Telluride Alum Works on Solutions to Overcome Social Determinants of Health

The following post is by Caitlin Farrell, M3, and Telluride ’14 Alum, and can also be found on her blog, Medical School Confessions. Caitlin, a true leader in patient safety, is currently following a passion in public health…

Bling bling

In medical school, no one teaches you how to set a ring tone on a cell phone. But that’s what I was doing, sitting in the basement of the homeless shelter where the local community health clinic was set up. My patient was a 70-year-old African-American lady, who looked to be about 90. She had, after months of working her way through the system, finally secured an independent apartment. After moving in, she spent weeks sleeping on the floor, because of course she did not own any furniture. She had made her way to the clinic today after taking two buses and walking several blocks.

As we pressed her about her medication, we asked her how the blister packs were working. Blister packs are packages created by the pharmacy which places all of a patient’s medication for a single day together in one nifty little package. That way, there is less chance that a patient will forget to take a certain medication. Our patient stared back at us blankly. What’s a blister pack? The little packages from the pharmacy, where they put the medication you are supposed to take that day in a pop-out package, we explained. Another blank stare. She said the pharmacy was giving her bottles, no packs. The doctor and I stared at each other. There was no way to know if our patient was taking her medication, or if she was taking it correctly. Based on her blood pressure as she was sitting in front of us, 150/89, there was clearly something happening with her hypertensive medication.

We had to brainstorm. We called the pharmacy, who assured us that they had been creating blister packs for our patient. These intricacies of medicine, the teasing of details from patients, calling pharmacies, understanding the determinants of health, are the topics that current medical education fails to address. In school, we are taught very clearly about the treatment of chronic diseases; what medications and lifestyle modifications should be recommended for hypertension, hypercholesterol, diabetes. We write on our prescription pads, then send the patients out the door. Clearly, this system isn’t working. As we see more and more uncontrolled chronic diseases, and label more and more patients as “noncompliant”, I believe that the medical profession needs to take a long hard look in the mirror and see if we are doing all that we can for our patients.

The doctor that I was working with that day had been serving this population for years. He spent his life working in community health clinics and substance treatment facilities, and often had unconventional methods. The only way to be sure that this patient was getting her medication and taking them correctly was a drug delivery service to her house. We asked her if she had a phone. Oh yes, she said. Well does it work, we asked. She assured us that it did. Unconvinced, we dialed her number from the office phone. It buzzed in her overstuffed pocketbook. Well, how will you know that it is ringing if it’s in your bag and you can’t hear it? You won’t be able to get your medications if the service comes to your door and calls you to answer. So the task was set to me, to set a loud ringtone so that our elderly patient would know that the phone was ringing. We then made her show us that she knew how to actually answer it. Once everyone was satisfied, she wrapped it in a piece of paper and folded it back into her bag.

A few days later, we had the patient return with all of her medications, just to be sure that she knew what to take and when to take it. She arrived with a bag full of bottles – the pharmacy hadn’t been putting her medications in blister packs after all. While this level of tedious care is not always possible with every single patient, the fact of the matter is, it should be. If all we are doing as providers is writing prescriptions and hoping that our patients can navigate the healthcare system alone, then we are failing our patients. So make sure you know how to set ringtones, friends. It might actually make the difference for a patient’s health.

A New Friend and Teacher in Health Disparities

I am so fortunate to have recently gained a new teacher and colleague in patient safety, Ron Wyatt, MD, MHA, who also serves as Medical Director in the Division of Healthcare Improvement at the Joint Commission. I was introduced to Ron by Knitasha Washington, Ph.D., Executive Director of Consumers Advancing Patient Safety, and another colleague, friend and patient safety partner. Knitasha has also been a fantastic mentor in my quest to learn more about the stories, the names and faces, of those whose lives have been touched by the disparities that still exist in our healthcare system, affecting the safety of still so many patients.

I have much to learn when it comes to the data that drives action in the health disparities domain. However, I realized I do not need a doctorate to understand pain and suffering, or possess the desire to help every patient receive safe, effective, high-quality care no matter their race, socioeconomic status, education or age: data points that light up as warnings of variable healthcare delivery. I’m happy to pass on the knowledge gained through Ron’s and Knitasha’s experience; two healthcare professionals whose lives have been touched by loss due to health disparities. And so…

Here is a link to a recent article by Dr. Ron Wyatt, The Stuff That Is Killing Us, posted on the Robert Wood Johnson Foundation website discussing his experience as an IHI Fellow looking at Disparity in the Deep South. Ron was also a speaker at the inaugural RWJF Scholars Forum:Disparities, Resilience, and Building a Culture of Health,” held on December 5, 2014, where “a distinguished panel shared their insights on the urgent problem of health disparities in the U.S.” Following is a video from the RWJF event: