The Clinical Problem Solvers is a multi-modal venture that works to disseminate and democratize the stories and science of diagnostic reasoning
Twitter: @CPSolvers
Website: clinicalproblemsolving.com
In this episode of WDx, Dr Rebecca Berger joins Kara, Jane, & Sharmin to discuss a clinical unknown. Presented by Kara, the case starts with a young woman presenting with chronic isolated thrombocytopenia.
Dr. Rebecca Berger
Rebecca is an academic hospitalist and assistant professor of medicine at Weil Cornell Medicine and New York Presbyterian Hospital. In addition to her clinical work, she serves as the Director of Patient Safety for Inpatient Services for the Department ofMedicine and teaches medical students and residents, including leading small groups with students on their medicine clerkships focused on clinical reasoning and diagnosis.Rebecca obtained her undergraduate degree from Stanford University in 2009, her medical degree from Columbia University Vagelos College of Physicians and Surgeons in 2013, and completed her internal medicine internship and residency training at Massachusetts General Hospital (MGH) in 2016. She served as a NEJM Editorial Fellow from 2016-2017 and worked as a hospitalist at MGH before moving to Cornell in 2018.
Maddy Conte and Seyma Yildirim introduce a new series on the podcast: “The Rafael Medina Subspecialty Series,” which will always be in loving memory of our dear friend and CPSolvers family member, Dr. Rafael Medina. Rafa presents a nephrology clinical unknown to Drs. Ashita Tolwani and Mustafa Muhammad.
The goal of this series is to expand access to subspecialty, primary care and internal medicine-adjacent specialty education to learners around the world. If you would like to get involved as a case presenter or discussant, fill out this form here: https://forms.gle/RLbx6A2vELp6PTYp9
Case presenter and facilitator: Dr. Rafael Medina
Rafa was a Brazilian medical graduate who proudly shared on Twitter, “Son of a tailor and confectionary vendor born and raised in rural Brazil. And now incoming internal medicine resident at the University of Colorado. Never let anyone tell you that your dreams are too big for you!” He tragically passed away last week. He impacted the lives of so many and touched every corner of the CPSolvers community, and rippled far beyond. Rafa helped spearhead the subspecialty series; this series has been renamed after Rafa and will continue strong in his honor. Rafa, we love you.
Case discussants: Dr. Ashita Tolwani, Professor of Medicine at the University of Alabama at Birmingham (UAB). She was the Nephrology Fellowship Training Program Director from 2004-2010 and is now the Associate Program Director. She is also the Director for ICU Nephrology at UAB. (Twitter: luck_urine)
Dr. Mustafa Noor Muhammad, nephrology fellow at the University of Alabama at Birmingham.
Episode 285: Anti-Racism in Medicine Series – Episode 21 – Psychosocial and Cultural Considerations for Providing Healthcare to Immigrant and Refugee Populations
May 02, 2023
Episode 21 – Psychosocial and Cultural Considerations for Providing Healthcare to Immigrant and Refugee Populations
Show Notes by Kiersten T. “Gillette” Gillette-Pierce
May 2, 2023
Summary: This episode highlights the psychosocial and cultural considerations for providing healthcare to immigrant and refugee populations. During this episode, we hear from Dr. Altaf Saadi, a neurologist who focuses on neuropsychiatric health disparities and addressing the needs of displaced populations at Mass General Hospital and Harvard Medical School, and Dr. Naweed Hayat, a child and adolescent psychiatry fellow at the University of California San Diego, who applies his own lived experience of resettlement to his clinical practice. Together, our guests explain how trauma shows up in those who experience resettlement, and the role of trauma-informed and culturally-responsive care for refugee, asylee, and immigrant population in clinical practice.. This discussion is hosted by Sudarshan Krishnamurthy, Ashley Cooper, and LaShyra Nolen.
Episode Learning Objectives
After listening to this episode, learners will be able to…
Explain how the current state at the border is informed by historical immigration injustices.
Describe how physiological and psychological trauma show up among immigrant and refugee populations as a result of the violence and injustices experienced during migration, at the border, during the resettlement process and across the lifecourse thereafter.
Identify the role of trauma-informed, culturally-responsive care for refugee, asylee, and immigrant populations and how it can be operationalized in clinical practice.
Credits
Written and produced by: Sudarshan Krishnamurthy, Ashley Cooper, LaShyra Nolen, Kiersten Gillette-Pierce, Rohan Khazanchi, MD, MPH, Dereck Paul, MD, Jazzmin Williams, Victor A. Lopez-Carmen MPH, Naomi F. Fields, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins, Michelle Ogunwole MD, Utibe R. Essien MD, MPH
Hosts: Sudarshan Krishnamurthy; Ashley Cooper, and LaShyra Nolen
Infographic: Creative Edge Design
Audio Edits: Garrett Weskamp
Show Notes: Gillette Pierce
Guests: Dr. Altaf Saadi and Dr. Naweed Hayat
Time Stamps
0:28 Introduction
0:31 Episode introduction
1:15 Guest introductions
3:50 Origin stories
8:06 The current state of the border
18:13 Culturally competent and trauma-informed care
24:50 ICE and policing
36:28 Application of teachings
Episode Takeaways
Origin Stories — For Dr. Hayat and Dr. Saadi, the work that they do is deeply informed by their lived experiences as migrants themselves as well as in their professional roles as clinicians who serve immigrant and refugee populations.
State of the Border — Policies that happened under the Trump administration and now under the Biden administration have left people vulnerable to injustices in Mexico and other Central American nations. People are fleeing persecution, gang violence, and other violence such as sexual or other violent assaults and now they must also face the additional burden of the lack of access to basic necessities like food, water and shelter. A lot of compounding trauma occurs at the border that has potential downstream mental health implications for individuals and their families.
