Sunday, February 23, 2020

Another Social Determinant of Health

Now that I’ve completed my second week at Patan Hopsital, I’ve settled into a routine. Each morning, I arrive at 8am for morning report, at which residents or medical students present an interesting case or two from the previous day. After the social history, the presentation includes two components which I have never encountered before: the patient’s concern and the patient’s expectation (almost invariably, the concern is something like “they are not well” and the expectation is “to go home soon”).

After the presentation and a multidisciplinary discussion, we begin rounds. Our team, consisting of three residents, an attending, and sometimes a fellow, cares for around twenty patients. The attendings stroll from room to room, as the residents scramble to retrieve and replace our patients’ paper charts. Presentations occur at bedside, in a mixture of English and Nepali. The patient’s family features prominently in the history and plan.

Whether visiting the clinic or admitted to the hospital, each patient carries a folder or, when the history is more substantial, a bag filled with folders. These contain everything from outpatient and discharge notes, to lab, echo and imaging reports, to the actual imaging films themselves, to medical bills and receipts. During rounds, we frequently ask the family for pieces of this record. If the patient needs rehabilitation, we ask the family to walk them around the hospital. If blood needs to be sent to the lab, we ask a relative to take it. If a patient needs to be transported, the family does it; if not enough relatives are available, the test or procedure may be delayed. If the patient eats something when they are supposed to be NPO (nothing by mouth), we may scold the family. If no one is at the patient’s bedside, we may ask another patient’s caregiver for assistance. For example, after drawing an arterial blood gas from an elderly man’s radial artery, the resident asked another man—a complete stranger to our patient—to hold pressure on the puncture site for five minutes. He did so, without question or even gloves, as the resident left the room to carry out his other duties.

I consider how some of these tasks may put patients or their relatives at risk. I also wonder what family members think about being assigned these tasks. Are they happy to assist in the care of their loved ones in whatever way possible? Do they consider it an additional burden? Do they accept it as a necessity of a system with limited resources? “Patients here have very low education levels,” several doctors have noted. “They will often do exactly as the doctor says, without questions.” In the words of another’s, “Many people view doctors like a god.”

I’ve only identified a few factors that limit physicians doing what they deem best. The first, and largest, is cost. Nepal provides certain medications (about 70) for free, and is in the early stages of rolling out a national healthcare system, but by and large patients pay their own way. Compared to the US, most medications, tests, and procedures are relatively cheap (e.g. ~$0.30 for a liter of fluids; ~$60 for a CT), but for Nepalis with meagre earnings, these small amounts can add up, even with the financial assistance that the hospital offers. Providers may present choice between a test or treatment that is first-line and one that is suboptimal but cheaper, such as a head CT instead of a MR angiogram for our young woman with refractory epilepsy, warfarin over a novel oral anticoagulant for our elderly stroke patient with atrial fibrillation. In both cases, the patients and their families chose the cheaper option.

Additionally, younger and female family members may cede decision-making to older and male relatives. For a 62-year-old man who fell after drinking two liters of alcohol (double his regular daily intake), we advised treatment of his alcohol use disorder and liver damage; his sons hesitated to agree to this because of his desire to leave the hospital—despite the fact that, in his delirium, he could not state their names, where he lived, where we were, or why he was there, and that he was actively visually hallucinating. When a 35-year-old man was admitted for acute pancreatitis, a potentially life-threatening illness, his wife seemed similarly torn by our recommendations and his demand to go home, and she remained silent when he decided to leave against medical advice (or, as it is written here, LAMA).

In addition to lack of education, poverty, and social hierarchy, among the other social determinants of health is patient communication (much like in the US). Take the case of a 47-year-old woman recently diagnosed with rheumatoid arthritis (based on heel pain, treated with methotrexate, leflunomide, hydroxychloroquine, and corticosteroids), who was admitted with severe mouth sores, a fever (T 101), low platelets (90), low hemoglobin (7.5), and low white blood cell count (less than 1000, with an absolute neutrophil count around 300). Along with oral mucositis and neutropenic fever, she was diagnosed with acute liver failure, oral candidiasis, staphylococcal skin infection, and, a few days later, alopecia. A medical student might recognize the cause of all these symptoms—methotrexate toxicity. Rather than taking it once a week (a dose appropriate for rheumatoid arthritis), she had taken methotrexate daily (a dose appropriate for cancer chemotherapy). “Completely iatrogenic,” the attending lamented. Moreover, her foot x-ray showed a calcaneal spur, and none of her labs were suggestive of rheumatoid arthritis. In other words, she was treated improperly for a disease she likely didn’t even have. After a week of withholding the medication and proper supportive care, everything besides her hair loss had resolved, and she was discharged. Since then, two more women have presented with almost the exact same story (although they likely do have rheumatoid arthritis).

We typically finish rounds between 11 and 1pm and then break for lunch for an hour or so. In the afternoon, I either assist the residents as they complete tasks for our team’s patients, or I shadow other team members at the outpatient department, which is somewhat like an urgent care, where patients are seen without appointments. My day concludes by 4pm, or a little later if there are remaining tasks. The duty resident stays overnight, admitting patients, seeing consults, and advancing care, until we all arrive the next day at 8am.

The internal medicine residents take 32-hour call every 3-4 days. There are no duty hour restrictions, no post-call days off, and, for many weeks during the first year of residency, no days off whatsoever. In a typical week, they work more than 90 hours. “Do you like this schedule?” I ask a group of residents. “This is the best place to train,” they reply. “It is better here than some other places.” Having just completed my residency interview tour, these attitudes are not foreign to me.

The internal medicine doctors display a deep and wide range of knowledge and skills, rarely needing to consult UpToDate or PubMed. I’ve observed first-year residents performing renal biopsies, bone marrow biopsies, lymph node biopsies, and joint fluid aspirations. On the floors, the generalists will independently manage strokes, seizures, pleural tuberculosis, dilated cardiomyopathy, and ulcerative colitis, without specialist consultations. Would patients benefit from specialist input? Most likely. Are such services available? Generally not.

In the coming week, the team has asked me to follow, write progress notes for, and present on one or two patients each day. While I’d readily accept this easy task at Columbia, I find myself hesitant to do so here, where I am still growing accustomed to the foreign environment. What if the language barrier leads me to misinterpret a patient’s complaint? What if I miss or misplace a report buried in the massive paper chart? What if I document something in the wrong place? I’m probably overthinking this, especially since the team is so laid-back and supportive. I just don’t want to become another social determinant of health, when patients already contend with so many. Then again, if I want to be impactful, now and in the long term, I will have to overcome this apprehension.

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