[Leslie Kao]

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.

[Leslie Kao]

From Ali Saker:

If we take the effort to ask our patients about their access to food. People feel ashamed to share unless they get asked. SDH has a multigenerational impact. Our job is to work teaching patients about different resources put in by the state for the community, educating patients especially who has Medicaid and Medicare about free transportation offered by their insurance, and possibly grouping their appointments on the same day, and grouping family’s appointments on the same day. That will help achieve a better show up rate and better overall health. IF we are moving forward to recognize these health problems, that would increase the overall population health. If children are born to low socioeconomic status families, the lack of education will have significant correlation to health outcomes which is frightening.
I believe to improve healthcare in general, we should ship healthcare funds to increase the social support in order to address the invisible link of SDH.

[Leslie Kao]

Submitted by jahid:

Ms. J is a 54y/o obese woman with HTN who presented for health maintenance. She lives in AFC home, and has been adherent to bp medications. She presented with no acute events, she is not a smoker nor does she drink alcohol. Social Hx consist of former smoker, illicit drug abuser and has been drug free since Dec. 2015. To date Ms. J has had a difficult time maintaining normotensive levels in bp just above 140/90s. Unaware of the dynamics of her housing, I discussed DASH diet and importance of daily exercise. When she being to explain the meals that are prepared for her, I realized how can I educated a woman who currently doesn’t have control of the food that is provided and prepared for her. Additionally, the daily activities that are schedule for her as a member of the AFC home, cleaning the house and her job working as a janitor cleaning a concert stadium contributed to my lack of appreciation for her living dynamics. Prior to being place in AFC home she had been unemployed living in shelter.

Objective
As the article entitle “Social Determinants of Health Inequalities,” stated “a focus on material conditions and control of infectious disease must not be to exclusion of social determinants. The circumstances in which people live and work are important for communicable as they are for non-communicable disease.” In Ms. J case I thought of ways she could improve are activities of daily living that could benefit her health. I told her to ask for more of the green leafy foods in proportion to small size of other items on her plate. While working take breaks walking up and down some of the stadium stairs every other day in addition to routine work. My plan with next clinic visit to find health affordable snacks she my request or even purchase.

Assessment
I realize I don’t have an idea of what is provided in an AFC home or any transition housing system that may have a positive or negative effect on the health of my patients.
To effectively address my patient issue it is necessary to gain knowledge about limitations that may alter course of patient care. As stated in the article “Social Determinants of Health Inequalities, “treating existing disease is urgent and will always receive high priority but should not be to the exclusion of taking action on the underlying social determinants of health.”

Plan
My plan is to learn more about the settings of AFC homes and how they help manage heal thing living for their occupants.

[Leslie Kao]

Submitted by Lubna Fatiwala:

Subjective:
This week during Friday reflections we identified an interesting factor influencing health disparity within our patient population. Education. We discussed the impact of education on the health literacy of our patients. The question we had at the end of this was the degree of influence of education over a patients understanding of their health factors and the level of compliance associated with this understanding.

Objective:
An interesting study in Pubmed analyzes “The relationship between health, education, and health literacy: results from the Dutch Adult Literacy and Life Skills Survey.” (https://www.ncbi.nlm.nih.gov/pubmed/24093354) The study aimed to study whether health literacy could be a pathway by which level of education affects health status. Health literacy was measured by the Health Activities and Literacy Scale, using data from a subsample of 5,136 adults between the ages of 25 and 65 years, gathered within the context of the 2007 Dutch Adult Literacy and Life Skills Survey. Linear regression analyses were used in separate models to estimate the extent to which health literacy mediates educational disparities in self-reported general health, physical health status, and mental health status as measured by the Short Form-12.

In conclusion Health literacy was found to partially mediate the association between low education and low self-reported health status. As such, improving health literacy may be a useful strategy for reducing disparities in health related to education, as health literacy appears to play a role in explaining the underlying mechanism driving the relationship between low level of education and poor health.

Assessment:
The external validity of this study to our patient population maybe limited as it was conducted in a different socioeconomic environment, with a primarily European patient population. However it did point out a positive association between Education and level of personal well-being.

Plan:
As a practicing physician in the metro Detroit area, when evaluating my patients, I can gain a cognition of the level of education of my patients and ensure a clear understanding, clinical reasoning and communication pathway exists between us, so that the patients can feel comfortable to bring up all of their questions and concerns.

[Leslie Kao]

Reply by Chyrisha:

Great post, I’m glad Dr. Nnodim suggested to read yours. It seems that when we reflect on the things that we assume people have access to, that is the moment that we slapped in the face by the reality of what we actually don’t know. Great recommendation to request healthier food options, if possible. The patient population that you are caring for is multifaceted. Knowing more about AFC home and occupant living circumstances will in fact provide a sound foundation for you when you encounter this patient or others in her situation in the future.

[Leslie Kao]

Submitted by Kenisha Evans:

Ms. J is a 54y/o obese woman with HTN who presented for health maintenance. She lives in AFC home, and has been adherent to bp medications. She presented with no acute events, she is not a smoker nor does she drink alcohol. Social Hx consist of former smoker, illicit drug abuser and has been drug free since Dec. 2015. To date Ms. J has had a difficult time maintaining normotensive levels in bp just above 140/90s. Unaware of the dynamics of her housing, I discussed DASH diet and importance of daily exercise. When she being to explain the meals that are prepared for her, I realized how can I educate a woman who currently doesn’t have control of the food that is provided and prepared for her. Additionally, the daily activities that are schedule for her as a member of the AFC home, cleaning the house and her job working as a janitor cleaning a concert stadium contributed to my lack of appreciation for her living dynamics. Prior to being place in AFC home she had been unemployed living in shelter.

Objective
As the article entitle “Social Determinants of Health Inequalities,” stated “a focus on material conditions and control of infectious disease must not be to exclusion of social determinants. The circumstances in which people live and work are important for communicable as they are for non-communicable disease.” In Ms. J case I thought of ways she could improve are activities of daily living that could benefit her health. I told her to ask for more of the green leafy foods in proportion to small size of other items on her plate. While working take breaks walking up and down some of the stadium stairs every other day in addition to routine work. My plan with her next clinic visit is to find healthy affordable snacks she my request or even purchase.

Assessment
I realize I don’t have an idea of what is provided in an AFC home or any transition housing system that may have a positive or negative effect on the health of my patients.
To effectively address my patient issue it is necessary to gain knowledge about limitations that may alter the course of patient care. As stated in the article “Social Determinants of Health Inequalities, “treating existing disease is urgent and will always receive high priority but should not be to the exclusion of taking action on the underlying social determinants of health.”

Plan
My plan is to learn more about the settings of AFC homes and how they help manage healthy living for their occupants.

[Leslie Kao]

Submitted by Kenisha Evans:

Ms. M is 63 y/o woman 3 cigarettes/day smoker with unknown 5 year hx of muscle spasms and radiculopathy, who had previously changed PCP due to issues with obtain physical therapy with previous physician, presented to clinic for medication therapy for muscle spasm and radiculopathy. Ms. M was not my own patient but was returning for refills on flexuril that had been prescribed for 10 days PRN and Lyrica to which she was not own. Patient was completely sold on Lyrica and flexeril to managed her symptoms and was not open to hear about any other medications or other forms of treatment options. She was most recently prescribed Gabapentin 400mg BID but per patient she was not taking this medication has it doesn’t relieve her symptoms. Patient was convinced Lyrica was the answer to her problem. Patient stated she had an EMG but initial was unsure when. On EMR review, Ms. M had known history of chronic pain management s/p L knee replacement and osteoarthritis. I was quick to MAPS patient to rule out substance abuse and dependence than investigating the nature of EMG study, which was later found and reviewed and recommend follow up with neurology.

Objectively
Although referral for reevaluation was made for neurology, I was not looking for any acute changes in Ms. M underlying condition as my top differential for patient with chronic pain management but my thoughts were how can I treat her dependence or let me rule out substance abuse. As stated in the article “Physicians and Implicit Bias: How Doctors may unwittingly perpetuate Health Care Disparities,” we base our perceptions of reality on received info and experiences reinforced until they become automatic. Even at this early stage of my medical career I have learned as part of culture of patients of this community I see I must be particularly skeptical of patients that are chronic pain med seekers, which is true. However it creates an underlying bias for all patients who request certain meds as oppose to looking for a new etiology of the pain vs chronic uncontrolled/ inappropriately managed pain.

Assessment
I should see each patient as a separate individual encounter, not use my thoughts of one or more patients with similar stores to determine the reasoning/ assumptions of their visit. As with most patient with history of chronic pain there has to be line between new acute event and their management need of their tolerance compared to pain management dependence, and substance abuse, no matter who is presented.

[Leslie Kao]

Submitted by Sindhuri Benjaram:

During my clinic week I had an encounter with a patient who had a follow up visit but came primarily for medication refills. In the clinic patient had high BP and mentioned he has not taken his medications for a week because he ran out off his meds. He brought with him empty bottles of anti hypertensive meds. When I looked into his records same problem have arose on his previous clinic encounters and on scrolling through his medication list he had enough number of refills, but he stated that he called the pharmacy and they never got back to him. He is not homeless but not educated and has little understanding of his health status and how multiple comorbities affect each other.

Given our hospital’s patient demographics we often have such patients. When I looked at the chart a few questions came into my mind firstly is he complaint with his medications, looking at the empty bottles what is he doing with his meds, always has same issues so is there something else going on. He was on an appropriate regimen for his anti hypertensive meds. So I called the pharmacy and enquired into the refills issue. I figured that there was a communication gap between the patient and the pharmacy. I realized that there are often other issues like patient’s education status, understanding ability which are also important. He has a home and is insured but is not educated enough to contemplate the communication gaps, does not ‘google’ about his health problems. After this encounter I told myself always consider the patient’s social status, education level before using the words non-compliant or coming to the clinic for others meds.