Culturally Competent and Trauma-Informed Care — Interpersonal components such as screening for trauma exposure and providing resources to families are an important aspect of trauma-informed care, and it should also include efforts at the organization level to create sanctuary or immigrant-friendly spaces and implement immigration-informed care, which builds on the concept of trauma-informed care by honing in on the unique factors associated with immigrant populations, e.g. protocols for broaching sensitive topics like immigration status and policies to ensure people are safe from immigration enforcement.
ICE and Policing — Instances of immigration enforcement in healthcare settings are rare, and when they do happen they can look like patients being interrogated at the bedside or even being arrested as they step out of the hospital just after visiting someone. These instances contribute to immense fear that can act as a deterrent from seeking care or engaging with any other helping professional institutions in the future–this goes for the individual(s) directly impacted and the people within their communities.
Impact of Health Records — The impact of health records within the context of healthcare for immigrant populations is complex because migration status really should not be documented explicitly as it can open people up to harms such as stigma from providers or being turned over to law enforcement agencies who may cooperate with immigration enforcement. Many organizations, such as the American Medical Association Journal of Ethics, recommend against documenting immigration status in medical records.
Application of teachings — It is advised to amplify the work that is already being done in communities and identify what areas at the systems level need to change as well as the key stakeholders.
Pearls
Dr. Hayat discusses the five major waves of migration in the last fifty years, resulting from the Soviet-Afghan War, the Afghan Civil War, the Fall of the Taliban, August 2021 US and western forces departure, and how he grew up during the 1990s right after the collapse of the government. He recounts street fights in Kabul as well as an overall theme of people going back to a focus on survival, or the need for food, shelter, water and safety.
Dr. Saadi discusses how her parents left Iraq under Saddam Hussein’s dictatorship, where he was targeting many Iraqis with Iranian ancestry and Shi’a Muslims–which included members of her family. She notes she was born in Iran and her family emigrated to Canada and then to the United States just a month before 9/11. She recounts this time as particularly tumultuous for not only Muslim Americans but also South Asian Americans, Sikh Americans, as well as Arab Americans who were not Muslims.
Dr. Saadi highlights that the majority of immigrants do not come through the US-Mexico border, even for undocumented folks. Additionally, in the case of folks who are undocumented, it is likely the case that they attained this status as a result of overstaying their previously valid visa.
Dr. Saadi discusses the Biden administration rule proposal that would essentially prohibit refugees from seeking asylum in the US, making them ineligible for asylee status.
Dr. Saadi highlights that there needs to be a greater focus on the continuum of experiences when we discuss patients who are immigrants or forcibly displaced because there is not often a clear pre-post distinction. Many people’s journeys can involve being in an encampment, being detained in immigration prisons, or stopping in multiple countries before reaching the final destination.
Dr. Saadi also uplifts the fact that while we focus primarily on those we have clinical encounters with, it is always important to mention that there are many people that did not make it to clinic for an amalgam of reasons — many people lost their lives in the quest for better lives and freedom from persecution.
Dr. Hayat stresses the difference that cultural psychiatry, cultural competency, and the biopsychosocial model make in building rapport and there is a lot that goes on in between pre- and post-resettlement and those experiences have to be taken into account, especially in cases where there are language and cultural barriers. He highlighted the DSM-5 Cultural Formulation Interviews.
Dr. Saadi recommends avoiding documentation of immigration status in medical records, or having clear guidelines on what to do if immigration enforcement is present at the clinical setting.
Dr. Saadi notes that we must not see people as the sum of their traumas, they are so much more than that — especially in the case of forcibly displaced peoples and immigrants. We must not reduce people to their trauma exposure alone.
Dr. Hayat interestingly mentions that some organizations have been able to build relationships with law enforcement, educate them, and share different challenges to help realize a common goal.
Dr. Hayat notes that while organizations recommend against documenting immigration status in medical records, needs can still be met through partnerships with community organizations. Dr. Saadi adds that we can collect this data, and there is immense groundwork that must be done to develop protections for immigrant and refugee populations and ensure the data are protected.
Dr. Saadi mentioned a toolkit around policies and actions that can be implemented at an organizational level that is publicly available at www.doctorsforimmigrants.com. She also mentions additional organizational-level policies and actions that can take place beyond what is mentioned in the toolkit such as setting up a medical legal partnership where people can connect to attorneys that can help them with their immigration case or civic engagement promotion. She also mentioned Dr. Mark Kuczewski’s sanctuary doctrine toolkit that focuses more on the individual level. Refer to Good Sanctuary Doctoring for Undocumented Patients for more information. Dr. Hayat mentioned his colleague, Dr. Olivia Shadid, who does work on mental health evaluations for asylum seekers, which can be found here.
References
Morris JE, Saadi A. The Biden administration’s unfulfilled promise of humane border policies. Lancet. 2022 May 28;399(10340):2013. doi: 10.1016/S0140-6736(22)00741-3. Erratum in: Lancet. 2022 Jun 2;: PMID: 35644152.
Shi M, Stey A, Tatebe LC. Recognizing and Breaking the Cycle of Trauma and Violence Among Resettled Refugees. Curr Trauma Rep. 2021;7(4):83-91. doi: 10.1007/s40719-021-00217-x. Epub 2021 Nov 13. PMID: 34804764; PMCID: PMC8590436.
Valtis Y, Okah E, Davila C, Krishnamurthy S, Essien UR, Calac A, Fields NF, Lopez-Carmen VA, Nolen L, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 16: Live from SGIM: Best of Antiracism Research at the Society of General Internal Medicine’s 2022 Annual Meeting” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. May 3, 2022
Berkman JM, Rosenthal JA, Saadi A. Carotid Physiology and Neck Restraints in Law Enforcement: Why Neurologists Need to Make Their Voices Heard. JAMA Neurol. 2021;78(3):267–268. doi:10.1001/jamaneurol.2020.4669
James J, Heard-Garris N, Krishnamurthy S, Cooper A, Calac A, Watkins A, Onuoha C, Lopez-Carmen VA, Krishnamurthy S, Calac A, Nolen L, Williams J, Tsai J, Ogunwole M, Khazanchi R, Fields NF, Gillette-Pierce K. “Episode 18: Remedying Health Inequities Driven by the Carceral System” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. October 18, 2022.
