Reference no: EM133629688
Assignment:
1. Explain how the formal healthcare system may have contributed to the oppression experienced by the patient in the case.
2. Identify and describe at least one way in which the social worker in the case showed cultural humility and application of anti-oppressive practice.
3. Identify and describe an additional way in which you would advocate for the patient, and for others in similar situations, as a medical social worker.
4. Describe at least one ethical concern that arises in the case and explain how you would address it.
Case Study Below:
Definition of the client
Our clients are typically patients who arrive for either dental or medical care. Robert, a 45-year-old Black man, lived in a small apartment in Trenton with his common law wife and their 11-year-old son. He was working three different jobs when we first met him in 2019. He stocked shelves at a discount store, drove a "hack" (much like Uber or Lyft but not regulated), and did construction jobs off-books for a neighbor's contracting service. He first came to HJAHC with a terrible toothache and was seen in our dental clinic. As is our practice, his blood pressure was measured and found to be 181/138, considered hypertension, and it rose when taken a second time. He reported that he had tried to sell blood earlier in the month but was turned down because of high blood pressure. The dental clinic packed his tooth with antibiotic and wanted him to go straight to the emergency department for cardiac assessment, but he explained that he was the only driver in the family and that he needed to collect his son from school.
Although the dental clinic attempted unsuccessfully to convince him to go to the ED after the pickup, they did not let him leave without scheduling a primary care appointment. He kept that appointment three weeks later and was diagnosed with hypertension, "pre-diabetes," and tobacco addiction (he acknowledged smoking a half to a full pack a day). He also reported smoking cannabis regularly to relax, along with "social" alcohol use. He understood the PCP's explanation of how smoking raised his blood pressure and risk for cardio-vascular disease (CVD). He agreed that he wanted to stop smoking. An anti-hypertensive was prescribed, as was Chantix for support while he tried to stop smoking.
I was introduced to Robert in the exam room after the PCP called to say that he was interested in smoking cessation.
Robert interacted with me briefly, but clearly questioned what this older white man might have to offer him. He was grateful for the Chantix prescription but did not see the use of setting an appointment with me to discuss strategies for quitting. I talked about the benefits of support and sharing strategies, but he showed only polite interest. He did not attend our scheduled appointment and, indeed, we did not see Robert again until 2021, despite my telephone outreach to him and calls by medical and dental providers.
In 2021, Robert arrived asking for a COVID-19 test and he was automatically re-connected with his initial PCP to get his results (which were negative). He reported that he had reduced his cigarette use in 2019 to 16 a day while taking Chantix, but that his insurance would not cover Chantix, so he returned to smoking soon after and was currently smoking a pack to a pack and a half a day. He understood the connection to his continuing hypertension and was more motivated to quit because he wanted to get a commercial driver's license to obtain a steady job but had been turned down because of his high blood pressure.
I was able to meet with him promptly to explore these areas of motivation. He explained his earlier attempts to stop and how nicotine gum and lozenges did not taste good to him and how he really was interested in some sort of medication assistance. I contacted our pharmacist and made arrangements for the first available telehealth appointment to assess his eligibility for bupropion or other medication.
Robert came for one more visit with me and it felt like our connection was building, but he was clear that he did not see any use for discussion until the pharmacist saw him.
During our sessions, he had also acknowledged that he had been drinking alcohol quite heavily during the beginning of the pandemic in 2020, but that he was "working to stop" currently. I discussed strategies for reducing use of both alcohol and cigarettes. I told him about Quitline, but again, he felt that he did not want to move forward with other strategies until he saw the pharmacist. While awaiting that appointment, I sent him a secure message with the information about Quitline and tried to no avail to set other appointments to support his efforts to reduce cigarette and alcohol use. I tell my staff, and I believe, that we should never give up. We should respect the choices people make but also keep coming back with support, more information that might enhance motivation, and we keep trying to engage: we never give up.
Before he saw the pharmacist, Robert arrived again at primary care with worries about an HIV exposure. The PCP did the counseling and connected him to our clinic to educate him about and begin use of PReP (a protective medication to avoid HIV infection) because he reported that his partner had recently informed him of her positive HIV status. This derailed Robert and he did not arrive for our scheduled appointments or the first pharmacist appointment.
In his re-scheduled meeting with the pharmacist, Robert learned that his alcohol use raised his risk of seizure in combination with bupropion (see Brewer, 2021) and he was urged to consider nicotine patches and behavioral support for reducing and/or stopping cigarette use. He was quite discouraged. I was able to "tag team" the pharmacist's telehealth visit with my own and Robert and I discussed ways to identify the most important cigarettes of his day and to quit using the less important ones. We talked about reducing his alcohol use so that bupropion might become a possibility.
Nevertheless, he was clearly hoping for a medication that would offer a quicker solution.