[Yellow Cohort] Module 1

[Leslie Kao]

Module 1 SOAPs

Beyond Health Care, Heiman HJ et al.

Social Determinants, Marmot M.

[Leslie Kao]

Submitted by Kalyna Jakibchuk:

S: It is unfortunate that patients are not able to get the same quality of care based on their income/socioeconomic status. This can create frustration for patients and physicians.
O: A patient of mine has atrial fibrillation and was not able to consistently come to coumadin clinic so he was put on eliquis. This drug costs hundreds of dollars and the patient says he cannot afford it. We provide samples for the patient when he comes to clinic while his insurance covers only a portion of the payment.
A: I wish I knew more about resources available to patients like him
P: Discuss with our nurses in clinic, what other options may be available to help him pay for this drug

[Leslie Kao]

Submitted by Shanker Kundumadam:

S : Perception of the topic
Article that we read at the beginning of the week dealt with the inequalities between the populations especially within a wide geographical distribution. There are multiple factors within such contexts as poverty, access to education etc which determines the status of health. In our clinic we don’t see patients from a wide geographic distribution but we do have patients who are immigrants.

O
My patient is a 70 year old female who is an immigrant from Bangladesh and she lives as a dependent with her daughter and son in law. She has cirrhosis from NASH and has had at least 3 to 4 admissions in this year for hepatic encephalopathy and uncontrolled diabetes. She came to US about 2 years ago and until then was completely unaware of the diagnosis of cirrhosis or any liver disease. We could say that from the circumstances which she came from and the part of the world she lived in earlier it is likely that she may never have had a regular medical evaluation as we have in US. So most of the times the diseases are not diagnosed at an early stages. Once they come to US there are couple of issues they face one being financial as they are dependent on their family (especially geriatric immigrants ) and also the language barrier. They are at much higher risk for elderly abuse. In this patient the major factor which was leading to the recurrent encephalopathy was that she did not have a good family support despite she living with them. The daughter was not aware of her medications and they had a care taker who was also an immigrant (who cant communicate in English). This caretaker was the one giving her medications and we noticed that she was getting H1 anti histamines round the clock and also was not getting regular doses of lactulose. We had a discussion with the patients daughter about these issues and made her aware of the importance of having a good support for these patients who are by themselves dependent on others. Considering her recurrent admissions and she not being a candidate for transplant we wanted to address the code status too. But in many countries outside US code status discussion is not something which is usually done.

A
I believe I was able to bring into the attention of the family about the need for more attention towards her care. We also discussed about the option of placement in her case if the family doesn’t have the resources needed. We also successfully initiated a conversation on goals of care. Myself being an immigrant having done med school in an outside country I remember most of the times we initiated the code status discussions as the patient is actually coding.

P
In the future in dealing with these kind of patients who are immigrants and especially geriatric population who are dependents we have to spend more time into the family dynamics and also in tackling the language barrier. We have to be watchful for cases of elderly abuse. We need to address the goals of care as many of these populations are not aware or used to such discussions.

[Leslie Kao]

Submitted by Deya Obaidat:

Patients of all races, socioeconomical statuses, level of education or gender supposed to be having the same healthcare, in a perfect world two random patients with the same medical condition should be treated the same way and should be having the same health baseline, but unfortunately this is not the case in our world, poor patient will be having trouble getting to their appointments, getting their medications and being able to reach the healthcare provider. what is even more unfortunate now that poverty nowadays is an excuse to have a bad health condition.

Ms C is a 48 year old female patient with PMH of HTN, DM type 2 with CKD stage 3, last seen in the clinic back in 2016 and she didn’t see a doctor for about a year and a half when she came up to the clinic 30 minutes late for her appointment, at the beginning I thought that the patient was doing this because of ignorance to health medical condition as HTN and DM are painless conditions that patient won’t even have any symptoms from until they get a complication, but the patient the patient was ahead of me when she addressed the real reason why she doesn’t come to the clinic more often, she told me that the real problem that she has problems get into the clinic because she doesn’t have a car and it is difficult for her to get into the clinic in time most of the time. that was my first real encounter with a patient who tells me that she want to be treated the right way but has a problem getting into the place to do it, we’ve been taught about that matter back in med school that this is one problem that we can face with patients specially those who live far away from the hospital but I’ve never thought at the back of my mind that this is a real issue, I always thought that my Doctors at med school was exaggerating the situation until I’ve seen this patient in the clinic.

