: Unfortunately, patient adherence takes more than simply a prescription and a well-educated patient. As I’ve previously mentioned, even the best laid plans go awry. Despite our best intentions, there are many barrier to care plan follow-though, whether these be on our end as providers, the patient end, or health systems based. Even with excellent physician awareness of these issues we will continue to face barriers that limit the effectiveness of our care plans, but a better understanding and frequent reflection on these barriers allows us to plan around them and take them into account when developing care plans with our patients. It can no longer fall back on the paternalistic pattern of I’m the physician that knows what to do and you are the patient that is to do what I say, but rather a team effort to develop a plan that is workable and realistic to complete.

P: Forming the above team with the patient is often my goal in developing care plans and will continue to be so. This team effort does not always work, as some patients prefer to fall back on a paternalistic way of care, however, as our articles this week point out, patient that feel they are involved in decision making are more often to adhere to recommendations. Keeping this in mind, my challenge moving forward is to encompass this way of thinking into my clinic visits in an efficient and timely manner. This approach to patient care takes time, often more than what is ascribed to us in clinic. However, with further practice and concerted effort I will try my best to maintain this approach.

[Nabil Al-Kourainy]

[Yellow Cohort] Module 3 – Patient Adherence

S: The term “non-compliant” is often a tag line in an H&P or PN. It leads the reader to immediately form an impression, usually a negative one of the patient. Often times as physicians, we gasp when reading these words when seeing a patient for the first time, wondering what kind of challenges we are going to face and how we can break through this cycle. However, this kind of approach fails to take into account the reasons for non-adherence. Despite a physician’s best efforts some patients are not only resistant but steadfast in their resolve to refuse certain treatments. However, I submit that this is the minority of the non-adherent patients. Instead of approaching pts in this manner, and assuming they are simply “difficult”, the physician must instead seek to better understand the reasons for non-adherence.

O: As the articles rightly pointed out, there are a plethora of reasons for non-adherence, and it behooves the physician to consider these and to try to address them. These reasons include but are not limited to a lack of rapport with their physician, mistrust in the system, poor health literacy, concerns about potential adverse effects or side effects, and the reason that is universally dreaded, “I heard from a friend of mine that…”. After reading the articles I tried to employ a couple of the strategies referenced in the article. One pt was a 60 yo female who had previously refused screening exams and vaccinations, including the influenza vaccine. The pt reported to me that a girlfriend of hers had told her that she “got the flu from the shot” and because of that fear, she was refusing the vaccination. I first acknowledged her concerns and explained that this is a common misconception about the flu shot and that I was happy that she brought it up so that I could better understand what her concerns were. I then attempted to educate her, informing the pt that it was medically impossible to get the flu, from the non-live version of the vaccine. I further explained the difference between the live and non-live vaccines. I explained how the strains for the vaccine were decided, that it was a scientific approach and not just a ‘guess by a bunch of doctors’ like the pt had remarked to me. I also explained to her that some side effects from the vaccination, including cold-like symptoms were not only expected, but positive signs. She balked at this suggestion, however I went on to explain how the primary immune response worked and how generation of antibodies to influenza would give her a better chance of protection against the virus. She was still hesistant, so after my explanation, I tried to appeal to her instincts as a grandmother. She informed me that she had a nine-month-old grandson whom she was caring for at home. I informed her that according to the USPSTF, which I explained is a body of independent physicians who have no financial conflicts of interest, who get together based on the latest scientific research to establish guidelines that we as physicians employ to guide our recommendations. I explained to her that her grandson was at a fragile point, and that while she may be able to tolerate the flu, he was at risk of serious complications. After making this assertion, she agreed not only to the influenza vaccine, but also to herpes zoster. I was also able to get her referred for a mammogram and colonoscopy, both of which she had never had previously, due to non-adherence.

