CASE 7

Isabel Delgado

A 47-year-old Dominican woman with hypertension

Debbie Salas-Lopez, MD, MPH, FACP, and Eric Gertner, MD, MPH

Lehigh Valley Hospital and Health Network, Allentown, PA, USA

Educational Objectives

TACCT Domains: 4, 6

Case Summary, Questions and Answers

Mrs. Isabel Delgado is a 47-year-old woman from the Dominican Republic who presents to the Emergency Department (ED) complaining of severe headaches. She has a history of chronic hypertension and her blood pressure is elevated in the ED. After ruling out life-threatening conditions, she is referred back to the residents’ outpatient clinic where she has been followed for general medical care for the past 4 years. On this day, she returns to the clinic and is seen by a medical resident who she has never met before. He asks her if she has been taking her blood pressure medication, and she answers, “Not really, only once in a while.” He admonishes her to do so, stressing that she is at risk of having a stroke, or a heart attack, or developing kidney failure, and indicates that her headaches are probably caused by poorly controlled hypertension.

1 Is the resident’s response likely to motivate Mrs. Delgado to take her medication on a regular basis?

Medication adherence is affected by many factors. Often it is framed strictly in terms of what the patient fails to do, and patients like Mrs. Delgado are labeled as “non-compliant.” When poor patient adherence is seen only as a patient problem, this attitude can interfere with the building of a rapport between the patient and the physician. However, poor adherence also may arise from physician failures and inadequate delivery of care. To improve adherence, physicians should explore the patient’s explanatory model of illness during the initial history of present illness. Although this inquiry may require a few additional minutes, it can go a long way in helping the physician understand the patient’s perspective. Mrs. Delgado’s explanatory model of illness for high blood pressure may be very different from that of her treating physician. If the resident had asked, he would have learned that Mrs. Delgado does not understand that high blood pressure needs to be treated every day, even in the absence of symptoms. Consequently, she believed that she needed to take her medication only if her blood pressure was high enough to cause a headache. Eliciting this information may be initiated by asking, “Mrs. Delgado, what does having high blood pressure mean to you?” (see Appendix 2).

In addition, Mrs. Delgado is frequently seen by a different resident every time she comes to the clinic. She is weary of having to repeat her story to each new resident, and so she is not very forthcoming with information. As a result, only a cursory history is usually obtained, that her level of understanding of the meaning and significance of her illness has never been fully captured by her physician. Having a constant provider at the clinic, whether it is a resident, nurse practitioner, or an attending physician, can help to alleviate this problem for many patients.

2 What other influences might affect Mrs. Delgado’s decision to take her medication?

Mrs. Delgado’s frame of reference about her illness may be based on what she knows about high blood pressure from newspapers or television or what it means to her family and friends. Patients often have trusting relationships with family and friends and may seek additional medical advice and/or obtain medications from them, which may be contradictory to the physician’s advice. Therefore, it is important to explore with Mrs. Delgado what she has learned about high blood pressure from other sources. In fact, Mrs. Delgado left the clinic and later asked her neighbor for advice. The neighbor referred her to the local pharmacy and gave Mrs. Delgado instructions to ask for Carlos, the pharmacy technician. She told her that Carlos was very good at finding different medicines that were less expensive and over the counter.

In the local pharmacy, Mrs. Delgado explained to Carlos that she did not believe her diagnosis of high blood pressure because she usually feels fine with the exception of occasional headaches. In fact, she was feeling perfectly fine today. She went on to explain that what she really needed was to lose weight, eat better, and relax more from a stressful nighttime job. Carlos helped Mrs. Delgado, by recommending a weight loss dietary supplement, vitamins for better appetite, and something to stay awake at night while at work. Given that her neighbor had vouched for Carlos, and his apparent helpfulness, Mrs. Delgado decided to purchase the over-the-counter product instead of the medication prescribed by her physician.

3 What other social factors should be considered for Mrs. Delgado that might impact her adherence?

Life responsibilities such as work, care of children and obligations at home, and family may be significant and overwhelming and can greatly impact patient adherence to physician recommendations. Patients are not necessarily or immediately forthcoming about these social determinants of health, and thus physicians should have a low-threshold for asking about these factors. With respect to Mrs. Delgado, she works at night and takes an over-the-counter medications (“pep pill”) to stay awake during work. She is reluctant to share this information with the resident. When she returns home in the early morning, her husband is on his way out to work. She must get her four children off to school and ensure they have everything they need for the day. She is not only worried about her high blood pressure, but she is also concerned about what may happen to her children if she is not well enough to work.

One month later, Mrs. Delgado returns to the outpatient clinic for follow-up. She is seen by another resident, who determines that her blood pressure is still high. When the resident asks her if she is taking her medications daily, she says she is trying to do her best but finds that she can’t always take them every day. The resident asks why, and Mrs. Delgado says that she is just too busy. The resident begins by admonishing her to take the medication daily and says that she must also follow a low-salt diet to reduce her blood pressure. Once again, Mrs. Delgado listens carefully and begins to wonder how she is going to comply with this. She returns to the clinic 1 month later and her blood pressure is still uncontrolled. She admits that she has not changed her diet.