Chiesa V, Chiarenza A, Mosca D, Rechel B. Health records for migrants and refugees: A systematic review. Health Policy. 2019 Sep;123(9):888-900. doi: 10.1016/j.healthpol.2019.07.018. Epub 2019 Jul 30. PMID: 31439455.
Disclosures
The hosts and guests report no relevant financial disclosures.
Citation
Saadi A, Hayat N, Krishnamurthy S, Cooper, A, Nolen L, Gillette-Pierce K, Calac A, Essien UR, Fields NF, Lopez-Carmen VA, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 21: Antiracist Healthcare for Immigrant and Refugee Populations ” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. April 25, 2023
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Dr. Ravi Singh presents a case of right arm weakness to Yazmin and Sridhara.
Yazmin is a Mexican Graduate from the Universidad Autonoma de Yucatan. During her medical training, she developed a strong interest in Public Health, Medical Education, and Health Equity and is looking forward to pursuing a career in Internal Medicine. When she is not volunteering on a project, she likes taking care of her plants, developing her skills in the fine arts, or learning a new language.
Sridhara is a board-certified internist, neurologist, vascular neurologist, and hypertension specialist. Currently, he holds the position of Clinical Assistant Professor at Thomas Jefferson University Hospital and serves as the Director of Neurology for Jefferson New Jersey.
As a medical professional, he is passionate about case-based learning, clinical reasoning, and teaching decision-making while avoiding the pitfalls of heuristics. His goal is to bridge the ever-growing gap between neurology and internal medicine, an area in which he has a keen interest.
Ravi (Ravitej) Singh is originally from Greenwich, London U.K where he grew up playing soccer and rugby. He attended medical school at University of Debrecen, Hungary and completed residency at Medstar Harbor Hospital in Baltimore. Currently he is an associate program director for Sinai Hospital IM residency program in Baltimore as well as a Hospitalist on the teaching service. He is a faculty member at the Johns Hopkins School of Medicine and takes time out of his schedule to run a series of case-based teaching sessions as well as medical simulation with all of the medical students that rotate at Sinai throughout the year. He is also a co-chair of the ACP Maryland IMG committee where he advocates for IMG issues Jo and highlights their contributions to the healthcare system
Episode 20 – Medical Racism and Indigenous Peoples
Show Notes by Sudarshan (“Sud”) Krishnamurthy
April 4, 2023
Summary: This episode highlights the checkered past of medicine and the advancements in the field that have occurred at the expense of the humanity of Indigenous peoples. During this episode, we hear from Dr. Nav Persaud, a staff physician in the Department of Family and Community Medicine at St. Michael’s Hospital in Unity Health Toronto, and Dr. Alika Lafontaine, the current President of the Canadian Medical Association. Together, our guests explain how Indigenous knowledge systems are the foundation of modern medicine and also share strategies to promote truth and reconciliation with Indigenous Peoples in North America. This discussion is hosted by Alec Calac and Gillette Pierce.
Episode Learning Objectives
After listening to this episode, learners will be able to…
Explain how the dark legacy of discrimination and deliberate oppression of Indigenous Peoples has led to present-day disparities across the world
Describe how medicine has held some white men to high esteem, even when they harbored significant racist and sexist notions
Identify the role of Indigenous knowledge systems in shaping much of modern medicine today, yet experiencing erasure from the mainstream
Credits
Written and produced by: Alec J. Calac, Gillette Pierce, Sudarshan Krishnamurthy, Rohan Khazanchi, MD, MPH, Dereck Paul, MD, Jazzmin Williams, Victor A. Lopez-Carmen MPH, Ashley Cooper, Naomi F. Fields, LaShyra Nolen, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins, Michelle Ogunwole MD, Utibe R. Essien MD, MPH
Hosts: Alec J. Calac and Gillette Pierce
Infographic: Creative Edge Design
Audio Edits: Caroline Cao
Show Notes: Sudarshan (“Sud”) Krishnamurthy
Guests: Dr. Nav Persaud and Dr. Alika Lafontaine
Time Stamps
0:00 Introduction
0:45 Episode Introduction
1:10 Guest Introductions
3:30 Existing global disparities among Indigenous Peoples
6:00 How access to medications are impacted among Indigenous Peoples in Canada
8:30 Framing around the Design of Structures in Canada to suppress Indigenous voices
13:30 Legacy of Osler and the importance of rediscovering forgotten dark histories
16:20 Dehumanization of individuals belonging to marginalized groups by the healthcare system
27:50 Modern medicine and its roots in Indigenous knowledge systems
31:30 Provision of healthcare to Indigenous Peoples in Canada
34:50 Alec’s own advocacy around renaming a campus parking garage
36:55 Weaponization of professionalism
45:00 Clinical takeaways and practical tools for clinician listeners
Episode Takeaways
Indigenous communities around the world experience significant disparities in life expectancy, burden of disease, and socioeconomic status, due to deliberate exclusion of Indigenous Peoples from the mainstream and suppression of their voices in the design of the system.
Within medicine, we tend to hold white men from history books in high esteem, often without recognizing the dark legacy that accompanied their lives. William Osler is one such example who, along with numerous other sexist and racist misconducts, took remains of Indigenous people with him as a gift to his mentor in Germany, that is still held by a German museum who refuses to return it.
The dehumanization of individuals of color at the margins of society by the healthcare system is not simply a thing of the past, and is certainly a persistent phenomenon. Cindy Gladue, Brian Sinclair, and Joyce Echaquan are three Indigenous individuals who suffered immense harm at the hands of the healthcare system.