I do believe that the patients differences (including the socioeconomic status) shouldn’t be a reason to treat one person better than the other as it is the right to ever person to have a healthy life away from any stress and illness.
the problem that we have isn’t something that we need to deal with on our own as physicians, it should be involving every person in the society which require us to work as one hand to achieve equality in terms of healthcare for everyone.

although I feel like I’m handcuffed when it comes to how should I be dealing with this as I’m only one person in a huge community that needs to stand up to address this important situation, but I really started to feel like I can understand how the social determinants can really make a big difference in the patient’s management, and I feel like I’m obligated to discuss this issue with my fellow co-residents as well as my attending physicians so we all can stand up together and address this issue as a whole.

[Leslie Kao]

Submitted by John Dawdy:

S:

The article supplied for this week’s reflection was an early article published by the WHO’s Commission on Social Determinants of Health in 2005 at the beginning of their formation and tried to lay the foundation that addressing social determinants of health is an important public health goal moving forward. They illustrate this point by using global health statistics and identifying how social factors such as socioeconomic status and education can impact various health outcomes both between and within countries. What I believed was the goal of this article for the purpose of our weekly reflection was to make us aware that these social determinants of heath are a force that we need to account for in each of our patient interactions in order to best address “the causes of the causes” or the conditions that really give rise to the health disparities we see within our city. Within our hospital system it is difficult to avoid realizing that there are a tremendous number of social factors that limit our patient population’s ability to achieve their health goal or even perform the bare minimum recommendations to keep them functional. From day one of residency we often feel smacked in the face with the tremendous number of social barriers that we must hurdle in order for our patients to fill their prescriptions, attend their appointments or be discharged from hospital safely. It is not uncommon to hear both residents and attendings alike bemoan the time-consuming nature of these social aspects of care. However, it is often these efforts that allow our patient to see the results that we strive for, or at least to be able to make it to their next appointment without hospital admission. These social aspects of care are necessarily included in each of our patient interactions and our awareness of them is what will allow us to provide them with the best care possible.

O:

An important social determinant is community/social support and is the focus of my patient interaction reflection concerning two different patients that I saw in clinic this week. These two patients had different issues concerning their wheelchairs. The first patient Mr. W, had the arms stolen off his wheelchair, making transfers very difficult and making his day to day activities much more taxing. He had bilateral lower extremity amputations and lived on his own in an apartment without any family connections. Although our office had sent the required paperwork to the equipment supplier, the patient had no transportation available to go pick up the new arms. His medical transportation service would not cover this trip and he had no family of social support to provide him with assistance. After the initial rejection by his transportation company the patient stopped following up and never received the new wheelchair arms. At our visit this week he brought up this issue again. With a phone call to the equipment supplier our office arranged for them to drop off and install the new arms the next day. All it took was a phone call and an explanation that the patient didn’t know he could make, but now his daily functioning will be significantly increased moving forward, allowing him to better care for himself. The second gentleman was Mr. P, who was getting a custom wheelchair made. Mr. P has multiple sclerosis and had excellent family support provided by his sister and nephew. Although they had to jump through many hoops in order to get this paid for by his insurance, their persistent support allowed them to receive this with little input outside of paperwork from our office. The difference between these two cases illustrates the varying degree which our patients will rely on our assistance in order to complete similar tasks. Taking the resources that each patient has at their disposal is necessary in order to allow them to adhere to treatment plans as best as possible.

A:

My background in public and environmental health has provided me a solid foundation of knowledge and awareness that the social aspects of health are an essential aspect of community and individual health. Along the same vein, my experiences as a medical student here likely gave me a head start on some of my colleagues knowing what to expect with our patient population here in Detroit. That being said, we are working with a population that this becomes readily apparent from day one of our residency. Fully understanding how the social aspects of health impact our patient population individually and as a whole presents a challenge, and understanding each of their stories is important to provide them care as an individual and not just as a disease process. Working with them to provide not just information and recommendations but to provide a workable individual health plan is necessary to provide them the best chance to succeed in achieving their health goals. Understanding and taking into account the social determinants of health need to be the starting point of these individual plans and an important part of our curriculum.