4 In what way could the patient’s cultural background be playing a role in her poor adherence?

Understanding a patient’s cultural background is extremely important as it can facilitate communication and potentially strengthen the doctor–patient relationship. Mrs. Delgado came to the U.S. 10 years ago from the Dominican Republic to visit her family. She stayed in the U.S. and has never returned to the Dominican Republic. She has an expired visitor’s visa and lives in fear of deportation. Even though she has lived in the U.S. for a decade, she does not understand nor accept many of the American, health beliefs, or practices and holds on to traditional cultural health beliefs and practices from the Dominican Republic. Because of her cultural background, she is also extremely respectful of physicians and therefore, when originally given the prescription for the anti-hypertensive medications, she never considered asking about side effects, costs, or mechanism of action.

Understanding that Mrs. Delgado may have different dietary practices, does not believe in taking prescribed medications, and prefers to take natural supplements and vitamins may yield a better response from the patient regarding her treatment. Physicians should take the time to ask patients about culturally relevant practices in a nonjudgmental manner, including the use of over-the-counter and other medications. Equally important, asking patients about the use of other healers or health consultants may reveal that the physician is not the only person the patient seeks health advice from (see above).

Mrs. Delgado returned to the clinic 3 months later, as requested by the medical resident. This time she was fortunate enough to see the same medical resident who remembered her story. When the young physician asked if she had taken the medication, Mrs. Delgado acknowledged that she had decided to purchase an over-the-counter weight loss supplement, a vitamin, and a “pep pill” to stay awake at night. The resident looked up the supplements in the Physician’s Desk Reference and explained to Mrs. Delgado that they had known significant effects on blood pressure. Mrs. Delgado gave him the name of the pharmacy where she purchased it so that he could get more information. The medical resident called and asked to speak to Carlos. After explaining to Carlos the importance of the treatment of hypertension in acutely ill patients, he asked him to refrain from giving patients medical advice or substitutes for prescribed medications. Mrs. Delgado agreed to buy the prescribed medication and return to the clinic 1 month later to see him.

5 In what way does a system of seeing a different resident at each visit adversely affecting Mrs. Delgado’s health?

Lack of continuity reduces her ability to develop a relationship with a physician and promote a realistic health care plan. Residents, especially in busy clinics, focus on quantitative goals (normalize blood pressure and blood sugar levels and “doing what the physician said”) as parameters of success without evaluating the qualitative aspects (how and why) of a patient’s life and the context of a life she lives within. Without this latter component, the emphasis on “good numbers” does not translate to improve health outcomes. Hence, training in areas such as cultural competency and assessing health literacy are essential for effective medical interviewing.

6 Was it helpful for the medical resident to call the pharmacy to speak to Carlos?

Physicians should ask patients who else is involved in their health care. With permission, they can then engage those individuals when needed. Asking Carlos to refrain from giving medical advice is important in this case and also helps Mrs. Delgado better understand that she takes significant risk when she does not follow medical advice. Understanding who is part of the health care team is important for the physician in practice. The physician can then negotiate a mutually acceptable solution with the patient. Dr. Robert Like and his colleagues have developed the ETHNIC framework that is simple to use and remember, as shown in Table 7.1.

Table 7.1 ETHNIC: A framework for culturally competent clinical practice

Source: Like R.C., Steiner R.P., Rubel A.J. Recommended core curriculum guidelines on culturally sensitive and competent healthcare. Fam Med 1996;28:291–7.

E: Explanation What do you think may be the reason you have these symptoms?
What do friends, family and others say about these symptoms?
Do you know anyone else who has had or who has this kind of problem?
Have you heard about/read/seen it on TV/radio/newspaper? (If the patient cannot offer explanation, ask what most concerns them about their problems.)
T: Treatment   What kinds of medicines, home remedies, or other treatments have you tried for this illness?
Is there anything you eat, drink, or do (or avoid) on a regular basis to stay healthy? Tell me about it.
What kind of treatment are you seeking from me?
H: Healers Have you sought any advice from alternative/folk healers, friends, or other people (non-doctors) for help with your problems? Tell me about it.
N: Negotiate   Negotiate options that will be mutually acceptable to you and your patient and that do not contradict, but rather incorporate your patient’s beliefs.
Ask what are the most important results your patient hopes to achieve from this intervention.
I: Intervention Determine an intervention with your patient. May includeincorporation of alternative treatments, spirituality, and healers as well as other cultural practices (e.g. foods eaten or avoided in general, and when sick).
C: Collaboration Collaborate with the patient, family members, other health care team members, healers, and community resources.

References: Case 7

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Like R.C., Steiner R.P., Rubel A.J. Recommended core curriculum guidelines on culturally sensitive and competent healthcare. Fam Med 1996;28: 291–7.

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