A: For my patient, I believe it was the acknowledgement of her concern and education about how and why the flu shot is made and why it is important, as well as appealing to her maternal instinct to protect her grandchild, that ultimately led to adherence. After taking the time to explain the how and why of the influenza vaccine, I found that the pt was more receptive to my explanations about herpes zoster, the need for colonoscopy and mammogram and other screening tests. In a short time I had established a level of trust with this pt which I hope continues into the future.

P: As physicians it is our duty to identify and address these potential barriers to care. The article was instructive on approaches that one can take including methods such as collaboration, simplification of medications, communication – explaining key elements about a proposed treatment or examination, as well as providing behavioral support. As I move forward in my medical career I will continue to employ these strategies to improve adherence, to see non-adherence as a challenge, and take it upon myself to make efforts to identify, acknowledge and address my pt’s concerns about a treatment, lab or study, and then seek to educate them on the how and why, so that together, we can come to an agreement which will be in the pt’s best interest.

[James Bathe]

S: what is my perception/feeling of the topic/encounters.
• Adherence to medical treatment has always been a problem in medicine. I’m willing to bet that everyone has had instances of poor adherence to treatment. Personally, I know it from refusing to take medications due to flavor as a child, to allowing a medication to run out and not refilling it, to just being bullheaded. However, adherence is a complex problem that isn’t just based on choice. Most of the time, it appears to be due to issues with complexity, lack of understanding, or miscommunication between provider and patient. I think it is vital that we assess and pursue increased adherence in our patients as treatments don’t work if they aren’t being used.

O: a summary of interventions/skills I performed.
• Assessing adherence through asking if they are still taking medications. Asking if there are issues obtaining medications or taking them. Providing resources when medication cannot be afforded.

A: my assessment of my performance/understanding/awareness
• I’ve been deficient in the past in checking adherence. The extent of most patients’ assessments is asking if they are still taking medications listed from their previous clinic visit. However, this is deficient in really assessing adherence in some patients. Spending time identifying patients at higher risk of non-adherence would help target the longer process and make it much more high yield.

P: My plan for improvement or new challenges.
• I will spend time assessing for patients who take medications more than once a day and more than 3 medications and working through how really adherent they are. Asking about when medications are taken, if they’ve missed doses, and assessing for other complaints which make adherence difficult.

[Shivani]

S:
Adherence is a term we often use to describe a patient following our prescribed regimen. One faculty member suggested using adherence instead of compliance when explaining why a patient failed treatment. It is often multifocal why a patient is not able to follow through.

O:
I had a patient this week in clinic who I have seen on several occasions. During the four-week block between clinic weeks, I was contacted that her insurance company wanted pre approval for a specific test. The test was ordered by a sub-specialist, this test was indicated for this patient. However, the insurance company wanted another test performed first. I went to speak with the sub-specialty faculty about the test who agreed the original test was the correct one. I called multiple phone numbers for the insurance company/appeal line but ultimately was not successful in obtaining the approval for this test. I felt despite the patient’s best efforts to obtain this test and my follow up with the various numbers, we were not able to get the test approved. This clinic week I referred the patient back to the sub-specialty for further discussion and follow up.

A/P:
This clinic week I experience a situation where the patient was motivated to get her test but the insurance company was serving as a barrier. I understand health care costs are rising and insurance companies need to regulate resources. However, the insurance company made it impossible to obtain a resolution for the patient despite me following all the instructions. I will continue to advocate for my patients to do what is best for them.

[Deya Obaidat]