[Leslie Kao]

Submitted by Neelambuj Regmi:

I like many of our residents here at DMC must have taken care of sickle cell patients. There are few sickle cell patients that visit us almost on a monthly and sometimes weekly basis for a pain crisis. I was also taking care of a patient who had been admitted to the hospital 6-7 in the last 4 months or so. His rate of admission was suspicious to me and I assumed unconsciously that the patient is in the hospital for “pain medications”. But with further workup, we found out that his hemoglobin was dropping. I hadn’t realized until I saw his lab reports I was not empathic towards his pain problem.
I realized that assumption in medicine can be very detrimental. Medicine is such a dynamic field that any assumption would eventually be proven otherwise. Esp with regards to patient and pain, assumption that the patient is addicted to pain medication without actively taking history and examining the patient can mean more pain and suffering to the patient.
After this encounter, I have tried to see patients in a non-judgemental manner. I promised myself that I would be more careful about the history and physical findings before I label someone as “pain meds seeker”.

[Leslie Kao]

Submitted by Yuliya Sharakova:

Ms.S is 44-year-old female with past medical history of HIV on anti-retroviral therapy. She has been patient of mine for more than a year, and every time she comes to the clinic, she complains of symptoms of mild upper respiratory infection and requests disability for several days due to illness. So every time I see her name in my schedule, I already have an idea why she is here and what to be ready for. In other words, I have been already biased. Last week during visit she was complaining of diarrhea of 3 days duration, which prevents her from leaving her house, since she goes to the bathroom 5-6 times a day. And as usually she was asking for disability for several days. Upon thorough history taking and examination, I found out that recently she had urinary tract infection and was treated with antibiotics, given by Urgent Care next to her house. I suspected diarrhea due to C.difficile, and tests I ordered confirmed that. Appropriate treatment provided. But as physician I felt uncomfortable, because I was not ready to take this patient seriously when she came to see me.
Analyzing this experience I can now say with confidence: even patients, that physician thinks he/she knows everything about, deserve thorough and unbiased approach in order to provide good timely patient care.

[Leslie Kao]

Submitted by Maninder kaur:

It is only 3rd month of my residency period, but in these three months I have observed that we all have unintentional bias in regarding different groups of patients. For example, we assume that most of patient with high risk behaviors like I/V drug abuse, smoking they are not compliant with their treatment and doctor’s advice and have more drug seeking behavior. But we don’t remember that every patient has his/her own identity and thought process, not all patient with addiction are non- compliant and non-serious to their doctor advice
Last week I met in clinic with 2 patients, they both were I/V drug users. One patient came with complaint of URTI leading productive cough. We gave him trial of oral antibiotics as cough was productive. On 4th day of his antibiotic course, I called him to make sure antibiotics are working for him, but he told me that he did not take his antibiotics and he was not having any clear reason not to take his treatment. I advised him again that antibiotics are very important for his throat infection , but I am not sure he will take his treatment .1 day before that I met with other patient, he was also I/V drug user and he was having T2DM, he was fully compliant with his treatment, use to follow up with podiatry and ophthalmology yearly for complications work up and was having a thorough knowledge of his diabetes and even the risk of I/V drug use and was willing to join methadone clinic also. In short, he was a good patient for me.
So, we should not assume that all the patients with high risk behavior are noncompliant, non- serious, who are not having any understanding of their disease process. We should treat them as other normal patient, because they have equal I Q as others, they will get our point about their disease if we explain them in same way as to other patients and if we are able to convince them, they can make up their mind to stop that high-risk behavior. So, it all depends on doctor-patient relationship.
I will try to be non- judgmental about any group of patients and will make good relationship with my patient to guide them and treat them in an effective way.

[Leslie Kao]

Submitted by Hadeel Sahar:

As part of my self believes, I am trying to do my best to provide an equal and unbiased care to all patients regardless of their racial difference, age or sex difference, insurance difference, etc.
My philosophy is that every patient should receive an equal attention and care, taking in consideration his/her internal believes, educational level and other factors. Sometimes things go out of our hands as in this patient.
A 55 year old African American gentleman with history of HIV (on HAART with 100% adherence to medications) and recurrent DVTs and PE (all unprovoked). He was seen by the hematologist and planned to get a lifelong anticoagulation therapy (due to unprovoked nature of his DVT/PE) in the form pf Apixaban. The reason why apixaban recommended over warfarin due to HIV status (HIV medications can interact with warfarin causing labile INR, In addition HIV medications tend to change and HIV patients at time may require prophylactic antibiotic therapy, which may also interfere with warfarin ie.it would be difficult to maintain a safe and therapeutic INR). We have send pre-authorization twice to acquire an approval for Apixaban, but till now we couldn’t get a feedback. Luckily the patient is getting a free samples of apixaban from the hematology clinic.
In my patient’s story, I am happy that he is getting free samples from the hematology clinic, but at the same time I feel very sad that we couldn’t get a prior authorization for such an important therapy for him.
I think such problem should be addressed and discussed thoroughly to reach a solution to my patient and similar other cases.

[Leslie Kao]

Submitted by Adi Shemesh:

This week, I encountered an elderly professor who came in for a well-care visit. Though she was prediabetic, she was otherwise in good health and showed understanding and willingness regarding lifestyle modifications in order to prevent developing diabetes. It was obvious that she had a better understanding than the average patient regarding diabetes due to her education, and that at least some of her compliance stemmed from that understanding.

Educational gaps can be a major cause of health disparities due to the effect of understanding on a patient’s judgement of whether to adhere to proposed management. As a physician, I understand that with most of the patients I have encountered thus far as a resident, I don’t have the privilege of being a pure physician without first being an educator. To reach the patients and increase their compliance, especially relatively healthy patients that require preventive care, they have to be first taught in a manner that they understand the importance of the proposed treatment. Therefore, my goal is to achieve the same adherence from a professor and a less educated patient by being able to adjust my level of medical education to their understanding of the medical field.

[Leslie Kao]

Submitted by Yeohan Song:

Mr. L is a 37yo gentleman who suffers from chronic pain following a GSW in 2001, requiring R nephrectomy, added on to my clinic schedule for the afternoon. I reviewed his chart and saw that he had several recent visits within the past month, for various reasons. Knowing that he was likely on on-term prescription analgesics, I tabbed through to his list of prior UDS logs and pulled up his PMP-Aware data sheet. As I had expected, I was faced with an extensive list of prescription narcotics.

At first glance, the entire screen seemed covered with high-dose narcotics—not only morphine, but also oxycodone in the tens to hundreds of prescribed pills each month. A quick glance at the last prescription fill date made me realize that this was much too soon for his next prescription, and at that moment, the patient wheeled himself into the room.

I started the visit off with a greeting, asking open-ended questions and asking what brought him in. The conversation was quickly being redirected to his request for a refill of his opioid medications, so I asked him what other issues I could help address at the visit aside from his chronic pain, as it was still too early for prescription renewal. At that moment, there was a brief moment of silence, when he began to think, and slowly, he began to share about a friend who had been recently killed, and for whose death he felt partially responsible, with an immense sense of guilt. As it was our first meeting, he was hesitant to share any more than that, but that was enough to start the conversation about his grieving process, and eventually led to his request to be referred to a counselor.

In considering the approach I had regarding this patient and his initial reason for the visit, I readily admit that my perception of the patient was already being formed, if not set, before I ever laid eyes on him, which was in large part based on his anticipated reason for visit. However, as noted by Chapman et al. JGIM 2013, I was able to counter this initial impression through an act of perspective taking, considering the trouble he must have taken to make his way to the clinic on his wheelchair and thinking about him as a person, trying to make the most of the day in spite of his ever-present pain, and his dependence on the pills that give him the bitter-sweet moments of tangible, if fleeting, relief.

Through taking the moments to consider the other person in the room, to in fact recognize their humanity aside from their distilled chief complaint, I realize that I can recover the empathy needed to deliver care, rather than to merely resolve a problem.

[Leslie Kao]

Submitted by Sally Azzo:

During residency I started to notice that most physicians including “me” spend more time in front of the computer than spending time with the patient, we always try to gather as much data as we can from the medical records and unfortunately sometimes we start judging the patients based on previous notes. I see the word “non compliant” a lot. In fact, this is the reality, we have a lot of non-compliant/ non-adherent patients, some of them have their own reasons to become non compliant while others don’t.
Unintentional bias can happen while encountering passive patients, patients who smoke, patients who abuse various substances, non-adherent patients, and passive-aggressive patients.
I had a patient with multiple co-morbidities and on several medications; she only shows up in the clinic when she needs refill for her pain medications, she doesn’t want to listen to me about her HbA1C of 14 and her BP of 180/100 but the only thing she want is her norco. As a consequence, I feel bad and useless; I would be biased towards her and sometimes towards her entire population group, but even if I feel that I would still educate her, prescribe the medications that she is not taking, and continue my care at standard level.
Finally, I like to refer to this quote “the three big pieces of how humans work together in a medical encounter: “What is happening to the patient before the doctor walks into the room, what is happening to the doctor before he walks into the room, and what happens in the room.”

[Leslie Kao]

Submitted by Sally Azzo:

Geriatric population is growing very fast and as internal medicine specialist; it’s my job to give the best quality of care to this population group.
I have a lot of elderly patients who live by themselves without any family support, and watching my mother as a primary caregiver for my bedridden hospice grandmother makes me think more about those patients. I see my grandmother surrounded by a lot of family members who refuse to leave her alone without any company despite her being under the effect of morphine.
During this clinic week I had an 85-year-old gentleman with history of DM, HTN, CKD III coming with constipation. He was already seen in the clinic for constipation and he was given stool softeners and ordered CT abdomen to be done which came back negative for any obstruction. He came to the clinic and he told me that the constipation is better with the stool softeners but once he stops taking the pills he develops constipation again. This patient is 85 y/o and he is very compliant with his medications and follow-up appointments and he completely takes care of himself, I questioned him about the type of food he usually eats and I found that most of the time he doesn’t eat cooked food, he doesn’t eat much fibers because he can’t really cook for himself and he rely on fast or junk food only. In addition, while talking to him he mentioned that he lives in a residential building on the ninth floor, and there was no power for two days, which made him climbing nine flights of stairs to get his daily needs.
Understanding patients needs and having detailed conversation during the 15 minute encounter could be challenging but some times spending the extra minute to listen can give us a lot of explanations and create a path to start offering some help, such as home assistance trough involving the social worker, offer durable medical equipments including walkers, shower chair, grab bars, referral to nutritionist to choose better healthy choices with best prices, finally this kind of conversation will strengthen the patient doctor relationship because it will show how we care and how patient’s safety is important for us.