There is strength in reconciling Indigenous history, and we must prevent further erasure of Indigenous knowledge systems. The solutions to these issues do not fall upon one community’s shoulders, but instead on the shoulders of all of us along with the oppressive systems that have led us here.
Pearls
Alec begins by contextualizing this episode with the fact that although Indigenous people make up 6% of the global population, they compose 15% of the global population experiencing extreme poverty. Additionally, Indigenous communities experience lower life expectancy, higher burden of disease, and lower socioeconomic status compared to non-Indigenous Peoples. These disparities are likely attributable, in part, to the disruption of Indigenous knowledge systems, inadequate infrastructure, and poor identification of health data among these groups, rather than individual behavior. [Supplementary Resource for Listeners: CPSolvers Episode 12: Addressing Anti-Indigenous Racism in Medicine with team members Alec Calac and Victor Anthony Lopez-Carmen]
Nav discusses that despite publicly funded healthcare systems in Canada and federal protections in place for certain Indigenous groups, Indigenous populations and other groups facing discrimination and historic oppression are much more likely to report not being able to take medications due to cost. Although healthcare services are publicly funded, access to medications depends on private or public insurance and is linked with employment. While some have the impression that there is a safety net in Canada for life-saving medications, Nav still sees patients in his practice who are harmed by the system and not able to afford life-saving medications, many of them Indigenous, and this is a violation of their right to access essential medicines.
Alika expands on Nav’s framing by highlighting the three broad demographics in Canada: the Inuit, the Métis, and the First Nations. In contrast to settlers in the United States where “conquering” through deception was a priority, the spread of settlers was more so through the signing of agreements that were never lived up to. Indigenous peoples in Canada have deliberately been left out of the mainstream to ensure their voices were suppressed in the design of the system.
Alika elaborates on the history of Indigenous populations in Canada and how they would conduct X-Rays on the Inuit children, and ship these kids away for 3 to 10 years if they found tuberculosis in the lungs, without even allowing the children to say goodbye to their parents. Alika recalls stories of individuals in Ottawa who were on the same floor for several years, only to realize that they were members of the same family after being placed in these TB sanatoriums and crossing paths there.
Nav begins to discuss how Osler is still revered as one of the most prominent historical physicians in Canada and the United States. A colleague brought information to Nav that Osler had brought remains of Indigenous people as a gift to one of his mentors in Germany. This led him to look into Osler’s history a little further, and Nav found it easy to find other instances of racist and sexist misconduct by William Osler. These remains are still in a museum in Germany, with no plan of return to Indigenous communities. [Supplementary Resource for Listeners: Read Dr. Persaud’s initial article on Osler here]
Osler lived in the time of Numbered Treaties and the North-West Rebellion under Louis Riel, when Indigenous rights were front and center. It is ridiculous to consider that a physician brought Indigenous remains with him as a gift during this period in history, when Osler knew Indigenous people were fighting for their rights and lives. So, we must rethink the esteem that we hold white men like Osler in, and rediscover the forgotten history that accompanies them. [Supplementary Resource for Listeners: You can read more about the North-West Rebellion here]
Alika discusses the dehumanization of individuals of color and other identities who exist at the margins within the healthcare system and emphasizes that these are not phenomena of the past. He highlights the hostility within the healthcare system and how healthcare must be a service that is available equally to everybody, and not treated as a favor being done to individuals. He narrates the stories of Cindy Gladue, Brian Sinclair, and Joyce Echaquan, all of whom suffered immense harm at the hands of the healthcare system as Indigenous individuals. [Supplementary Resource for Listeners: You can read about Cindy Gladue, Brian Sinclair, and Joyce Echaquan here]
Nav expands on this aspect of dehumanization of Indigenous peoples and speaks about how the Indigenous remains are being treated in Germany today. Although there is guidance that they must be returned, they have decided to retain them. In addition, there is writing within these skulls with numbers written on the inside, as if to catalog them. The museum has also added multiple barriers for those who wish to rightfully receive these remains, and has placed the onus on these communities for these remains to be returned.
Alec importantly highlights that while these harms might seem historical and like things of the past, they have taken place within one or two generations and even today. He discusses his experiences as an Indigenous person in California who attends a medical school that begrudgingly decided to return Indigenous remains, from one of the largest collections in the world.
Alika talks about strength in knowing his history. He discusses the medical knowledge of settlers in Canada believing in four humors and the practice of bloodletting to relieve sickness. At that time, Indigenous Peoples were harvesting plants at their peak potency and concentrating these plants in teas, and delivering medications through oral and transdermal routes. He talks about how Atropine, a commonly used drug by anesthesiologists like Alika, is derived from Belladonna and how folks practicing traditional medicine use Belladonna.
Alika also delves deeper into the provision of healthcare to Indigenous peoples in Canada. He mentions that healthcare was provided to Indigenous peoples rooted in a charitable effort, rather than as a basic human right. It is important to move beyond being nice to each other, and begin to think about the requirements and obligations we have to each other as human beings.
Alec goes on to highlight that as much as we have gained, we have much more to fight for. In episode 12, we discussed how the American Indian and Alaskan Native life expectancy as of 2021 was equivalent to that of the American public in the 1940s. The solution to these issues shouldn’t fall upon one or a few of our shoulders, but instead upon the shoulders of all of us along with the systems that have the resources and infrastructures to inform change.
Alec used Nav’s article to advocate for the renaming of a parking garage on campus that was named after William Osler. Our spaces reflect our values, so the question he asked was why they had a parking garage named after an individual who has no relation to the local community in San Diego? We think about the legacy in medicine, but forget about the community we are in. [Supplementary Resource for Listeners: Read Alec’s Editorial about his advocacy related to renaming a street and parking structure in his medical school campus here.]