social determinants Week 3

S: patient’s well-being is our ultimate goal as physicians, and one way to achieve that is to identify diseases and try to treat them with giving medications, and in order for us to be sure that we are heading in the right direction when it comes to that we need to make sure that our patients are taking our medications, although I don’t have the longest experience when it comes with dealing with patients but I’ve noticed that there is a lot of patients (I would say 40-50%) not taking the medications as instructed by their PCP or me, in a lot of times it is a misunderstandment (like stopping taking an antibiotic because the patient is already feeling better) or simply because the patient doesn’t feel that he needs it, which leads to my story with one of my own patients that i’ve seen in this clinic this week, she is a female in her 50s which has an established diagnosis of Lupus and Lupus nephritis and has been recently admitted to the hospital for a flareup, and at the discharge time she was sent home with a high dose of prednisone among other 10 medications for different comorbidities, and along with the high dose steroids ( which was prescribed for a long time) they gave the patient Bactrim as a prophylaxis measure which has been proven in the literature that it can decrease the incident of opportunistic infections in people who take high dose steroids for a long time, the patient when I saw her mentioned that she is not taking the bactrim and when I asked her about the reason behind that, she said that she thinks that she doesn’t need it specially that she is taking another 11 medications along with it, and she said that she doesn’t want to take another medications for “Just in case” situation, as she was feeling that too much medications to be taken would be harmful for her body, I sat down with the patient and explained the importance of such a protective measure, and while carefully explaining the need for the other medications and how we can come up with a long term plan to decrease the number of the medications that she is taking at the moment, along with that I talked about the importance of the bactrim and what it is supposed to be doing and talked a little about the side effects of the medication. patient was understanding the situation, but unfortunately was still not agreeing on taking the bactrim.

O: a lot of studies talked about the compliance of the patients when it comes to the reasons and ways to fix the issues with the non-adherent patients, one study said that almost 40 % of the patients sustain significant risks by misunderstanding, forgetting, or ignoring healthcare advice, which makes it even more challenging to the physician to follow up with the patient’s medical condition to obtain the maximum expected results from the management offered to the patient. the study also suggested that the success of the methods used depends upon tailoring interventions to the unique characteristics of patients, disease conditions, and treatment regimens and that there is no specific intervention that has been proven to have a better effect on the patient’s adherence

A: patients adherence to their medications is a serious problem that physician need to address and solve with their patients to gain the ultimate benefit from the management plan offered for the patient

P: as part of routine visit I always ask whether the patients are taking their medications and whether or not that they have any concern regarding any medications, but for now I’m going to use different methods with my non-adherent patients to try to achieve the ultimate goal of healthcare, depending on the patient personality, reason for non-adherence and the type of education I’ll start addressing the patient’s concerns regarding their medications so they can have a better understanding of their medications and why they are taking them to begin with.

[Marvin Kajy]

Subjective:
The topic of this week dealt with the concept of patient adherence. Adherence may be defined as the extent to which a patient’s behavior (in terms of taking medication, following a diet, modifying habits, or attending clinics) coincides with medical or health advice Adherence has always been a problem in medicine. A patient comes to the physician for an issue. The physician gives the patient a specific set of instructions on how to deal with said issue. Then for personal or financial reasons, the patient does not carry out the instructions. It is very easy for a doctor to become frustrated with the patient and label the patient as “difficult” and “non adherent”. However, physicians often overlook a patient not taking any medication could be multifactorial in etiology. Potential reasons could be lack of understanding of directions, no transportation to and from the pharmacy and unable to purchase medications. Sometimes, the reason could be as simple as not agreeing with the physician.

Objective:
There have been numerous studies published about patient adherence. For example, one study looked at treatment adherence and how it is affected by physician-patient communication. They found that physician communication is significantly positively correlated with patient adherence; there is a 19% higher risk of nonadherence among patients whose physician communicates poorly than among patients whose physician communicates well.
Another study looked at the effect of social support with patient adherence to medical regimens. They found that adherence is 1.74 times higher in patients from cohesive families and 1.53 times lower in patients from families in conflict. Interestingly, marital status and living with another person (for adults) increase adherence.