[Leslie Kao]

Submitted by Raya Kutaimy:

Taking care of a patient involve multilevel process, that needs special relationship between the patient and physician with the main component is trust and understanding. Mrs. X she is 58 year old lady with PMH of DM and HTN, when she started to follow up with me she was complaining of non-specific joint pain that is worsening gradually, she was already referred to pain clinic and she follows with them for pain management which also did not improve her pain. All her rhematological work up with rheumatology clinic evaluation which was done later was negative. She complained of whole body pain and unable to cooperate with physical therapy. Of a note from 2 -3 clinic visit with the patient that she was silent most of the time, has very little knowledge of her medical problems or her medications, though she is complaint. When discussed her social issues, she lives by herself, has friends from church and one son who lives in far city. PHQ9 was done and it is positive. She was referred to psychotherapy, after 2 months she came for follow up visit, with significant improvement, in her pain level to the point that her pain clinic decreased her pain medications and though she was ok with it. She looked different, even the way she dressed and the smile on her face. She reported much improvement
It is crucial component of patient care is to address social issues and environmental circumstances, though sometimes it becomes challenging to address these issues with busy schedule but that can be managed better with continuity of care for patients.

[Leslie Kao]

Reply by Eugene:

Thoughtful post Hamza. I agree with you that we are all too focused on external problems (money/resources or someone providing access to health) that we forget about a person’s individual situation. The example about Greece in the article was wonderful and shows how a relatively healthy culture (I use the term loosely) and good genetics are no less important than whatever medicine we can provide. I hope that your patient comes from a place and upbringing that will allow him to have the psychosocial support and coping mechanisms that needs at this time above all else so that he can focus on his overall health.

[Leslie Kao]

Submitted by Hamza Salam:

It was a rainy and unexpectedly cold afternoon in midtown when Mr. T came to the clinic. On a clinic day like that I am usually expecting a low patient turnover at the clinic, appointments are usually rescheduled and patients with relatively poorer health outlook are the ones who maintain close follow up. Mr. T had no medical comorbidities. 35 year old guy, works at a tire shop in Midtown, Detroit. His presenting complaint was “I don’t want to talk to anyone.” Now, he had my full attention! “So, what can I do for you Sir?” I asked. “I don’t know, you’re the doc” he replied. I went straight to the review of systems to allow him time and space to open up to me. He is a pack per day current smoker, drinks excessive quantities of alcohol on the weekends, denies drugs. His BMI was 32, did not exercise as he worked 10-12 hours a day and would be too tired to do anything afterwards. Recently, his diet had worsened, he had been smoking more and also drinking alcohol on the weekdays. The patient had a divorce 2 weeks ago and now was fighting for the custody of his kids. His mother was recently diagnosed with a terminal illness and he was finding a placement for her. His HR was 110 and BP 175/110 with no prior history of hypertension. He had his hands around his head and was looking downwards with his eye’s closed. There was objective evidence of emotional and social stress affecting a healthy young adult. If this continued, he most likely would develop HTN and/or DM within a few years. A permanent modification to his lifestyle was needed on top of this acute episode of stress.

Objective
As mentioned in the article, Greece had a per capita income approximately 1/4th of the US, but had a similar life expectancy when compared to the US population. On the other hand the Aboriginal and Torres Strait Islander peoples in Australia have a life expectancy less than that of India, but when it comes to income and availability of resources they belong to one of the most privileged societies on earth. Even the infant mortality rate in these people was closer to that of developed countries. So what determined a 10-20 year difference in life expectancy than the normal population? There is no doubt that societies that are economically underprivileged lack the basic necessities governing health; including the availability of clean drinking water, healthcare, education, hygienic living conditions etc. But the Aboriginal and Torres Strait Islander peoples didn’t lack these facilities, the issue most likely was that these were socially isolated communities. The reason I decided to choose this particular example is because I don’t see the entire population of Detroit as one that is devoid of food, water and basic facilities. Yes, there is a large homeless population and people who have never seen a doctor before. But, this does not account for Detroit’s one of the lowest life expectancy in the US and an infant mortality rate similar to that of Nigeria, which is a middle to low income country. Detroit does have one of the lowest income per capita in the US, but it is still 5 times more than that of Nigeria. What are we missing here? We have hyper-focussed on the economic aspect of a society’s correlation to its health. Although important, but this had made us miss the bigger picture. The social determinant of health is as important. Mr. T had a home, a living income, health insurance, access to healthcare, education etc. His lifestyle was the cause of her morbidity. I need to focus on his lifestyle and how to slowly modify it for a better health outcome.

Assessment
How do I approach this in my patient encounter? How do I tell him to exercise and control diet when I know even I could not have done it if in her position? What would be the right approach to counsel him into giving up alcohol when that is all he looks forward to every week? What can I do to convince him, that health care above else, will also determine her mental health. Mental health in turn governs physical health; when I know what social trauma he has gone through?

Plan
These are the aspects I feel that need to be worked on. It is easy to guide a patient on health lifestyle practices, but when it’s tough to understand what disables them to follow our guidelines and how to tackle it from patient to patient.

[Leslie Kao]

Submitted by Ali Alateya:

Ms. S.P is 58 yrs old AA F pt with multiple comorbidities including DMII & morbid obesity, because of her obesity pt is tried to loss weight to improve her A1c levels with no success, pt was refereed to our dietitian & pt initially did loss some weight but eventually pt rebounded & gained all the weight she lost although she trying to follow her dietitian instructions, our next step was to refer to weight loss clinic but unfortunately because of her insurance she has to pay a lot of deductions which she can’t afford, it was a major set back for the pt that there are many options to treat her condition but because of her poverty she can’t access it.
as a team unfortunately we don’t have many other options to offer to the pt other than to discuss these events with our dietitian so she can come up with new & more aggressive plan so pt can loss weight again.

[Leslie Kao]

Submitted by Pranav Shah:

S: I was fulfilling my CCR tasks during the week and I ran across a patient who was requesting insulin. When I went through the chart I noticed that the patient had recently had her insulin refilled during her office visit. I decided to call the patient. The patient told me that her young daughter got a hold of her insulin vial and threw it off the table. On top of that the patient was in Florida visiting family and had only brought one vial. Originally I would have simply just filled the prescription and moved on, but due to this course I wanted to learn more about this patient.

O: I found the pharmacy that was closest to where the patient was currently visiting in Florida and sent a prescription to the pharmacy, instead of refilling the prescription blindly and sending it to her normal pharmacy in the system and having the patient call for a transfer.

A: Although this time I was curious of possible social determinants I felt like normally I am as perceptive. On top of asking about which pharmacy would be best for the patient, I talked to the patient about safety concerns as Hurricane Irma is about to reach her region. Patient stated that they were going to fly back, however all flights were cancelled due to the storm.

P: I would like to see more consistent efforts when thinking about social determinants of patients. Questions such as how will they get their medications, can they afford them, or do they have children at home who might break their medications are important to my overall understanding of a patient’s needed. The idea of providing EQUITY and not EQUALITY really resonated with me. Each patient is different, even though they may mostly be “AAM” or “AAF”. Possibly I will need to change how I begin my SOAP notes to address this issue at a more psychological level.

[Leslie Kao]

Submitted by Carli Denholm:

S: Social Determinants are a key area of study for physicians as our patients are often faced with struggles that are due to these social determinant factors. We MUST address these issues in order to provide the most effective health care possible. I am glad that we are tackling this issue head on with this new curriculum. I think that many of us have already dealt with some of these issues by virtue of the patient population that we serve in Detroit and we are inherently poised to learn a great deal more.
O: As this week’s article pointed out, there are a wide variety of social factors that contribute differences in health care outcomes. Some of the most frequently seen social determinant challenges in our clinics include low income, lack of transportation/access to healthcare, poor education, addiction, and lack of social support. As an example, Ms L. is a patient I saw this week who was lost to follow up with rheumatology and has advanced rheumatoid arthritis. She did not wish to be referred to the clinics nearby, stating that she has had poor care experiences at them. However, she depends on public transportation, which is not a reliable or practical option for getting to other clinics in the suburbs due to her limited income and distance needed to travel. In the end, that patient agreed to be referred to a downtown clinic because it was important for her RA to be treated by a specialist. But, the interaction did illustrate a few of the challenges that she, and may others, face.
A: I feel that I have a fair understanding of how social determinants affect my patients. As I mentioned before, residents in our program have an advantage in studying many of these issues because of the population that we serve. While we are often able to identify and understand may of the challenges that our patients face, what we frequently lack is the knowledge of how to help our patients overcome these challenges
P: I think that the Social Determinants curriculum has the potential to be very useful to us all. I look forward to learning more about social determinants and how to address them (when possible) to provide the best care that I can for my patients. And, maybe, to narrow health care disparities in general in the community.

[Leslie Kao]

Submitted by Yahya Ibrahim:

Mr. M. presented to the clinic to follow up on a relentless left wrist pain and hand swelling that has been going on for 3 weeks despite starting him on appropriate management with Colchicine and Ibuprofen. After addressing his major complaint we also discussed screening for colon cancer. It was marked in the chart that the patient is not interested in it. When I inquired as to why he has this opinion, he explained that given his insurance plan it will be cheeper for him to do the test rather involve his medical insurance and pay the deductible. Unfortunately, colonoscopy was also not something he could afford and he added “there is blood in stool test that could do the same thing for me and it is much cheaper.” I explained that that test modality though more affordable would not substitute the technique used in colonoscopy to screen for colon cancer. He stated that he now understands better and he might consider doing it given what he learned during this visit.