Nav describes professionalism as a vague concept that is often used to oppress individuals from racialized and marginalized backgrounds. Professionalism is often antithetical to a rights-based approach to medicine, where every member of a team feels comfortable to speak up when everything is not right with a patient’s care and professionalism can scare people from speaking out when needed.
Alika expands on this explanation of professionalism in terms of what is acceptable, decided by whoever is in control. It can be used to amplify what leaders think is important and suppress what leaders do not like, demonstrating the importance of leadership from diverse backgrounds and varied lived experiences. Retaliation can be severe to violations of professionalism, and it’s hard to know the effects of retaliation unless one has experienced these themselves. [Supplementary Resource for Listeners: Read about the experience Dr. Lafontaine describes regarding his own experience with reporting unprofessional and unacceptable conduct here]
Nav states that it is important for us to reflect on what has happened and recollect all of the work people have done to chronicle anti-Indigenous racism. Racism is not new, and there have been numerous reports that document racism and anti-Indigenous discrimination over decades and centuries. We must respect what has happened, and recognize as non-Indigenous people that we benefit from advocacy and efforts of Indigenous peoples for Indigenous rights over generations.
Alika emphasizes that the point of this conversation is not to make anyone feel like they are a bad person, but instead to help them acknowledge that in this healthcare system we provide both health and harm. Providing our patients with more space and ensuring our patients feel human again is a great first step. It is also important to remember that in the course of restructuring power, there are winners and losers and we may not all have the same voice around the table that we did before. We entered medicine to help people, and sometimes the best way to help people is by getting out of the way and allowing for others to step forward.
References
Persaud N, Butts H, Berger P. William Osler: saint in a “White man’s dominion”. CMAJ. 2020;192(45):E1414-E1416. doi:10.1503/cmaj.201567
Reid P, Cormack D, Paine SJ. Colonial histories, racism and health-The experience of Māori and Indigenous peoples. Public Health. 2019;172:119-124. doi:10.1016/j.puhe.2019.03.027
Redvers N, Blondin B. Traditional Indigenous medicine in North America: A scoping review. PLoS One. 2020;15(8):e0237531. Published 2020 Aug 13. doi:10.1371/journal.pone.0237531
Fredericks CF. Mapping the Sustainable Development Goals onto Indian Nations. In: Miller RJ, Jorgensen M, Stewart D, eds. Creating Private Sector Economies in Native America: Sustainable Development through Entrepreneurship. Cambridge: Cambridge University Press; 2019:185-194. doi:10.1017/9781108646208.011
Browne AJ, Lavoie JG, McCallum MJL, Canoe CB. Addressing anti-Indigenous racism in Canadian health systems: multi-tiered approaches are required. Can J Public Health. 2022;113(2):222-226. doi:10.17269/s41997-021-00598-1
Persaud N, Ally M, Woods H, et al. Racialised people in clinical guideline panels. Lancet. 2022;399(10320):139-140. doi:10.1016/S0140-6736(21)02759-8
Lafontaine AT, Lafontaine CJ. A retrospective on reconciliation by design. Healthc Manage Forum. 2019;32(1):15-19. doi:10.1177/0840470418794702
Lafontaine A. Indigenous health disparities: a challenge and an opportunity. Can J Surg. 2018;61(5):300-301. doi:10.1503/cjs.013917
Durand-Moreau Q, Lafontaine J, Ward J. Work and health challenges of Indigenous people in Canada. Lancet Glob Health. 2022;10(8):e1189-e1197. doi:10.1016/S2214-109X(22)00203-0
Okpalauwaekwe U, Ballantyne C, Tunison S, Ramsden VR. Enhancing health and wellness by, for and with Indigenous youth in Canada: a scoping review. BMC Public Health. 2022;22(1):1630. Published 2022 Aug 29. doi:10.1186/s12889-022-14047-2
Berger P. Canadian Physicians’ Breach of Duty to Patients and Communities from the Acquisition of Indigenous Skulls in the 19th Century to the Abandonment of People with AIDS in the 20th Century. J Biocommun. 2021;45(1):E13. Published 2021 Aug 15. doi:10.5210/jbc.v45i1.10849
The hosts and guests report no relevant financial disclosures.
Citation
Persaud N, Lafontaine A, Calac A, Pierce G, Krishnamurthy S, Essien UR, Fields NF, Lopez-Carmen VA, Cooper A, Nolen L, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 20: Advancing Medicine at the Expense of Indigenous Humanity” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. April 4, 2023
Episode 281: The Consult Question #8 – Pancytopenia and Rash
Mar 23, 2023
https://clinicalproblemsolving.com/wp-content/uploads/2023/03/3.23.23-TCQ-RTP.mp3Dr. Vipul Kumar presents a fascinating case of pancytopenia and rash to guest discussant, Dr. Anand Patel. Dr. Vipul Kumar MD PhD is a hematology-oncology fellow at UCSF. He is currently in his second year of fellowship and has a clinical interest in oncology of all forms as well as a passion for teaching. Dr. Anand Patel is an assistant professor of medicine at University of Chicago where he treats patients with leukemia and myeloid malignancies. He also serves as medical director of the inpatient leukemia service. His research focuses on the development of clinical trials to help improve the standard of care for patients with high risk leukemias and myeloid malignancies. Twitter: @Anand_88_Patel
Simone and Moses review their approach to chronic lower extremity weakness in a patient with new-onset jaundice, as Vale presents them a case with a neuro flavor to it.
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Yazmin presents a case of lethargy and myoclonus to Kiara and Maria.
María Jimena Alemán was born and raised in Guatemala where she currently works in community and rural health care. After suffering from long standing neurophobia, she has embraced her love for neurology and will pursue a career in this field. She looks forward to dedicating her life to breaking barriers for Latin women in medical fields and improving medical care in her country. Maria is one of the creators of a medical education podcast in Spanish called Intratecal. Her life probably has a soundtrack of a mix between Shakira and Ella Fitzgerald. Outside of medicine, she enjoys modern art, 21st century literature, and having hour-long conversations over a nice hot cup of coffee or tequila.
