[Green Cohort] Module 1

[Leslie Kao]

Module 1 SOAPs:

Beyond Health Care, Heiman HJ et al.

Social Determinants, Marmot M.

[Leslie Kao]

Submitted by Neelambuj Regmi:

Mr. S is a 67 YO man with HIV, neuropathy, severe osteoarthritis and depression. He was a new patient who wanted to establish a care with a PCP. He was complaining of b/l knee pain. Examination showed crepitation in his knees. He was very thin; temporal wasting was striking. He told me that he had lost 20 lbs in the last 3 months or so. I noticed, he was wearing torn out clothes and during the conversation, he told me that he was very poor, and was not being able to afford healthy food. He was compliant with HIV medications, had been following up with ID doctor. He was trying to do everything possible to maintain a good health. But due to poverty, he was not being able to feed himself. He asked me for a referral to HIV clinic in downtown Detroit which focussed on the dietary requirement for an HIV patient. He also asked for a referral to psychiatry clinic at Detroit City central for his depression. From this, I thought that he was concerned about his health and was trying his best to maintain a good health. He also told me that he had problems with transportation and actually walked 4 miles to get a bus to our clinic. I was surprised that with his osteoarthritis, he was actually willing to walk that far. I was thinking the whole time that even if you try to maintain your health, your economic status determines whether you can live a healthy life or not. But his effort was really inspiring.

It’s well documented that the economic status of a person influences his health. There have been many studies showing direct relationship of life expectancy with the average income. And we read the same thing this week about income and health inequalities. But even though the patient described above was poor, he was trying very hard to maintain good health with all his effort.

I believe that there are many things, that cannot be changed, that influence your health. But there are many things that are just the choices you make. It’s always easier to opt for the easier option, but striving for a better healthy life should be our goal.

From now on whenever I have to choose between the easier “lazier” option and the difficult “better” option, I will remember the patient’s effort and choose wisely.

[Leslie Kao]

Submitted by Hadeel Sahar:

Mr. F is a 60-year-old man, know to have history of metastatic lung cancer. He was diagnosed 3 years earlier, when he underwent a lobectomy followed by adjuvant chemotherapy and radiotherapy. Despite treatment he developed metastasis that was shown upon follow up visit. He received chemotherapy, but his tumor was chemo- resistant with short expected life span. I was the one communicate these bad news for him.
Mr. F came for follow up to the clinic and he was frustrated. He was following with psychiatrist recently. He relates his frustration to multiple factors beside his illness. He stated that “I lost my wife 1 year earlier due to cancer and my kids live far away and never asked about their father “. Mr.F asked “please doctor tell me any good news?”
I sat down with Mr.F face to face with good eye contact and started to inform him about his current medical status. I asked him first what do you know so far about your illness ? After a period of silence, he seemed to be unaware of his current medical situation.Is he denying ? or it’s a lack of information? I decided to communicate clearly with him and told him that: The tests have confirmed that your tumor has spreaded widely and that less likely to respond to any kind of therapy at this point of time”. After a period of a pause and quietness, I started to realize at this point a very much worthier information about my patient.

Studies of terminally ill patients have found that the majority of patients wish to know the full truth about their condition. Furthermore, in most cases, patients who are told their diagnosis in an up-front, clear manner have better emotional adjustments to their situation than those who are not told about their condition. By providing direct, clear information in a compassionate manner, and by making clear to the patient that everything possible will be done to provide medical and emotional support, physicians can elicit trust and reduce anxiety.

As a physician will keep in mind these factors in coping with terminally ill patients:
1.Aid in psychological and spiritual coping process.
2.Assessment and treatment of psychiatric illness:Like major depression.
3.Maximizing comfort.
For example pain control, and other symptomatic discomfort.

[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.

[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 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 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]

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 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]

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]

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]

Reply by Ijeoma Nnodim:

Great reflection!

[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]

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]

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]

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 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 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 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]

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.

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