P:

My broad goal for the week was to ask why whenever one of my patients did not adhere to a previous plan of care, and my more targeted goal this week was to become more aware of the services offered by medical supply companies in the city as it pertained to my patients and how best to interact with them. Although this will continue to be a work in progress, I know that I am more comfortable interacting with these companies today than I was this time last week.

[Leslie Kao]

Submitted by Lea Monday:

S: what is my perception/feeling of the topic/encounters.
-topic article was about health inequities all over the world. I found it interesting that there is such a discrepancy in health and aging outcomes between aboriginal people and others in Australia, yet I would have easily know those issues exist in America in our Native American population comparisons. I am often quick to judge America as an extremely racist messed up disfunctional country founded on violent and exploitive means and now therefore suffering those violent consequences. Sometimes I forget these inequities exist in other first world countries as well.

O: a summary of interventions/skills I performed.

Skills gained was meeting dr Carr and learning about other resources I can reach out for to help my patients. The handout she gave us was a wonderful summary tool

A: my assessment of my performance/understanding/awareness
– the article was a lot about discussing inequities and not much on solutions. Dr carrs information was more helpful. I cannot assess yet how I will use this tool because a situation has not presented since Friday but I am glad to have it for future.

P: My plan for improvement or new challenges.

I plan to spend more time reading about resources for my patients and trying to volunteer a few times with dr Carr. I’m tired of being encouraged to do “research” for my “cv”, I’d rather get better at helping real people. I’m tired Of hearing about how much “research” the world is doing but my patients don’t even have water or a ride to clinic.

[Leslie Kao]

Submitted by Shivani:

S: Social inequality is something we see every day in the diverse patient population we serve. It can be challenging for patients to navigate the complicated medical system. Someone may be smart, but health literacy can be complicated.
O: During this clinic week, I saw a follow up patient. She is a mid 20s aged female who had complaints of wide spread body pain. On previous visits, she had been referred for PT, imaging and specialty evaluation. However, she was unable to follow through with the appointments. To further complicate matters, she has several young children and her significant other is hospitalized with a severe diagnosis.
A: From the history and exam, it seems that her pain has a psychological component. We spent quite a bit of our encounter reassuring her and offering her resources to help make her life easier. For example, we gave her a print out of exercises she could do until she can see PT at her previous visit. We also looked up resources to help her with her children. We also gave her appropriate medication for her condition until she can complete her work up.
P: Medicine does not always have a clear answer. We have to balance what the patient wants versus what the patient needs. It is important to consider all the factors that can affect a patient’s health and well being. In the future, I will continue to take a holistic approach in my patient’s care. I am glad to know about the services Dr Carr’s clinic offers, I will refer appropriate patients to her.

[Leslie Kao]

Submitted by Nabil Al-Kourainy:

Subjective:

One of the reasons that many of us, myself included, chose to train in Detroit is because we wanted to treat and learn from a medically underserved and often underrepresented patient population. The socioeconomic realities of the majority of Detroit’s inhabitants lend themselves to a level of disease severity and comorbidities that while not unique to Detroit, are certainly greater than the American average. While this presents the budding clinician with a golden opportunity to treat severe pathologies, this also comes with the charge to help address the social determinants of health that lead to the disease disparities seen amongst the Detroit patient demographic.

Objective:

As a Wayne State medical student I took advantage of a myriad of clinical and community outreach volunteer opportunities that going to school in Detroit offered. Through that experience I realized that as Dr. Marmot stated in the article, that economics are only part of the story. While Marmot’s article does not address this directly, I feel that it is important for us to discuss the realities associated with being homeless in Detroit, especially since so many of the patients we encounter at DRH in particular, fall into this category. Beyond simply financial there is a stigma that is associated with homelessness. I remember a lecture I attended in medical school where one formerly homeless gentleman said that the hardest part about being homeless was that people stopped treating you like a fellow human being. He said that people walked right past him when he was homeless, failing to acknowledge that he was even there. He said this experience made him feel less human, and was far more challenging than the economic realities of not knowing how to make ends meet. I reflected upon this and realized that I too was guilty of failing to acknowledge the homeless at times for fear of safety concerns or worrying that I would be solicited for money.