Kiara Camacho-Caballero was born in Lima, Perú and she is a medical doctor at Universidad Científica del Sur. She is passionate about Internal Medicine, Cardiology, and medical education. Her research interests are cardiology, neurology, and, geriatrics. Her plans are to apply for Internal Medicine residency in the US this year. Outside medicine, she is a past triathlete and her dream is to perform an IRONMAN 70.3 someday. Kiara enjoys running, and spending time with her dog named Zack and her favorite food is turkey legs.
Yazmin Heredia
@minheredia
Yazmin is a Mexican Graduate from the Universidad Autonoma de Yucatan. During her medical training, she developed a strong interest in Public Health, Medical Education, and Health Equity and is looking forward to pursuing a career in Internal Medicine. When she is not volunteering on a project, she likes taking care of her plants, developing her skills in the fine arts, or learning a new language.
Episode 275: Anti-Racism in Medicine Series – Episode 19 – Reframing the Opioid Epidemic: Anti-Racist Praxis, Racial Health Inequities, and Harm Reduction
Feb 09, 2023
Episode 19 – Reframing the Opioid Epidemic: Anti-Racist Praxis, Racial Health Inequities, and Harm Reduction
Show Notes by Alec Calac
February 9, 2022
Summary: This episode highlights racialized disparities in addiction treatment. During this episode, we hear from Dr. Jessica Isom, a board-certified community psychiatrist and faculty leader in the Yale Department of Psychiatry’s Social Justice and Health Equity Curriculum, and Dr. Ayana Jordan, the endowed Barbara Wilson Associate Professor in the Department of Psychiatry, Addiction Psychiatrist and Associate Professor in the Department of Population Health at New York University (NYU) Grossman School of Medicine. Together, our guests explore and unpack how the criminalization and racialization of substance use builds to the present-day opioid epidemic and shapes inequities in care. There is a special emphasis on the use of public health models that prioritize harm reduction and person-centered care to prevent drug-related fatalities and curb the opioid epidemic along lines of race and class. This discussion is hosted by Ashley Cooper, Sudarshan Krishnamurthy, and new team member Gillette Pierce.
Episode Learning Objectives:
After listening to this episode, learners will be able to…
Explain how the criminalization and racialization of substance use builds to the present-day opioid epidemic and shapes inequities in care.
Describe how the media shapes public sentiment toward substance use and addiction treatment.
Identify realistic solutions to drug policy reform that promote health equity among marginalized communities living in the United States.
Credits:
Written and produced by: Ashley Cooper, MPhil; Sudarshan Krishnamurthy; Gillette Pierce; Alec J. Calac; Michelle Ogunwole, MD, PhD; Ayana Watkins; Chioma Onuoha; Naomi F. Fields, MD; Victor A. Lopez-Carmen, MPH; Rohan Khazanchi, MPH; Sudarshan Krishnamurthy; Utibe R. Essien, MD, MPH; Jazzmin Williams; LaShyra Nolen; Jennifer Tsai MD, MEd
Hosts: Ashley Cooper, Sudarshan Krishnamurthy, and Gillette Pierce
Infographic: Creative Edge Design
Audio Edits: Caroline Cao and Ashley Cooper, MPhil
Show Notes: Alec Calac
Guests: Jessica Isom, MD, MPH and Ayana Jordan, MD, PhD
Time Stamps:
1:30 Guest Introductions
4:15 Framing the Sociohistorical Context of the Opioid Epidemic
10:47 Racialization of Substance Use and Medicalization of the Human Experience
14:28 Changing “Faces of Addiction” and Impact on U.S. Drug Policy
16:35 United States, Chinese Laborers, and Anti-Chinese Sentiment (“Opium Fiends”)
19:30 “Moral Panic”
23:00 Separating Minoritized Individuals from the Majority
23:40 Cocaine Possession Sentencing Disparities
26:50 Shifting Social Attitudes Toward Substance Use and Addiction
30:30 (Mis)framing of Substance Use as a White Problem to Enact Change
33:15 Rectifying Racial Health Inequities in Opioid Addiction Treatment
36:10 Take-Home Methadone and a Less Clear Need for Methadone Clinics
40:40 Understanding Substance Use Disparities with Racially Disaggregated Data
47:00 Pushing Back Against “One Size Fits Most”
49:30 Harm Reduction Practices
53:00 Narrowing the Empathy Gap and Connecting with Patients
55:25 Spirit of Sankofa: Looking Back to Move Forward
59:15 Reducing Harm and “Optimizing Safety”
1:08:00 Community-Centered Solutions
1:10:20 Drug Policy Reform
1:15:42 Episode Takeaways
Episode Takeaways:
Health care providers, especially physicians, cannot be equity-ignorant or egalitarian in our racialized society. They can use their training and privilege to advocate for meaningful policy reform.
The opioid epidemic is more than a white problem. Demographic data in research and practice must always be disaggregated by race and ethnicity.
Screening for substance use and offering connections to treatment and community-based services are important strategies that clinicians can implement in their own practice today.
Pearls:
In 2020, American Indian and Alaska Native (Indigenous) communities experienced the highest drug overdose mortality rate of any racial or ethnic group, also surpassing rates among the non-Hispanic white population. Between 2007 – 2019, Black individuals experienced a higher death rate for opioid overdose deaths than any other racial or ethnic group. [Supplementary Resource for Listeners: CPSolvers Episode 12: Addressing Anti-Indigenous Racism in Medicine with team members Alec Calac and Victor Anthony Lopez-Carmen]
Dr. Jordan begins our episode by framing the racialization and criminalization of substance use in the larger history of the United States, emphasizing that American society has seen substance use as “criminal behavior” or a moral failing, rather than as a medical condition, which began towards the early 2000s. She mentions that academia, as well as the media, have contributed to this complex social phenomenon by tying together race, gender, and substance use, especially in the context of maternal health and neonatal abstinence syndrome. The foundational literature in this area has furthered stigma and bias, especially towards Black birthing persons. These narratives have vilified individuals who would benefit from comprehensive, person-centered substance use treatment, rather than incarceration and other adverse harms.