Assessment:
This week, I had a follow up visit with a patient after starting him on COPD treatment 5 weeks ago. The patient was admitted for COPD exacerbations monthly. We started him on the appropriate inhalers, told him to quit smoking and referred him to outpatient PFT and 6-minute walk test. The patient took used his inhalers as prescribed. However, he did not follow up on the outpatient tests. When asked about why he did not perform these tests, the patient replied that he felt great. He is breathing much better and is able to do all his previous activities. He did not think there was a reason to pursue such tests.
I wanted to illustrate this case because it demonstrates how patient “tailor” their own recommendations. The patient decided to follow up with the medical regimens, but declined to do the outpatient tests. The first thing I did was complimenting him on using his medications as prescribed and cutting the smoking. I emphasized the importance of these tests. I explained to the patient that these tests will help further fine tune his medicines. This will allow him to make even greater improvements. The patient expressed understanding and he said that he will follow up with these tests.

Plan
Current methods of improving medication adherence for chronic health problems are mostly complex, labor-intensive, and not predictably effective. Low compliance to prescribed medical interventions is an ever present and complex problem, especially for patients with a chronic illness. I think that the main tool the physician has at his disposal is education. Education not only to the patient, but also to family members that accompany the patient. It took me 4 years of college and 4 years of medical school to understand what COPD is. Imagine explaining that to a patient in a 20-minute time window.
During our group sessions, a question was raised about whether we get frustrated and how to cope with that. However, that question is invalid and will not change management. As a doctor, you cannot become frustrated because that may impair patient treatment. A doctor is not only seen as a healer in the community, but also as an educator. The best thing that we can do is explain the medical condition and explain how the medical treatments can improve their quality of life. This will help the patient to become a partner in his own care.

[shanker kundumadam]

S : this week the articles dealt with the adherence. it distinguished adherence from compliance. It also mentioned the different types of non adherence and also measures to improve upon the same

O : I had a patient this well who had a fib (chronic ) and has been on elquis for the same. He said he hasnot taken the same for the last 2 days as he ran out of them. when asked why he said the copay is 200 dollars and he cant afford it. He didnt want to go back to coumadin nor did he want lovenox. We managed to give him free samples and he mentions he gets samples from cardiology clinic too. i tried to explain to him how there may be times when we may not have samples and that he may have to consider other options for anti coagulation too.

A : medication cost is a big factor for non adherence, despite having the insurance and having the guideline based indication patients most of times dont get the right medication. cheaper options have higher rates of non adherece. IN these situations we may have to 1. look for other options as free samples 2. educate the patient to anticipate that there maybe times when there wont be samples and make the prepared for a switch

P :
I plan to make sure that when i discharge a patient from the hospital that it is 100 % sure that the patient can afford the costs before i send them out on an expensive medication hoping that they will keep getting free samples

[Kalyna Jakibchuk]

S: Patient adherence is something every clinician hopes to understand better I think. It is difficult to understand why some patients are able to follow through with a treatment plan and others are not. I think that asking the patient is a great first step. I also agree with some of the other techniques mentioned in the literature including: greater patient involvement in creating a plan and decision making, and creating simpler paths for patients to get imaging or referrals.

O: I had a patient this week, and multiple weeks, that came in not having completed an imaging study. We had discussed it at the previous visit, I had printed out the order form but somehow it didn’t get done. When I thought about it there were a lot of steps in between that I could not account for. For one, I didn’t even know if the patient was to call to arrange the imaging herself. As residents we were told that the front desk will direct the patient accordingly for images and referrals. How do I know that my patient even stopped at the front desk or that the clerk provided this information? Or did the patient forget? Or did radiology get booked up? The fact is that when there isn’t adherence time and sometimes money is wasted repeating tasks that never lead to an end point.

A: I understand the concept of non-adherence, but I don’t always understand why it’s happening and honestly I’m not sure that I am identifying it in all my patients. Sometimes there is misunderstanding and it is not obvious. One patient was taking an SSRI prn when she was feeling depressed. If she hadn’t told me she was taking it that way, asking if she’s taking the medication wouldn’t have revealed this.

P:Going forward, I would like to ask my patients in a non-judgemental way why they decided not to take a medication or why they weren’t able to follow up with a plan. I would like to involve my patients in plans and provide more opportunity for questions. I think that the more care providers can be involved, the better. For example, I may go over a plan for treating knee pain with a patient but perhaps I will forget to suggest that my patient take the NSAID with food, but the pharmacist explains this to the patient, and the clerk explains exactly how the knee xray will be arranged.