In addition to the dehumanization, I learned that there is often a great deal of mistrust of the medical profession as a whole within the homeless population. The reasons for this are certainly multifactorial, however I heard anecdotal accounts from patients who said they felt mistreated when going into the ED for care, that they were prejudged before they even had a chance to tell their story. Often times they felt as though their chief complaints were not taken seriously because they were homeless.

Another lesson that I learned from treating this population is that homelessness in and of itself is a traumatizing experience. PTSD and other forms of mental illness is common amongst the homeless which often impacts even non-veterans. According to Morton unipolar depression is the “…second highest cause of disease burden amongst adults age 15-59…”

Whereas the perception of the homeless is that they could pose a safety risk to the non-homeless, the reality is that the homeless are often subjected not just to mental abuse, but are physically attacked by hateful individuals or are victims of domestic violence. 16% of homeless persons are victims of domestic violence. Source: The U.S. Conference of Mayors 2013 Status Report on Hunger & Homelessness, A 25-City Survey (2013). Approximately 50% of all women who are homeless report that domestic violence was the immediate cause of their homelessness. Source: “Pressing Issues Facing Families Who Are Homeless.” The National Center on Family Homelessness. (2013).

In addition, the homeless are often assumed to be drug abusers or drug seekers. While drug abuse does unfortunately plague this population, prior to working with the homeless, I never fully understood the reasons why. I used to say to myself, that you would think instead of spending money on drugs, alcohol or cigarettes, you would prefer to buy food, or rent a low cost room somewhere. However, as one homeless patient eloquently put it to me, “What do I have to look forward to?” I learned that many homeless see their situation as hopeless and are often unaware of the community services available to them.

Another misconception of the homeless is that they are just lazy and do not want to work, often preferring to beg rather than contribute to society in a positive way. While this may be true for some, I met many recently homeless individuals who had come onto hard times. One gentleman in particular had five children and had worked as a carpenter since the age of 16. Now over 50, due to the economic downturn that hit Detroit during the recent financial crisis, he found himself out of work for the last 6 months. He was reluctant to ask for help from his children, some of whom still lived in Detroit, because he did not want to burden them as they were also struggling.

Assessment:

We can certainly draw parallels between the Australian Aboriginals and the Torres Strait Islander peoples with our Detroit patients. Like those populations, residents of Detroit are disproportionately affected by a high rate of mortality from chronic conditions such as cardiovascular disease and cancers. These patients have identifiable risk factors like obesity, tobacco use, alcohol abuse and poor nutrition. Many of these risk factors are modifiable and it is up to us as physicians to educate our patients and the community on how lifestyle modification can positively impact their overall health and quality of life.

Marmot makes the point that the life expectancy in nations like Iceland, Sweden, and Japan are amongst the highest in the world, however he does not specifically address the possible reasons for this fact. In comparison to the United States for example, one could say that these three nations are all considered wealthy nations. One possible reason for the difference in life expectancy between these nations and the U.S. is that the diets in these countries are vastly different compared to ours. In Japan for example, moderation is ingrained into the culture, whereas in the States, excess is the standard. Whereas the U.S. is a cosmopolitan society, the above mentioned nations are largely homogenous societies. I believe this plays a huge role in health disparities. In these countries, where people come from similar ethnic backgrounds it is harder to see your neighbor as being “different”. Whereas in the U.S. there is an institutionalized racism which exists which makes it very easy to see black and white Americans as different people. Ethnic minorities often congregate together, which separates them from the greater society. In the Scandinavian nations as well as Japan, the idea of doing things for the greater good of society as a whole are in line with their guiding principles. This is in stark contrast to the U.S. where the capitalistic model rewards individuals who self-achieve, and lambasts those who require assistance, with the mindset that those individuals need to put in more independent effort. There is a fallacy in the U.S. that everyone has the same opportunities to success. I believe that all of these factors contribute to the health disparities that we see in America, despite are vast wealth as a nation.