Dr. Isom continues the conversation around the intentionality of these structural processes and the language that frames the racialization of substance use in the United States by lawmakers, media, and the healthcare profession. This parallels another process, which is the medicalization of human experiences, especially those relating to childbirth and pregnancy. A more Western perspective on health care emphasizes the role of physicians and health care providers and marginalizes the role and contributions of doulas and midwives. She then ties this back to Dr. Jordan’s conversation about the criminalization of substance use and how resources and infrastructure are dedicated to incarceration, rather than psychotherapy and related treatments. [Supplementary Resource for Listeners: Advancing Health Equity: A Guide to Language, Narrative and Concepts]
Sudarshan goes further into the changing “faces of addiction” and asks our guests to describe its impact on drug policy in the United States. Dr. Isom first challenges our listeners to engage with anti-racist praxis and challenge dominant racial narratives about substance use, policing, and other encounters. She then goes into how the racialization of substance use drove positive public sentiment for the adoption of punitive outcomes for substance use. One example that is presented involves the complicated relationship between the United States and Chinese immigrants and farmworkers in California. Once the need for labor was largely met, anti-Chinese narratives (e.g., opium fiends) emerged around opium, gambling, and prostitution, which fits into this pattern or formula of associating specific racial and ethnic groups with substance use as a rhetorical threat to the “most valued demographic” in the United States (white women and children) to drive the adoption of punitive measures. This largely obscures the reality that substance use rates are similar among different racial and ethnic groups. [Supplementary Resource for Listeners: San Francisco Opium Ordinance described in Race and the Criminalization of Drugs – National Press Foundation | NPF featuring Dr. Jessica Isom and Dr. Helena Hansen]
Dr. Jordan echoes these thoughts and posits that divergence from the “ideal” American identity (i.e., white, cisgender, heterosexual) makes it possible to other (verb) individuals and enact policies and laws that punish individuals with marginalized identities. She shared that rhetoric used by Nixon and the subsequent war on drugs has similarities to Trumpism and messaging associated with Make America Great Again (MAGA). This is then reaffirmed during the Reagan Administration and is later codified into sentencing structures, in which we see vastly different amounts of cocaine possession (100:1 crack versus powder cocaine possession offenses) amounting to similar sentences, with crack cocaine use most prevalent among minoritized individuals and powder cocaine use most prevalent among the white majority. Involvement with the carceral system further intersects with issues around employment, household income, and other related disparities. To our listeners, how might we begin redressing these harms and reinvest in minority communities adversely affected by the war on drugs? [Supplementary Resource for Listeners: Cracks in the System: 20 Years of the Unjust Federal Crack Cocaine Law | American Civil Liberties Union]
The conversation then shifts into changing social attitudes toward substance use and addiction. Dr. Isom breaks down media messaging and the varying tones and contexts used to describe substance use disparities and how that contributes to social stigma. She explains how different types of stigma intersect with media messaging to craft narratives that encourage sympathy or even a lack of sympathy towards certain racial and ethnic groups and health behaviors. Dr. Isom then discusses that policy reform and changing attitudes toward substance use and addiction are largely driven by the hurt and pain of those in the white majority with substance use disorder, further minimizing the experiences of marginalized communities.
Dr. Jordan agrees with this characterization and goes more into the historical media coverage of substance use and the dehumanizing language that was (and is still) used to describe drug use among minority individuals. This segues into a conversation about the legacy of the war on drugs and today’s racial inequities in opioid addiction treatment. Ashley delineates that methadone has been disproportionately prescribed in predominantly Black communities, as a means to drive down crime, whereas white patients undergoing substance use treatment are more likely to receive buprenorphine. Dr. Jordan highlights the harm that these prescribing practices cause as they falsely associate race and substance use with criminal activity and neighborhood safety. She further goes into the stigma and stereotyping that continues to this day with the incessant and inhumane need to pick up prescription treatment once daily, submit “clean” urine samples under direct supervision, and submit to oral examinations. Dr. Jordan then questions the utility and continued operation of methadone clinics, especially as the United States largely moves on from the COVID-19 pandemic. She highlights actions taken by the United States Substance Abuse and Mental Health Services Administration (SAMHSA) to expand access to take-home methadone doses, which promoted patient autonomy and had comparable adherences outcomes and no significant changes in potential adverse harms, such as overdose and diversion. Other actions include elimination of the United States Drug Enforcement Administration (DEA) X waiver which was needed to prescribe buprenorphine. Dr. Jordan concludes by thinking about incentive strategies that would encourage health care providers to change their prescribing practices and minimize racial inequities in opioid addiction treatment [Supplementary Resource for Listeners: Lessons from COVID 19: Are we finally ready to make opioid treatment accessible? – PMC]
Dr. Isom highlights the differences in substance use disparities and infrastructure utilization from the national level moving into discrete communities. Using an equity lens, she shares her own experiences in Massachusetts examining treatment utilization and encourages health care providers to examine racially disaggregated data to make sure that services offering suboxone (buprenorphine and naloxone) are reaching and being used in the most impacted communities. She also discusses the importance of the patient-provider relationship and shared-decision making, which helps ensure that a full range of services are being offered to patients. Dr. Jordan and Dr. Isom both agree that simply offering treatment services and having an “open door” are not enough. Dr. Jordan discusses the importance of de-centering the majority and identifying the factors that are most relevant to minoritized individuals and communities. Oftentimes, researchers and practitioners working to implement addiction treatment programs and interventions are not from those same communities. Dr. Jordan pushes back on the notion that “one size fits most” is the optimal approach for treating substance use disorder and that the evidence we rely on for patients undergoing substance use treatment was largely informed by the experiences of white individuals. Therefore, traditional settings of addiction care may unintentionally cause harm to individuals with marginalized identities.