[Jie Chi]

Module 3 – Patient Adherence

S: Quality healthcare outcomes depend upon patients’ adherence to recommended treatment regimens. Patient nonadherence can be a pervasive threat to health and wellbeing and carry an appreciable economic burden as well. Our articles this week put emphysis on patient adherence to medical therapies rather than patient compliance. This is a topic that is vastly important in our practice of medicine and something that we likely don’t pay enough attention to on a day to day basis.

O : I had a patient with PMH of CAD, who is also a frequent flier for CHF, came in for NSTEMI, he wasn’t compliant with ASA or any other medications. After a stent put in he was labeled as high risk and Brillinta was started. Instructed on the importance of the medication and discharged. Pt came back 1 week after with another heart attack. He states he hasn’t taken any brillinta, which was brought to his hands upon discharge.

A: While no single intervention strategy can improve the adherence of all patients, decades of research studies agree that successful attempts to improve patient adherence depend upon a set of key factors. These include realistic assessment of patients’ knowledge and understanding of the regimen, clear and effective communication between health professionals and their patients, and the nurturance of trust in the therapeutic relationship. Patients must be given the opportunity to tell the story of their unique illness experiences. Knowing the patient as a person allows the health professional to understand elements that are crucial to the patient’s adherence: beliefs, attitudes, subjective norms, cultural context, social supports, and emotional health challenges, particularly depression.

P: So not only I will educate my patient to understand what they are supposed to do before they can follow medical recommendations, I will also spend time to understand what are the barriers of their inadherence. I need to make patients trust that I am someone who can understand their unique experience of being a patient, and someone who can provide them with reliable and honest advice.

[Marc Vander Vliet]

Subjective: I feel like I have a little more patience with adherence than some of the other challenges we have in internal medicine. Some of our patients are on a lot of medications; the science is complex; the names of the medications are quite long; and, even without barriers such as concerns about the side effects of medication or the accuracy of the patient’s diagnosis these factors can provide a significant challenge.

Objective: The article points out may reasons for non-adherence. The greatest challenge we have with our patients is figuring out these reasons in a short clinic visit. Patients may not always realize they are non-adherent, they may not have the health literacy to easily engage in dialogue in these matters, and there may also be other reasons, such as suspicion of the health care system, that they are not forthright with explaining. I have a patient that has stopped to the clinic twice with complaints of left foot pain. She has previously had autoamputation of her left big toe and looks to have a continuing issue with osteomyelitis. She comes in specifically asking to address issues of pain. Both visits I have explained to her the importance of seeing podiatry, and when, I was unable to arrange for a same day podiatry visit, she declined to go the emergency room both times for a problem that is clearly worsening. I explained to her the likelihood that the longer she waits the more likely she will have to have further surgery or even have worse complications. Her last visit she simply told me that she didn’t think they did much for her when she went to the hospital last time and continues to decline follow up in the ER for a problem for which treatment cannot be delayed. She is decisional, but there is still something clearly missing in our dialogue as to why she declines follow up (she has thanked me both times for seeing her, asks for Norco again, and then leaves without following up). I know that she has transportation challenges and that this might be part of the reason for her poor follow up but she always leaves me with the impression that she will be going to the ER after our office visit. This is an extreme example, but it shows that patients are complex, and despite knowing the barriers that exist we can still have a hard time identifying what the root cause of non-adherence is and how we can motivate patients to be adherent.

Assessment: I think it is important to continue to develop interviewing skills that can be used to identify reasons for non-adherence and apply those to patients to find ways to improve adherence.

Plan: I am going to make a mental note that when things don’t go the right way I will try to identify and document the reason for non-adherence and identify a plan to overcome these obstacles.

[wsumed]

The Will to Believe by William James · 9781438520810

[Author]

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