By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 1: Take the necessary time to assist patients in crisis, as they often present unexpectedly.
Skill: Patient Centered, Professionalism
Key Feature 6: Inquire about unhealthy coping methods (ex: drugs, alcohol, eating, gambling, violence, sloth) in your patients facing crisis.
Skill: Clinical Reasoning
Phase: Hypothesis generation, History
Key Feature 11a: When dealing with an unanticipated medical crisis (ex: seizure, shoulder dystocia): Assess the environment for needed resources (people, material).
Skill: Clinical Reasoning
Key Feature 4b: In patients not coping with the stress in their lives: Explore their resources and possible solutions for improving the situation.
Skill: Patient Centered
Phase: History, Treatment
Key Feature 5: In patients experiencing stress, look for inappropriate coping mechanisms (ex: drugs, alcohol, eating, violence).
Skill: Clinical Reasoning, Communication
Phase: Hypothesis generation, History
I am currently working at an HIV primary care clinic. What this means is that all of the patients attached to this clinic have HIV, but they present to this clinic to deal with all of the usual general medical concerns that any person may have along with their HIV care. With advancements in recent years in the diagnosis and management of HIV, this means that most patients here are actually quite stable when it comes to management of their HIV (most patients have undetectable viral loads and protective CD4 cell counts). Their lives are still certainly complicated by it, as they need to be diligent about taking their daily medications and receiving regular followup medical care, which really is not unlike care for most chronic diseases.
Today in the HIV clinic I met a 56 year old man who was doing perfectly well from an HIV medical care perspective. However, he was coping with a lot of financial stress in his personal life. He had recently been hired again a few months ago after losing his job for many more, and he was having a very hard time making ends meet. He presented with concerns about depressed mood or feeling "subdued," which was how he described it. Upon assessment, he was clearly having a relapse of Major Depressive Disorder, which he had been in remission for and off antidepressants for over 3 years. Clearly, financial stress was a precipitant for this active episode of major depression, so along with treating the depression, my role today was to help him address the reasons underlying it. I screened him for other interrelated comorbidities and coping behaviours that can have negative repercussions, such as substance use, and asked him about the consequences that his depressed mood was having in his life, to assess for complicating features. Experienced with having gone through a Major Depressive Episode before, he had a lot of insight this time around and presented to clinic before things got too far out of hand.
So many patients present for medical problems that are protracted consequences of the social determinants of health, and to address them, we really need to address those determinants. And it's not easy, particularly when you think about how deep their influence goes, such as impact of adverse childhood experiences (ACEs) and the pervasiveness of the impact. Fortunately, here at the well-supported HIV clinic, we have access to a Registered Social Worker on our team to assist patients with the many financial and other realities of life that have immense repercussions on patient wellbeing. While this doesn't eradicate all negative social determinants of health by any means, it helps to foster a culture of resilience whereby patients are empowered to live lives with better health and quality of life.
One of the supports that I think is fantastic is the nurse who triages patients who present to the HIV clinic on an urgent basis, without having booked appointments. This means that patients with urgent needs can be seen by a doctor that same day, while those with less urgent needs can get booked for an appointment within the next few days. Although the patient may be seen by one of the doctors working in the clinic that day, and this person is often not their primary care physician, the information about the patient is in their chart, and so there is more continuity of care than at a walk-in clinic. (There may also be a need for more specialized urgent care at the HIV primary care clinic rather than a routine walk-in clinic as well, since treatment decisions may be influenced by the presence and active treatment of the patient's HIV, which many physicians may not have much experience with managing.) The reality is that while many medical issues are best managed in an outpatient setting, and others require emergency medical care, many fall in the grey zone in between, needing so-called urgent care. There is a need to see patients who are having urgent issues not in the Emergency Department when they don't need a high acuity level of care, and ideally by a primary care practitioner who knows them well. Unfortunately, when the health care system is structured with a gap in primary care providers delivering urgent care services, patients have little choice. I think the best option is to have walk-in clinics for those who do not have a family doctor, but ideally attaching these patients at the same time to regular family doctors who can provide routine care as well as urgent care. The primary care clinic just needs to be set up in such a way so as to make that work (ex: in my home family clinic, one doctor every day leaves a certain number of slots open to address urgent concerns).
Back to the patient: The gentleman in clinic who I met with today received a referral to meet with the team social worker to discuss how he is currently managing and what his options are moving forward. As a family doctor in the community, I will likely not have the privilege of having a social worker at my fingertips, so it will be extremely helpful for me to become familiar with local resources, especially financial supports. At the same time, it's important to remember that there are social workers in the community who I may be able to refer patients to for extra support. And by setting up my practice so that I can help patients manage urgent concerns I am most likely to be able to do what needs to be done.