Our patients’ population in Detroit is of low economic status. That is no new news. But they have a budget where if explained adequately could help them in prioritizing their medical needs putting more important lines of management first. Asking more details about their lives would take more time but ignoring it could be detrimental.

• This reply was modified 6 years, 6 months ago by Leslie Kao.

[Leslie Kao]

Submitted by Msutafa Ajam:

Mr. R a pleasant 62-year-old male patient with a medical history of DM type 2 and hypertension; diagnosed more than 5 years ago. His last visit to the clinic was in January/2017. His diabetes and blood pressure were far from being well controlled; he was not compliant with his medications, necessary life style changes or his clinic visits.
At first, I thought maybe this gentle man does not understand the burden and possible consequences of his medical conditions if they were not appropriately treated. However, as I tried to assess that level of awareness it turned out he knew almost everything needed to better control his conditions. “Why this patient is so ignorant of his health?” I asked myself. Upon further questioning, the patient was meeting the criteria for depression and he was lacking the motivation to follow any advice from his doctors or to take the initiative to care for himself. He also felt overwhelmed by the many complicated advices he gets from his doctors which he finds difficult to follow.
As a physician who has just started his career, I understand that poverty has substantial impact on individual’s health, and I also understand that physicians are shorthanded when it comes to changing the inequality in health care delivery, but I feel committed to find solutions and use whatever resources available in the community that can help me deal with my patient’s conditions.
Thinking of poverty as a sole determinant of health status can lead us to overlook the importance of other major factors. For example, statistics show that worldwide, the second highest cause of disease burden among adults age 15–59 years is unipolar depressive disorder. Furthermore, we need to keep in mind that both poor and wealthy patients have unhealthy habits; smoking, lack of exercise and eating unhealthy food can be even more prevalent among higher socioeconomic status.
My plan is to entail health care delivery according to the patient’s needs and capabilities and avoid biased decisions like blaming poverty for poor health outcomes. I will screen for depression especially those patients who have chronic medical conditions. I will also try my best to simplify my medical advice; a patient who has 4 unhealthy habits will definitely feel overwhelmed and frustrated if we ask him to change them all at once, but if we help him focus on changing one at a time will improve his willpower and adherence to lifestyle changes and general well-being.

[Leslie Kao]

Submitted by Adel Elmoghrabi:

Coming from a developing country and practicing medicine in a predominantly under served population with widespread inequities I aspired to come to the US to seek broader knowledge and understanding the functionality of one of the most powerful healthcare systems in the world. Hence i had the belief that by becoming involved in the system and perhaps seeking an administrative experience in the health care system I would be able to grasp the necessary tools to participate in reshaping global healthcare in areas where health disparities and inequities result in the preventable death of less fortunate people. It wasn’t however until I started residency did I gain more insight that heath disparities and inequities are a global problem even in developed countries as the social determinants constitute one of the major obstacles in depicting this disparity.
During my first 2months of residency which were both on the floors I felt that I was studying for a master’s degree in sociology rather than being in a medical residency. Perhaps that was slightly disappointing for me during the early stages, especially when I felt that I was asked more questions during rounds relating to the patient’s social history than regarding their medical condition.
Although I asked myself every day, to what extent do we have to be involved in the social aspect of patient care I’ve come to realize that I myself could be a possible barrier to either blocking health care inequity or being one of the confounding factors that contribute to it. Understanding the statistics and the population we serve reshaped my understanding that spending as much time planning social logistics from transportation to durable medical equipment so patients can measure BP or Blood glucose at home, assisting in setting up home health care etc. is a new dimension which is no less important and perhaps is more challenging and arguably more significant than diagnosing the disease and treating it. Our social worker, case manager, PT/OT colleagues exposed me to a deeper perspective to help initiate and maintain an environment that helps eliminate these disparities illustrated by understanding the causes of the causes such as patients who have nowhere to sleep or lack of access to nutrition or are unable to independently rely on themselves yet have no social support.
To reiterate, prior to starting residency, my interpretation was based on the understanding that the only solution to healthcare disparities can come at an institutional level and that the political leadership and policy makers play the leading role solving this challenge. However, I ask myself how much could we as individuals contribute to help fixing this problem. Although not entirely correct, many of the social determinants of health inequity somehow relate to financial deficits and that poverty is a major cornerstone that correlates with health inequity. As a Tax payer I do expect that the government provides us the necessary infrastructure and basic needs to live in a civilized society however on the individualized level how much could we intervene or contribute or give to the less fortunate. I have grown to understand there must be justice in nature and that no one can or will ever have everything. Humans have an equal distribution of blessings, just distributed in different shape or forms. Some are stronger, others are wealthier, and others are healthier, some are happier or funnier than others but we all share one goal which is to live a good life. We are all reliant on each other and we all need each other in one way or another.
After reading this week’s article, I have been asking myself and thinking of possible solutions some of which are short term and others long term. My immediate action is to be able to understand the social determinants that may affect the patients I serve. It is however concerning that during the short encounters and time constraints during clinic or hospital encounters, it may be less feasible to address these issues in depth. Hence, I propose that we synthesize a questionnaire to be distributed to all our patients at clinic or hospital which helps us understand the background conditions that our patients are exposed to and the lack of access to the most basic needs of life such as water, a problem that we may take for granted however one that people are facing in the very same city we live in!
It strikes me that in many developing countries or even developed countries nonprofit and charitable organizations are taking the leading role in serving to abolish hunger, health inequities and addressing both national and global health catastrophes. Learning that there are clinics which serve the uninsured and treating at no expense inspires me that a long term goal once I am an attending would be to dedicate a fraction of my time and financial income to support the maintenance and establishment of such freestanding clinics that can ensure that high quality healthcare, medication and support is present in every city around the country. It is as such that small contributions from the more financially capable can help in abolishing one of the major lethal aspects of social determinants of health inequity which is Poverty!

[Leslie Kao]

Submitted by Mowyad Khalid:

Mr. D is a middle age gentleman. He was diagnosed with pulmonary hypertension, and multiple comorbidities including obesity. He came to the clinic for follow up.
He said he is not using his medications regularly.
After inquiring about his medication non-adherence, I found out the medications prescribed to him for pulmonary hypertension were extremely expensive, and that a single pill costs approximately 80 dollars. So, he bought a few as he could not afford more.
I asked our staff and we provided him with some samples, and prescribed a generic medication, with same efficacy but significantly lower price.
My point is, not every patient who is not taking his medications does that because he does not care. Most times, its financial or societal issues, and we should try as much as we can to help them

[Leslie Kao]

Submitted by Ahmed Yeddi:

My patient was a 32-year-old pleasant lady with type 1 diabetes mellitus (uncontrolled and complicated by diabetic peripheral neuropathy). She came to the clinic for medication refill as some of her insulin ampoules were broken and she was not able to have all her insulin shots the week before.
As you probably expected her blood sugar was > 400 and her urine was positive for ketones. We explained the significance of these findings to the patient and we advised her that she needs further evaluation and treatment at the emergency department.
Her response was the most shocking thing I have heard in a while: “ My job is at stake and I need to report back to work after my clinic appointment. I have to keep my job so that I don’t lose my health insurance because I have chronic diseases and I can not afford all these medications without insurance. Moreover, I need to work more hours so that I get some money to pay the rent. Today is my deadline for paying the rent (it was 09/06) and they will kick me out if I don’t pay by today”.

As a physician, your role is not just to give medical advice and prescribe medications. You should assess if your patient will be able to follow your advice regarding the diet and the medications (or any other instructions) you would like them to be on. Because If you didn’t, your instructions will be unattainable to most of the patients we deal with in our community. Unfortunately, a significant number of our patients may miss their clinic appointments because they can not afford a ride to and from the clinic (which is unbelievably sad but that is the truth). Here comes the importance of the social determinants of health which allows us to take many factors into consideration when we treat patients. Although some factors are beyond our control, there will always be things we can contribute for our patients. We need to see the patients as humans we are trying to help, not only a medical case that we are attempting to solve.
“It is better to light a candle than curse the darkness”. Eleanor Roosevelt.

[Leslie Kao]

Submitted by Hussam Tabaja:

Subjective:
Miriam-Webster’s dictionary gives a relatively simple definition of the word health by defining it as the condition of being sound in body, mind, or spirit. Notice how this definition is very “individualistic”. However, health is anything but simple or individualistic. Health is a function of economic and social conditions that people interact with. Factors such as educational level, profession, place of living, the people we interact with have a direct impact on our health. This was illustrated by the article titled Social Determinants of health Inequalities.

I saw the impact of social determinants on one of my patients during my floor month at Detroit Receiving Hospital. To illustrate, I was assigned to the care of a 66-year-old Hispanic female who was admitted for diabetic ketoacidosis with blood glucose in the 600s and HbA1c of 11. She is status post right below the knee amputation and has a history of poorly controlled diabetes with multiple admissions for DKA. She was initially managed by the MICU and then transferred to my care. Prior to meeting the patient, I thought that this is going to be one of the many nonadherent morbidly obese diabetics that pay little attention to what she eats or drinks. As soon as we get her blood sugar under control, she is going to resume her usual lifestyle. Wow, was I wrong.

Objective:
When I met the patient, she was frail and spoke little English. She said that she did not know much about managing her diabetes. She lives with her daughter and she is the one that manages her medications and her diet. Ms. CS stated that her daughter would measure her blood sugar every day and gives her insulin. Furthermore, she reported that she tries to eat healthy by eating salads and fruits. However, she does say that she often eats the same foods as the rest of the household. She ambulates with a prosthetic, but she does not like using it because it makes her feel unsteady.

