番茄社区

Amazing to see how sometimes noticing something small can bring about remarkable changes.

A few years ago, at an academic medical meeting, there was a poster that had reviewed prescriptions and the challenges that medication instructions sometimes impose on patients.

This group had looked at how often patients are asked to take their medication with food, either because physicians write that into the "sig" instructions of the prescription, or because pharmacists include it in the label they slap onto the prescription bottle.

"Take your medicine twice daily with food," the sig-line in the prescription often says. Or "Take 30 minutes before your largest meal." Or "Take 1 hour before eating."

Or that little prescription label that the pharmacist often affixes, along with "may cause dizziness", "do not operate heavy machinery while taking this medicine", that says "Take with food." These often include tiny pictographs of a glass of milk, a piece of fruit, a cupcake, or a hamburger.

However, the point of this study was not only to find out how often this is said, but included a focus group that asked patients how often this created a challenge for them in their everyday lives. For instance, when our patients don't have enough to eat, how do these instructions affect them?

It turned out that quite often, when we told our patients to take medications with food, if they had no access to food, they would skip the medication, despite this not being the intended result.

A while after seeing this research poster, at a large meeting where members of all of our practices came together with senior leadership, we were asked to go through and highlight all of the many challenges we and our patients faced in getting them ideal care, and where we hoped to put our efforts to try and improve things. As you can imagine, this generated a lot of input from those present, lots of suggestions, dozens and dozens of areas where we needed to fill gaps in care, improve access, work on patient safety, and improve the quality of the care we provide.

Interestingly, this is the first large meeting where I remember food insecurity among our patients coming up. We all know that many of our patients are challenged getting access to nutritious foods, often make poor food choices, sometimes have to choose between food and rent, or food and medicine, and they have many other challenges related to food, money, and health.

We are all aware of the concept of the "food desert," where access to healthy nutritious foods -- or even safe amounts of foods -- can be a critical challenge in some neighborhoods.

One large practice at our institution, using money from a grant to address problems related to social determinants of health, has been working aggressively to ask patients these questions about food during their intake to the visit, because this information, while critical to the health of our patients, is often neglected among all of the other things we have to work to figure out.

As providers are distracted by all the boxes they need to click, all the health maintenance items they have to attend to, and all the screening guidelines they need to make sure are in order for the regulatory agencies, it's probably hard to get to "Do you have enough food to eat; are you challenged to feed your family; where is your next meal coming from?" By instituting the screening questions, they were able to discover that this was a major problem at their practice, one that they previously had not been able to address.

And, like many of the other problems we aim to fix, we have told the leadership of our institution that we don't want to screen for something that we can't do anything about. No sense asking patients if they're depressed, if you don't have access to mental health resources. No sense screening for diseases if you don't have a way to treat them, or specialists who can manage them, or a surgeon who can remove what you find that needs removing.

It's not that we're not interested, but if you can't do something about it, instituting a universal policy of asking about it may not be in everyone's best interest.

But this clinic reached out to community health workers, community leaders, local clergy, neighborhood food banks, and a wide variety of other sources to be able to give their patients some options before they left the clinic that day. We may not be able to solve everything, or even permanently fix the problem of access to healthy nutritious foods for every patient on a long-term basis, but this has certainly been a success at fixing something that's clearly affecting the lives of many of our patients.

I learned that one practice is even working to develop some programs to bring a sort of "mini farmers market" to be set up outside the practice, with vouchers for their patients to use, and the ability to meet local vendors and farmers and potentially take some of the lessons of healthy eating back home, along with some groceries.

It's clearly going to be impossible for us as healthcare providers, working alone, to solve the massive problems of food insecurity, limited access to healthy foods, and the even larger questions of social inequity and poverty that these problems may point towards. But it's incredibly inspiring to see some practices addressing these challenges head on, and trying to make sure that when we tell our patients to take this medicine with food, they actually have some.

Food for thought.

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