Plan:

Continue to work to address modifiable risk factors through patient education in the inpatient and outpatient settings. Volunteer with community outreach organizations to increase the level of health literacy about preventable or treatable chronic medical conditions like cardiovascular disease, diabetes, and cancers which lead to greater mortality amongst the Detroit metro population. Continue to work against the stigmas and stereotypes that plague both the homeless and medically disenfranchised. When approaching a patient who is non-adherent try to understand the reasons why rather than simply getting frustrated. It is often tough to put yourself in the mindset of someone else, but as physicians we must try to understand the social determinants of health that lead to health disparities in our community. Only through education of our patients, society as a whole and holding ourselves to a higher standard of care for all individuals can we help to address the social determinants of health that lead to health inequalities and disparity in our community.

[Leslie Kao]

Submitted by James Bathe:

Subjective
Many years ago, well before I started at Wayne for medical school, I was working for my hometown ambulance service. One shift early in my career, I was called to one of our many trailer parks for a 60 year old woman complaining of difficulty breathing. I had just been getting into the groove of prehospital medicine at the time and I was still so wet behind the ears. Even on home oxygen, the patient was desaturating and we scooped her up and started respiratory treatment. Before flying off to the hospital, I performed my secondary assessment and discovered something that burned into my brain. Her left hallux was completely rotted. Dry gangrene crawled slowly into her foot from that dead digit. However, it wasn’t the dying tissue that stuck; rather, it was why she said it was that way. Why she had not been getting regular treatment for her COPD. Why she would die a couple months later. “I can’t afford to see a doctor.” And then I looked. I really looked at her. She wasn’t just my 60 year old COPD’er; she was a poor, black woman living in the middle of “lil Alabama,” and it was killing her.

Objective
At the time with this patient, I was only able to provide prehospital care and only minimally at that as I was a basic EMT and my partner, a medic, was going to helm the call. However, after attending Wayne, I’ve been able to reach out more and provide more than just basic medical care. Social work has been indispensable for educating me about resources available in the community for our patients. If I only had this level of support and knowledge back when I started in EMS, who knows the impact I could have had.

Assessment
I have been incredibly privileged in my life. A white, cis-male whose father was a police officer. For most of my young life, I thought I was in a typical situation. Growing up, going to Boy Scouts, studying to be a doctor someday. I never really thought outside of my bubble until I went to college where I finally was exposed to a more diverse population and could, with some generous help, pull my head out of my ass. So when I decided to pursue EMS as a stepping stone to my medical education, I was immersing myself in life situations that I had not been directly exposed to before. Those initial exposures prepared me to work with a community where there are a lot of negative effects from social determinants. So far, I feel that I have come a long way from that ignorant, young man but that farther I go, the more I see I have to learn.

Plan
Where to go from here? My current plan is to address my lack of knowledge of community resources through active work with social work and through staying in touch with local groups through internet resources. Further, I hope to, through my residency program, have the opportunity to see some of these resources first hand as to cement them in my mind as options.

[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.

[Marc Vander Vliet]

S: Health inequalities are an unfortunate across the world and in our own country. Sometimes these situation can be quite frustrating as a little bit of spending could prevent greater costs to the system, and more importantly, prevent complications to the patient but hurdles in insurance or other factors in our health system prevent common sense interventions.

Objective: I frequently have patients that have issues with transportation in getting to the clinic and to their diagnostic testing. This presents problems for continuity of care and for diagnostic workup. Sometimes I think it can also affect our attitudes as we can make the assumption that our patients are not showing up to the clinic because they are not being responsible. While this might be true at times there are many other factors that can also cause these problems including transportation issues and inefficiencies in scheduling.

Assessment: I think it is important to recognize in ourselves when we are feeling burnt out or getting cynical and always try to do a personal reset. It is also important to remind oneself to be persistent and not give up. I appreciated some of the resources I got to assist our patients with challenging social and economic circumstances.

Plan: I recently utilized on of the resources presented during our social determinants meetings to help them with transportation resources and with finding social work advisors to help them navigate our challenging health care system. I need to continue to remember that these resources exist and try to deploy them when the situation arises.

[wsumed]

The Will to Believe : William James : 9781438520810

[Author]

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