I contacted the patient’s daughter to gain a better understanding of the patient’s diabetic history. Her daughter told me that she would measure her mom’s blood sugar daily. Based on the reading, she would subsequently give an insulin shot in the belly. Her daughter explained to me that when the glucometer would read “high”, she would administer 30 units of glargine insulin. However, if her blood sugars were between 200-350 mg/ dl, then she would administer 15 units of glargine insulin.

After collecting the history from the patient and her daughter, it became obvious that both individuals have a limited understanding of the disease. I spoke with the daughter extensively about her mother’s medical condition and the need for better management of blood sugars. I told her at what times she is supposed to check the blood sugar and when to administer glargine insulin and aspart insulin. I gave the patient and her daughter handouts in Spanish about diabetes. In addition, the team consulted a Spanish speaking dietitian to talk with the patient and her daughter about managing diabetes.

Review of previous records revealed that the patient was discharged on long acting and short acting insulin. However, when I spoke with the patient’s pharmacy they told me that the patient had never picked up her short acting insulin. When the patient was discharged, I called the pharmacy and asked the pharmacist to please dispense the long acting and short acting insulins to the patient.

Assessment:
In order to fully assess this case, we have to go back to a concept that I was taught in my first year of medical school and that is the biopsychosocial model. The biopsychosocial approach systematically considers biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery.

From a biological viewpoint, the patient has been admitted multiple times for DKA’s. Given her elevated HbA1c, it is evident that her body is persistently exposed to elevated blood sugars. This predisposes her to micro-vascular and macro-vascular complications. Therefore, she needs close follow-up with her PCP. Each time the patient was discharged from the hospital she was given a specific set of instructions for her insulin regimen. For unknown reasons, it appeared that she was only getting the long acting insulin only to manage her diabetes.

From a psychological viewpoint, it is well known that depression is among the most common neuropsychiatric disorders in patients with type 2 diabetes. The patient’s PHQ-2 questionnaire was negative. When I spoke to the patient about her repeated hospitalizations for her diabetes, she was admittedly upset. She was upset because she felt it was not something she could control. Understandably, she did not like the repeated finger stick glucose testing and the repeated insulin injections. The patient stated that living with the disease was difficult, but her daughter was a tremendous support.

From a social viewpoint, my patient had several risk factors that make her especially vulnerable to falling ill. For instance, the patient was elderly (poor physiologic reserve), non-English speaking, she was dependent on others and the patient was mostly wheel chair bound. One important protective factor is that she lives with her daughter. This is her strong social support. She can constantly keep an eye on her mother and get her medications filled. It is important to identify the daughter our ally because she has the most contact with the patient.

Furthermore, during my interactions with the patient, she told me that she is an immigrant from Puerto Rico. Although, I did not know her insurance or citizenship statues, it is important to have the following discussion. The high costs of health care and the erosion of insurance coverage are significant challenges that confront all Americans. These problems are especially hard on immigrants to the United States, who have extremely low rates of health insurance coverage and poor access to health care services. Immigrants, both legal and undocumented, often rely on a patchwork system of safety-net clinics and hospitals for free or reduced-price medical care. Their reliance on this system has led many states and communities to be concerned about uncompensated health care costs for uninsured immigrants and the state and local fiscal burdens that result. This situation really complicates health care delivery to the immigrant population.

Plan:
My job as a health care provider is not just making sick people healthy again. My job also entails preventing healthy people from succumbing to an illness. If there is one thing that this case taught me is that I must identify people who are at risk of falling ill and to not be afraid to ask why. If a patient’s HbA1c comes back elevated, then ask why. If a patient is unable to come to the scheduled appointment, then ask why. If a patient was laid off, ask how they are doing at home and how are they coping with the stress. As physicians, we can use the biopsychosocial model to identify patients who are at risk of falling ill and intervene appropriately before their condition deteriorates. Equally important is the identification of allies in the treatment of the patient. Someone who can monitor the patient or assist them with their medical needs.

In addition, I think that the hospital system should identify locations where people who are under privileged can be referred. For example, referring them to clinics that provide free health care and prescriptions. I was a Wayne State University medical student and I had the pleasure of working at many free clinics, most notably is Cass Clinic. These clinics are managed by physicians and medical students who volunteer their time. Referring the patient to such clinic allows them to get some form of healthcare that prevents them from coming back to the hospital. Although, there is a flaw in this idea. If a hospital would refer a patient to a clinic that is managed by medical students, it could lead to liability problems.

Within our medical system, it is often difficult to stop and think about the tremendous social hurdles that our patients face day in and day out. After this week, I have realized that it is very easy for a physician to set a health goal for the patient. However, it takes an extraordinary physician to help a patient reach that goal.

[Leslie Kao]

Submitted by Marvin Kajy:

Subjective:
Miriam-Webster’s dictionary gives a relatively simple definition of the word health by defining it as the condition of being sound in body, mind, or spirit. Notice how this definition is very “individualistic”. However, health is anything but simple or individualistic. Health is a function of economic and social conditions that people interact with. Factors such as educational level, profession, place of living, the people we interact with have a direct impact on our health. This was illustrated by the article titled Social Determinants of health Inequalities.

I saw the impact of social determinants on one of my patients during my floor month at Detroit Receiving Hospital. To illustrate, I was assigned to the care of a 66-year-old Hispanic female who was admitted for diabetic ketoacidosis with blood glucose in the 600s and HbA1c of 11. She is status post right below the knee amputation and has a history of poorly controlled diabetes with multiple admissions for DKA. She was initially managed by the MICU and then transferred to my care. Prior to meeting the patient, I thought that this is going to be one of the many nonadherent morbidly obese diabetics that pay little attention to what she eats or drinks. As soon as we get her blood sugar under control, she is going to resume her usual lifestyle. Wow, was I wrong.

Objective:
When I met the patient, she was frail and spoke little English. She said that she did not know much about managing her diabetes. She lives with her daughter and she is the one that manages her medications and her diet. Ms. CS stated that her daughter would measure her blood sugar every day and gives her insulin. Furthermore, she reported that she tries to eat healthy by eating salads and fruits. However, she does say that she often eats the same foods as the rest of the household. She ambulates with a prosthetic, but she does not like using it because it makes her feel unsteady.

I contacted the patient’s daughter to gain a better understanding of the patient’s diabetic history. Her daughter told me that she would measure her mom’s blood sugar daily. Based on the reading, she would subsequently give an insulin shot in the belly. Her daughter explained to me that when the glucometer would read “high”, she would administer 30 units of glargine insulin. However, if her blood sugars were between 200-350 mg/ dl, then she would administer 15 units of glargine insulin.

After collecting the history from the patient and her daughter, it became obvious that both individuals have a limited understanding of the disease. I spoke with the daughter extensively about her mother’s medical condition and the need for better management of blood sugars. I told her at what times she is supposed to check the blood sugar and when to administer glargine insulin and aspart insulin. I gave the patient and her daughter handouts in Spanish about diabetes. In addition, the team consulted a Spanish speaking dietitian to talk with the patient and her daughter about managing diabetes.

Review of previous records revealed that the patient was discharged on long acting and short acting insulin. However, when I spoke with the patient’s pharmacy they told me that the patient had never picked up her short acting insulin. When the patient was discharged, I called the pharmacy and asked the pharmacist to please dispense the long acting and short acting insulins to the patient.

Assessment:
In order to fully assess this case, we have to go back to a concept that I was taught in my first year of medical school and that is the biopsychosocial model. The biopsychosocial approach systematically considers biological, psychological, and social factors and their complex interactions in understanding health, illness, and health care delivery.

From a biological viewpoint, the patient has been admitted multiple times for DKA’s. Given her elevated HbA1c, it is evident that her body is persistently exposed to elevated blood sugars. This predisposes her to micro-vascular and macro-vascular complications. Therefore, she needs close follow-up with her PCP. Each time the patient was discharged from the hospital she was given a specific set of instructions for her insulin regimen. For unknown reasons, it appeared that she was only getting the long acting insulin only to manage her diabetes.

From a psychological viewpoint, it is well known that depression is among the most common neuropsychiatric disorders in patients with type 2 diabetes. The patient’s PHQ-2 questionnaire was negative. When I spoke to the patient about her repeated hospitalizations for her diabetes, she was admittedly upset. She was upset because she felt it was not something she could control. Understandably, she did not like the repeated finger stick glucose testing and the repeated insulin injections. The patient stated that living with the disease was difficult, but her daughter was a tremendous support.

From a social viewpoint, my patient had several risk factors that make her especially vulnerable to falling ill. For instance, the patient was elderly (poor physiologic reserve), non-English speaking, she was dependent on others and the patient was mostly wheel chair bound. One important protective factor is that she lives with her daughter. This is her strong social support. She can constantly keep an eye on her mother and get her medications filled. It is important to identify the daughter our ally because she has the most contact with the patient.

Furthermore, during my interactions with the patient, she told me that she is an immigrant from Puerto Rico. Although, I did not know her insurance or citizenship statues, it is important to have the following discussion. The high costs of health care and the erosion of insurance coverage are significant challenges that confront all Americans. These problems are especially hard on immigrants to the United States, who have extremely low rates of health insurance coverage and poor access to health care services. Immigrants, both legal and undocumented, often rely on a patchwork system of safety-net clinics and hospitals for free or reduced-price medical care. Their reliance on this system has led many states and communities to be concerned about uncompensated health care costs for uninsured immigrants and the state and local fiscal burdens that result. This situation really complicates health care delivery to the immigrant population.

Plan:
My job as a health care provider is not just making sick people healthy again. My job also entails preventing healthy people from succumbing to an illness. If there is one thing that this case taught me is that I must identify people who are at risk of falling ill and to not be afraid to ask why. If a patient’s HbA1c comes back elevated, then ask why. If a patient is unable to come to the scheduled appointment, then ask why. If a patient was laid off, ask how they are doing at home and how are they coping with the stress. As physicians, we can use the biopsychosocial model to identify patients who are at risk of falling ill and intervene appropriately before their condition deteriorates. Equally important is the identification of allies in the treatment of the patient. Someone who can monitor the patient or assist them with their medical needs.

In addition, I think that the hospital system should identify locations where people who are under privileged can be referred. For example, referring them to clinics that provide free health care and prescriptions. I was a Wayne State University medical student and I had the pleasure of working at many free clinics, most notably is Cass Clinic. These clinics are managed by physicians and medical students who volunteer their time. Referring the patient to such clinic allows them to get some form of healthcare that prevents them from coming back to the hospital. Although, there is a flaw in this idea. If a hospital would refer a patient to a clinic that is managed by medical students, it could lead to liability problems.

Within our medical system, it is often difficult to stop and think about the tremendous social hurdles that our patients face day in and day out. After this week, I have realized that it is very easy for a physician to set a health goal for the patient. However, it takes an extraordinary physician to help a patient reach that goal.

[Leslie Kao]

Submitted by Hibah Ismail:

As I transitioned from my medical school in Lebanon to residency in Detroit, I was not aware of the tremendous amount of knowledge I would gain. Sure, we all expect to gain experience and knowledge during our training, however what I expected was expanding my knowledge on medical guidelines, treatment plans, ect. During my first week in clinic was the introduction to the new culture of Detroit. Patients would present with the same chief complains, the history taking and physical examination would be the same as those we learned in medical school, however little did I know that the management of the diseases we learned about would differ greatly.
Keeping HbA1c less than 6.5, counselling on DASH diet, and prescribing medications seemed to be an easy task. However, once clinic weeks progressed, we learned more about our patients. Asking deeper questions and learning about their living situations expanded my knowledge of the management of their illnesses. As I learned more about my 24 year old female patient who was looking for a job and attempting to feed her children, waiting for transportation to be able to show up to her appointment in clinic gave me a deeper sense to the struggle different cultures have and to the resources we should know about to help facilitate a better lifestyle, and thus a better health for her and her children. Thus, our experience began; acquiring information about Medicare and Medicaid, about different insurance plans, generic drugs, STD clinics, social-work and resources all became an integrated part of our practice.
Learning about the social determinants of health is in fact an integral part of our practice because it is an inevitable fact that learning about our patient’s struggles, obstacles, and available resources is key to identifying and optimizing the best plans for management of their illnesses, whether it is diabetes, heart failure, or dialysis. Although the utmost solution to healthcare might seem far-fetched as it involves improving patient’s finances, education, access to clean water supply, nutrition, and other factors that involves tremendous amount of time, effort, planning and monetary means from governmental institutions, however this does not remove our responsibility to really LEARN and KNOW the people we are treating and encountering. In the end of the day, medicine is a practice of art, and there is nothing more satisfying that using the art of language and words to learn about the core struggles of the people we try to help.

[Leslie Kao]

Submitted by Kunwardeep Dhillon:

When we see patients in clinic it is often very challenging to manage pain. Possibly because it is a truly multifactorial process with anatomic changes, physiologic changes and possibly a concomitant psychologic or psychosocial component. During this clinic visit I saw a patient chronic lumbar back pain. She had a recent ED visit at which time imaging of the lumbar spine showed no acute pathology. She presented to our clinic and was requesting norco for pain management.

On physical examination I did not note any alarm symptoms and I proceeded to discuss with this patient regarding her symptoms and request for pain medication. After discussing the risk and benefit of chronic pain medication it occurred to me that this patient did not truly understand the risk of chronic opioid medication.

This patient believed that pain medication would make her feel better and that she could stop at any time. While this is true in many patients I explained to her that there is a significant risk of opioid dependence and that if her pain is tolerable in this case avoidance of opioids and early activity are key. Furthermore I printed a monograph of Norco for this patient and went into detail on the negative side effects of the patient. She was truly grateful and appreciated the time taken to explain why pain medication is not ideal as opposed to a simple rejection.

This encounter made me realize that when patients come to see a doctor, they have so many questions and such little time to discuss them. As a physician I realized that explaining to someone the risks and benefits of medications and our thought process makes them understand our treatment plan. This reflection put into perspective that patents want to be involved in their own treatment and want to be made aware of their medical conditions. It made me realize the importance of medical education and the importance of closing the knowledge gap. I hope to identify more gaps in the future and address them!

[Leslie Kao]

Submitted by Vivek Reddy:

This reflection will be regarding a clinic patient of mine since I was an intern early in residency. I remember this patient who is a very pleasant elderly lady who came in with an elevated blood pressure. She has multiple other medical problems including diastolic congestive heart failure, Osteoarthritis, COPD and allergic rhinitis. At the day of her visit her blood pressure was elevated despite being on oral anti-hypertensive medications and my line of questioning started with her overall well being and eventually directed to her chronic medical conditions.

The patient told me that while she was given a diagnosis of hypertension, she did not like taking her medication as it caused her to urinate excessively making her daily activities difficult. I was well aware of untoward effects of medications, even if these were expected from the medication ( i.e. excess urination after starting a diuretic ) and I discussed with her the idea of switching to another medication to increase adherence. After further discussion the patient told me she believed that her elevated blood pressure was secondary to being stung by a bee and she did not believe that medication was needed.

At this point I realized that while this patient was very understanding and had no intention of being non-compliant with her medication, there was a clear lack of understanding of her disease process/processes. This patient believed that her diagnosis of hypertension was reversible and genuinely felt that these medications were not needed and the presence of this medication was causing unfavorable symptoms ( excess urination ).

I then started explaining to her such that she could understand her underlying conditions and not only was she grateful she understood the importance of medication adherence and also understood that whenever she had doubts with our medical practice she could verbalize her concerns.

It occurred to me that when a patient does not take medications or missess appointments, it is important to assess for the presence of a knowledge or communication gap. I hope that I am able to identify more patients with such barriers in the future.

[Leslie Kao]

Submitted by Khaled Janom:

I will start with a plan for myself. I will try to the best of my capability to understand what my patients are going through or went through socially and economically and try to incorporate that into the way I plan to help them. When you think about it, “minor” details in the patient’s story get overlooked when we as physicians try to know the medical history. We rush to the facts relating to the medical knowledge we learned at school. Why wouldn’t we? We spent the last four years, immersed in the vast medical knowledge and we had little time to contemplate the sociological aspect of medicine. When we study a disease, like heart failure, we never find in books “inadequate transportation” or “low income” as a cause of heart failure exacerbation, we conclude that adherence to treatment was lacking. I am optimistic however because I am acknowledging the “minor details” more often since I started my residency. It could be because I am living and training in Detroit, and thus I am seeing more examples, but I am sure it is because I am exposed to these obstacles more these days.

[Leslie Kao]

Submitted by Scott Smith:

The American healthcare system at its best provides underserved populations with a very basic safety net but is not great at giving comprehensive care. At its worst it ignores the needs of the underserved and they slip through the cracks until they come to the hospital with a health crisis. The unfortunate reality is that the system in its present form gives the best and most comprehensive care to those who can afford it, and safety net programs cannot match the funds that premium plans have available. Even if this injustice were remedied, the at-risk populations would still have difficulty attaining good care. Other factors prevent them including lack of reliable transport.

One of my patients Mr. S is an elderly gentleman who has multiple comorbidities including hypertension, COPD, and ankylosing spondylitis. Luckily his diseases are not very advanced and he has been very adherent with recommended therapy, but he does not have reliable transport to and from his office visits. He doesn’t have his own vehicle but can arrange transport through Medicaid. However it takes a lot of planning I order to plan these rides. You must arrange the transport few days in advance and then must set aside a block of time to wait for the transport. Sometimes the rides are not available that day. It is definitely not the optimal situation like a person who has their own vehicle, but Mr. S is unemployed and cannot afford a vehicle.

The problem of reliable transport is one that certainly affects at-risk populations more. It is a question of available cash and many at-risk individuals cannot devote that kind of money when they need to spend it on more important things. Bus systems can be used but take much longer than driving directly, and those who are working need to take off entire days just to go to an appointment. Medicaid rides are a great resource but not everyone has Medicaid and those who do may not know how to access these services.

One thing I will incorporate into my clinic practice is to assess how my patients plan to come to their appointments and recommend such resources if they need them.

[Leslie Kao]

Submitted by Nadine Abdallah:

When I first started seeing patients in clinic, I was excited to apply what I had learned about the recently updated guidelines on the management of hypertension, diabetes, dyslipidemia…, to preach about the DASH diet, exercise, and weight loss, but soon I learned that the task what not so simple. It was frustrating to see the blood pressure and HbA1c were not dropping, despite prescribing the right medications. I couldn’t understand why patients “can’t just take the medication”, “stop eating fatty food”, “schedule that mammogram”, or simply “not miss their appointments”. Unconsciously, I started labeling patients: “The lady who never takes her medications”, “the guy who never shows up”…, and became less zealous about treating them. However, several months into residency, inpatient rotations, and encounters, I came to realize that prescribing the right medication was not enough, and that the reasons behind non-adherence were not “laziness”. I started to investigate, and was met with answers that made me ashamed of the labels I had attached, and judgements I made. Of the answers I got, were: Lack of transportation to pick up the medication, loosing insurance, working full time and not having time to go to physical therapy or schedule the mammogram, not affording to join the gym, not affording the blood pressure machine, eating fatty food instead of healthy food because it was cheaper… Although this helped me “realize” what the problem was, a more difficult task arose, which is the: action. I was not taught in medical school what to do in such cases. I learned from my seniors and supervisors how to get creative. Asking patients to check their blood pressure at nearby pharmacies if they can’t afford a machine, cheap generic drugs at local drugstores… However, I still feel helpless in many scenarios that are beyond any creative solutions.
What I have learned to so far is to ask, inquire, and investigate, and tailor the management to the resources available, which can only be achieved by establishing a relationship with the patient and collaborating with them. Sometimes, they can give you the answer that books and websites cannot. What I hope to acquire throughout the rest of my residency is more solutions, and ways to work around the social, economic and transportation hurdles, to achieve the desired health goals.

[Leslie Kao]

Submitted by Amjad Kanj:

I still remember very well the cultural shock I had one year ago when I moved to Detroit 48201. After my first clinic week, I was left with many questions: Who are the patients that we serve and why are they all “black”? Where do they live and how come they are so poor? Are they insured, under-insured or un-insured and who pays for their medications, clinic visits,hospitalizations…?

To be honest, till now, I still don’t have answers to most of my questions. But I came to realize that understanding the demographics of the population we serve is essential for us as physicians to properly serve that population. We need to understand WHAT is going on in 48201. Seeing patients at the hospital and in the clinic for a year now, made me realize few simple things:

-Patients miss appointments because they can’t find or afford a ride to the appointment
-Patients eat fast/processed food because we have very few grocery stores in 48201
-Uninsured patients go to the ED for simple stuff, because we have very few clinics for the uninsured in 48201
-Free clinics can significantly decrease the financial burden on the healthcare system by decreasing unnecessary visits to the ED
-Many patients in 48201 who couldn’t afford care few years ago are now able to because of the affordable care act
-ETC…

I wish I can fight poverty, improve transportation in the city, or open new grocery stores, or provide care for to all the uninsured and underinsured… but there is one thing I can do to help, and I have been trying to work on this since day 1 of my residency and that is to KNOW MY PATIENTS to be able to help them as much as possible. I hope this new “reflection Friday” program will help me achieve my goal.

[Leslie Kao]

Reply by Jarrett Weinberger:

Great post! We often get jaded as physicians thinking that people don’t want to change, however, your story reminds us that people do not want to be addicted to substances but a lack of rehabilitative services certainly contributes to continued addiction.

[Leslie Kao]

Reply by Chyrisha:

The comorbidities of an individual living in poverty with one health issues can seem infinitely more insurmountable. I think that reflecting on who this woman is as a person, where she comes from, what her life is like, was helpful in your decision making. Her life struggles undoubtedly contribute to her weight, genetics can only go so far. After seeing that she is actively engaged in the clinic weight loss program, she seems to be taking a step in the right direction.

[Leslie Kao]

Submitted by Lubna Fatiwala:

Ms I is a 29 year old female with morbid obesity (BMI 77), OSA, Arthritis & Hypertension who came in to be evaluated for low mood. Patient reported symptoms of low mood/energy, sleep disturbance, increased appetite etc that had been going on for 1 month now without suicidal/homicidal ideation. When I inquired about her stressors, she said her financial situation was topmost on the list. She had been unable to secure and maintain a job for longer than a few months, her bills were piling up and she had difficulty providing for her family. I had to take a step back here, when I posed this question the obvious answer I was expecting was the inability to lose weight causing her to have these issues. But it runs deeper than that, was it her weight that had caused her to be in this financial crisis or was it the financial issues that had perpetuated her to reach this point. She was enrolled in our weight loss clinic and participating in a 6 month course of exercise classes before being eligible for bariatric surgery. She obviously cared about her health and had made an active effort to get on the right track. If I were to place myself in her shoes, not having enough money and trying to eat healthy is certainly challenging. Adding a third factor of not having the will or energy to get up in the morning to care for oneself can be crippling. Perhaps the problem runs deeper, a lifetime of poor dietary education, poor access to healthcare, regular follow ups, and ultimately poverty was the primary cause of this young woman reaching this point of hopelessness & despair. Her PHQ-9 score was consistent with mild depression, we agreed to pursue counslelling as the next step. I asked her to see me in 5 weeks so we could track her progress.

According to the Pubmed article on epidemiology of depression “Caring for chronic illness takes patient planning, time, and motivation. Depression may impair self-care of chronic illness by adversely effecting memory, energy, and executive function. Moreover, the sense of helplessness and hopelessness associated with depression may decrease motivation to care for chronic illness. A systematic review by Dimatteo and colleagues found that comorbid depression in patients with chronic medical illness decreased adherence to self-care regimens by threefold” (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181964/)

Social Inequity in healthcare can have a detrimental effect on patients’ mental health. It can have a negative impact on the long term management & prognosis of comorbid conditions. On an indivudual basis these patient need extra attention with motivational counselling & more frequent office visits. On a population basis improving education, access to financial and health resoruces may in the longterm raise awareness and help build healthier & wholesome communities.

As an individual doctor I can be more mindful of patients’ social situations and the impact it can have on their mental health. Instead of getting frustrated about noncompliance and blatant disregard for medical advice I can try to understand why patients are forced to make unhealthy choices for themselves. Being pounded with the same barriers over a lifetime can really wear a person down. After the lecture on Friday I can now link Ms. I to our wonderful social worker Ms Millen Carr where she can find resources to address her financial issues, and possibly link her with organizations such as “Forgotten Harvests” where it wont be a challenge to access nutritious foods so she can get back on track towards a healthier life. By doing so I can rest a little easier knowing that not only have I taken care of her as her doctor but also as a human being.

[Leslie Kao]

Reply by Chyrisha:

The homeless population is unique in that not only do they have this social identity of not having a place of residence but they can also suffer from a host of other ailments and illnesses. Cleanliness is a chronic struggle for this population and your thought to consider their life circumstance along with your treatment choices will be influential in his ability to tackle his health problems.

[Leslie Kao]

Reply by Ijeoma Nnodim:

Great reflection!

[Leslie Kao]

Reply by Chyrisha:

Great post. I think that the (re-)education of the risks of smoking outside of interactions with the asthma is greatly important. Hopefully, the fact that you took the time to review the associated concerns with smoking and helped her to state a conscious intention to try to stop smoking, will actually result in cessation. ?

[Leslie Kao]

Reply by Ijeoma Nnodim:

It can be very frustrating to provide care within the limitations of an unfair society. I absolutely agree with your approach to determine the things we have control over and what we can’t, let go. It is commendable that you acknowledged your limitations to your patient and then re-focused him on what you could actually do for him. Sometimes, we may find it difficult to even acknowledge our limitations, fearing that our patients may view us as less than. However, this is not accurate as it usually strengthens the physician-patient relationship, builds trust, and empowers the patient to participate in their care as the doctor is not “God”. I’m curious, what other information – personal experiences, literature, peer or faculty impressions/assessments can you apply to your impressions? Also, what specifically does it mean to be a “better physician” to you?

[Leslie Kao]

Submitted by Madiha Salim:

Mr. S is a 47 yo with HTN and history of alcohol use disorder presented to my clinic for a follow up for HTN. When I walked into the room, the first thing I noticed was that he had a hopeless look on his face, he was constantly fidgeting with the table corner. I started the conversation and he immediately told me that his last hospitalization where he developed DT was a wake up call, he does not want to drink that way that he ends up in withdrawal and experiences DTs. He states that he has learned his lesson, however he has a had a difficult time returning to normal life since he was discharged from the hospital. He stated that he is trying hard to find a job, stop living in a homeless shelter but he has not been very successful. He states that he is surrounded by the people who always influence him into drinking and drugs. This is not the route he wants to go but he has a difficult time making his life more stable.

As Mr. S spoke about his obstacles in trying to build a better life for himself. I tried to think about how his opportunities are so limited and how socially biased of a society we reside in that people who are trying to change and become better for themselves and care for their health are having a hard time doing so.

As we read in the article that there are serious discrepancies in social issues that also determine the a person’s health outlook and future. As seen that living his poverty has a great impact on where you end up, the resources maybe available but may not be easily accessible for these individuals. The core issue of homelessness and aggressively pursuing initiatives for patients who are willing to make seek better opportunities for their future, should have a better way of trickling down to those who truly utilize it. The healthcare inequality issue is strongly correlated to the program with such initiatives.

This encounter with Mr. S. was a reminder that there is still extensive work that needs to be done in order to create better initiatives for those who are truly willing to make their lives better and do have genuine care for their health problems. This is also a reminder that we can not be biased as physicians to let every patient with a drug addiction to be labeled as drug seeking, as we will see patient who do truly would like a better future for themselves.

[Leslie Kao]

Submitted by Tamara Mansy:

Mr. J is a 67 YOM with PMH of HIV, DM, HTN, depression and COPD came today to establish a primary care. I noticed that his clothes are dirty and smelly and his eyes were sad. Upon history taking he was found to have some bothersome cough lately concerning for TB. Off note he is a homeless living in a shelter and sometimes sleep in the street. I talked to him about the possibility of having TB or any other serious infection that can have increased risk due to living in a crowded shelter with similarly sick contacts. He then looked down and started tearing and said “I wish I could afford a better living for myself!”, for the first time I found myself stuck in my words not being able to answer, I could only rub on his shoulder and say I understand, and he started to release his words and frustrations. Then later, whether or not he had TB, I talked to him about the importance of being aware of the surrounding people’s who might be sick and the significance of seeking help early especially when you can’t change your choice of living (high risk place).

Lots of studies are being published about the infection rates among homeless and those living in shelters and poor hygiene places, and most of them agreed on providing education, safe practices and free TB screening to those people living there. To control the spread of TB, it require early detection of cases and outbreaks in shelters, screening for those persons with whom the infectious person has had contact and effective treatment

As a physician I will always start with listening and sympathy, especially when there is no a lot to be done, this is the first step in building the trust and help my patients get the best care and also to make them convinced with their treatment choices even though life is hard sometimes

[Leslie Kao]

Submitted by Maninder Kaur:

Ms. Polk is a 46 AAF with PMH asthma, paranoid schizophrenia, anxiety comes to the clinic for skin infection. Since last 1 year she has been suffering from various skin infections. During my first encounter with the patient in clinic, I came to know that she is on oral steroid and inhalers for moderate to severe asthma for 30 years. She has been smoking 2 packs of cigarettes per day for 32 years despite having exacerbation of asthma due to smoking. She was already prescribed nicotine patch by her pulmonologist. So, I thought she must be having enough knowledge about smoking side effects and its effect on causing exacerbation of asthma. Just to check her underlying knowledge about smoking, I asked few questions about asthma and smoking and she replied that it causes worsening of my SOB and I know only this. I realized that the level of knowledge of that patient regarding smoking is less and moreover she was not using nicotine patch. Then I explained her all side effects of smoking including caners, risk of heart attack, aging and her dependency on steroids causing immunosuppression and infections. Then She replied, Doc I was not knowing all these things and yes, I will try to reduce smoking first. I was contended because at first, she was not willing to listen my advice regarding smoking and at the end of our conversation she agreed that smoking has ill effects on her health and she needs to stop smoking. She was my last patient that day and I was very satisfied that I could convince my patient regarding smoking cessation and to join her free telephone counselling and to resume nicotine patch.

According to article in uptodate 2017 “smoking cessation management in adult “there is a clear evidence that brief clinician advice to quit at each encounter can increase smoking abstinence rate. Even if they are not ready to quit, smoker who are asked about their tobacco use or are advised to quit smoking report being more satisfied with their care than patient who do not receive such advice.

I think empathy and interactive communication are the very important part of medical profession. An effective communication process can optimize the chance that patients will make informed decisions, use medications properly, and meet therapeutic goals. I believe that by providing a good education about smoking effects on health and various smoking cessation methods we have, I could convince my patient or at least I have made her to think about stopping it. But for these patients you must remain very vigilant and persistent on every visit to change their behavior.

Next time when I see a patient suffering from substance abuse, I will try to provide every single piece of information to my patient in an empathetic and effective way. First, I will broaden my knowledge by reading more about substance abuse and methods of cessation and then I will make sure that I provide this information to my patients consistently during each visit.

[Leslie Kao]

Submitted by Adi Shemesh:

Mr. P is a homeless 43yo white male w/ MHx of seizures, R rotator cuff tear, R inguinal hernia repair presents to the clinic for right wrist injury. Was stabbed at the R wrist two weeks ago. Attended an urgent care center, got his wrist stitched, never referred for hand surgeon but rather to his PCP, which he couldn’t see due to changing insurance. During our encounter, he expresses his frustration at how the health system leaves behind the unfortunate ones considering he needed an urgent appointment but could not make one due to insurance issues. Now, he may have permanently lost function in his right and dominant hand, which could significantly impact his ability to support himself and even perform functions of daily living. In response, I acknowledged that the health system has a long way to go before I can fend for it and the way it biasly distributes health services to the American public, and that I all I can do is provide him the best care possible henceforth. The patient let go his frustrations and became more cooperative at this point, and it seems that I managed to establish an important aspect in healthcare that unlike social determinants is under my control – a good relationship with the patient on this first encounter.

As a physician, I took an oath to provide the best care to my patients regardless of their financial status. Unfortunately, I frequently find myself shackled by the limitations imposed by the healthcare system and have to find alternative ways in order to provide the best possible care rather than the best care to my patients. In order to do so, I plan to continue to focus and becoming a better physician so that I can provide the best care possible.

[Leslie Kao]

Submitted by Yeohan Song:

Mr. C is a 47yo AAM with hx of C6-C7 spinal fusion s/p MVA, GERD, and esophagitis confirmed on EGD, who presents to clinic following an ED visit for chronic back pain not quite relieved with his prescribed analgesics. As he walks into the room, he appears disheveled, yet committed to improving his current circumstances. After sharing initial words of greeting, we move on to the reason for his visit, and the reason for the patient’s appearance becomes clear—he is homeless, struggling to find the means to make ends meet, with chronic back pain that he feels never quite goes away. He already follows with a pain medicine clinic, but feels as though the medicine is just barely enough to take the edge off of his physical pain, leaving him to continue his struggle with the emotional and social stress of living in a homeless shelter, unable to turn his life around no matter how hard he tries.

As seen in the article by Dr. Marmot, one look at Mr. C will make it abundantly clear as to why there is such a large discrepancy in life expectancy not just on the international stage comparing one country’s population to another, but within the social spheres of the local community, with factors such as living in poverty, relying on whatever the shelter is able to provide on a given day, and facing the constant stress of chronic pain, social exclusion based on homelessness, and an increased tendency toward substance addiction. The more that can be done to address the core issue of homelessness and to support these patients’ initiative to find the means to pull themselves out of this unfortunate situation, the sooner they will be able to find some footing in the uneven terrain that leads to the healthcare inequalities so commonly seen among this population.

This encounter was a reminder that there are people going through a hard time in life, who still hold on to the hope that they can catch a break and work towards a better future. In Mr. C’s case, I learned about the available social work services in the clinic, a resource I was not aware of previously, and was able to connect him with someone who dedicates her time and effort to helping motivated individuals rise out of the mire of poverty to grasp a better tomorrow. I look forward to seeing Mr. C again, in a better place and with renewed hope in himself and in others.

[Leslie Kao]

Submitted by Kenisha Evans:

Ms. J is a 54y/o obese woman with HTN who presented for health maintenance. She lives in AFC home, and has been adherent to bp medications. She presented with no acute events, she is not a smoker nor does she drink alcohol. Social Hx consist of former smoker, illicit drug abuser and has been drug free since Dec. 2015. To date Ms. J has had a difficult time maintaining normotensive levels in bp just above 140/90s. Unaware of the dynamics of her housing, I discussed DASH diet and importance of daily exercise. When she being to explain the meals that are prepared for her, I realized how can I educated a woman who currently doesn’t have control of the food that is provided and prepared for her. Additionally, the daily activities that are schedule for her as a member of the AFC home, cleaning the house and her job working as a janitor cleaning a concert stadium contributed to my lack of appreciation for her living dynamics. Prior to being place in AFC home she had been unemployed living in shuttler.

Objective
As the article entitle “Social Determinants of Health Inequalities,” stated “a focus on material conditions and control of infectious disease must not be to exclusion of social determinants. The circumstances in which people live and work are important for communicable as they are for non-communicable disease.” In Ms. J case I thought of ways she could improve are activities of daily living that could benefit her health. I told her to ask for more of the green leafy foods in proportion to small size of other items on her plate. While working take breaks walking up and down some of the stadium stairs every other day in addition to routine work. My plan with next clinic visit to find health affordable snacks she my request or even purchase.

Assessment
I realize I don’t have an idea of what is provided in an AFC home or any transition housing system that may have a positive or negative effect on the health of my patients.
To effectively address my patient issue it is necessary to gain knowledge about limitations that may alter course of patient care. As stated in the article “Social Determinants of Health Inequalities, “treating existing disease is urgent and will always receive high priority but should not be to the exclusion of taking action on the underlying social determinants of health.”

Plan
My plan is to learn more about the settings of AFC homes and how they help manage heal thing living for their occupants.

[Leslie Kao]

Submitted by Catherine Czesnowski:

This Thursday at GMAP I had a patient who presented for f/u after a hospitalization for right LE cellulitis and mildly decompensated diastolic heart failure. She is a 51 yo AAF with severe morbid obesity with a BMI 61 among other comorbidities including OSA, COPD, pulm HTN, essential HTN, hypothyroidism, and OA. We discussed her hospitalization, her progress, medication changes and compliance. As her previous visit note stated she was referred for bariatric surgery, I wanted to touch base whether she follow up or not. She immediately became very uncomfortable, irritated and defensive when discussing her weight. She said she was attending classes on the surgery and immediately stated “ I know I’m heavy, why do you have to bring it up?” I explained the reason to discuss it was being overweight affects your health in many ways and contributes to many health problems and leads to premature death and I wanted to document whether she had a chance to follow up with the referral. When I tried to infer about eating habits and activity she blurted out ‘why do you assume bc I’m heavy that I eat too much and don’t do anything, I don’t eat much and I’m active”. I understood the patient likely had very poor insight to nutrition and I tried explaining that one’s weight is a balance between the nutrition/food one consumes and the energy expended. She continued to be angered by the discussion so I apologize for making her upset and that I understood it’s a sensitive topic and I didn’t mean to be insensitive. We summarized our plan for the encounter and I told her I would return with my attending for the final plan.

The patient was in clinic that day to discuss her cellulitis and recent hospitalization. She probably thought I was making judgements on her appearance bringing up her weight which is not how I intended to make her feel. I wanted to make sure she was having proper follow up on chronic conditions. She likely thought I had no insight into her life as we had not developed a relationship previously and she follows with another resident and attending on a regular basis. I think the biggest mistake I made in the encounter was assuming the patient would want to discuss the topic of obesity as it had been a discussion in the past. I should have asked her if it was ok to discuss her weight or if she would like to have future visits to focus on weight loss.

This patient has severe morbid obesity and multiple obesity associated conditions and literature shows reduction of 5-10% of body weight can have a significant impact on improving comorbidities. This should be the initial 6 month goal in weight loss. People living disparaged communities such as ours have such limited access to resources and programs that promote health and physical fitness and are burdened to survive on a low income which further fuels this already difficult situation. The initial factor to successful weight loss in obesity is willingness/readiness to lose weight. Also, having a support system which you feel comfortable discussing your weight,diet, progress or failures is paramount.

The take home I got from this encounter is when to discuss weight loss with someone who suffers with obesity. Yearly physicals and new patient visits are a great time to assess their BMI and willingness to lose weight as that is the time their general health is being assessed. Often times, it is not something to discuss or focus on unless the appointment is scheduled for weight loss management or significant weight gain is documented from the previous encounter. As it is a topic/condition that creates a lot of self turmoil and feelings of inadequacy it should be approached in the most delicate of ways. Furthermore, when someone is willing and asking for help I should have some concise resources available to give them. In turn, I downloaded some simple calorie based meal plans and emailed them to my inbox so I can print them when I am asked by patients. I reviewed some behavioral techniques I can counsel my patients to utilize. I will be more self aware on how I discuss sensitive topics with patients and be mindful to create an open line of discussion where the patient feels comfortable with the conversation at hand.

[Author]

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