Gillette moves the conversation into strategies addressing substance use disparities, particularly those that emphasize the importance of harm reduction. Dr. Isom begins by sharing her experiences in the clinic and how harm reduction approaches such as offering fentanyl test strips humanize substance use treatment and place individual and community health and well-being at the center of treatment. To her dismay, she also learned that her racially and linguistically diverse patient population was one of most affected by the opioid epidemic in the Commonwealth of Massachusetts. Reflecting on these health data and rethinking “traditional” addiction treatment strategies helped her connect with her patients and close a self-described empathy gap that she says patients accessing treatment often have with their health care provider. Dr. Jordan enters into the conversation and also shares how she best connects with her patients who often feel unheard and marginalized by the health care system. She discusses the strengths and limitations of harm reduction approaches and the continued need for a clinician-researcher workforce that reflects the diversity seen in communities experiencing hardship. An important part of her discussion includes the contributions of community health workers and a need not just to focus on harm reduction, but also to optimize safety among individuals using substances such as alcohol and opioids. This complementary approach has the potential to increase the positive impact that the harm reduction movement has made over time.
The group briefly discusses Dr. Isom’s article Nothing About Us Without Us in Policy Creation and Implementation | Psychiatric Services (2021) which highlights the need for patients and communities to be included in the creation and implementation of drug policy. This approach has the potential to best direct resources to the most impacted communities and may be more impactful than traditional community engagement models. Dr. Jordan has also written about culturally-responsive programs benefiting Black communities affected by the opioid epidemic and has completed a pilot study providing addiction treatment in partnership with faith-based organizations. Both guests acknowledge that academics do not always have the right solutions and that practitioners have to listen openly to community knowledge holders.
Towards the end of the episode, Dr. Jordan highlights opportunities for meaningful drug policy reform, including examining federal methadone regulations (e.g., dosing, availability), investing in harm reduction and safety optimization, and decreasing police involvement in mental health crisis response and police presence in substance use treatment settings.
New Host! Kiersten TâLeigh (Ta-Lee) “Gillette” Gillette-Pierce (she/they) is currently a student at Johns Hopkins School of Public Health pursuing a Master of Science in Public Health with a double concentration in Maternal, Fetal, and Perinatal Health and Women, Sexual and Reproductive Health. As an academic researcher, they focus on transnational racial/ethnic and gender disparities in pregnancy-related, sexual, and reproductive health outcomes for all persons with gynecologic organs, with a specific interest in people of African descent. She is published in the Journal of Advanced Nursing and Medicine, Science, and Law. Gillette has also published work with Rewire News Group and the Center for American Progress focusing on sexual and reproductive health and rights policy, reproductive justice, and health outcomes for Black birthing persons. With almost ten years of experience in the global sexual and reproductive health, rights, and justice field, Gillette aims to improve sexual and reproductive health care and outcomes for disenfranchised communities and significantly improve pregnancy-related outcomes for people of African descent.
Speaker Biographies
Dr. Jessica Isom, MD, MPH, is a board-certified community psychiatrist and faculty leader in the Yale Department of Psychiatry’s Social Justice and Health Equity Curriculum. She primarily works in Boston as an attending psychiatrist at Codman Square Health Center where she is leading a grant effort to infuse antiracism in Opioid Use Disorder (OUD) services. She is a nationally recognized expert on racial equity and justice in psychiatry with a focus on workforce development and organizational transformation. Her professional interests include working toward eradicating racial and ethnic mental health disparities, mitigating the impact of implicit racial bias on clinical care, and the use of a community-centered population health approach in psychiatric practice. She serves on multiple advisory boards and is a consultant, curriculum developer and presenter to a variety of organizations including Fortune 500 companies and medical societies through her company, Vision for Equity LLC. Dr. Isom received her MD from the University of North Carolina School of Medicine, and completed her residency at Yale University.
Ayana Jordan, MD, PhD, is the Barbara Wilson Associate Professor in the Department of Psychiatry, Addiction Psychiatrist and Associate Professor in the Department of Population Health at New York University (NYU) Grossman School of Medicine. She also serves as Pillar Co-Lead for Community Engagement at NYU Langone’s Institute for Excellence in Health Equity. As Principal Investigator for the Jordan Wellness Collaborative (JWC), she leads a research, education, and clinical program that partners with community members to provide optimal access to evidence-based treatments for racial and ethnic minoritized patients with mental health disorders. Through her multifaceted work, she provides addiction treatment in faith settings, studies health outcomes for people with opioid use disorder in the carceral system, and trains addiction specialists to provide culturally-informed treatment. Dr. Jordan is dedicated to creating spaces and opportunities for more people of color, specifically Black women in academia who are vastly underrepresented. She has numerous peer-reviewed publications, has been featured at international conferences, and is the proud recipient of various clinical and research awards. The fundamental message of equity and inclusion has informed her research, clinical work, and leadership duties at NYU and beyond.
References
Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2022. Designed by LM Rossen, A Lipphardt, FB Ahmad, JM Keralis, and Y Chong: National Center for Health Statistics.
Balasuriya, L., Isom, J., Cyrus, K., Ali, H., Sloan, A., Arnaout, B., Steinfeld, M., DeSouza, F., Jordan, A., Encandela, J., & Rohrbaugh, R. (2021). The Time Is Now: Teaching Psychiatry Residents to Understand and Respond to Oppression through the Development of the Human Experience Track. Academic Psychiatry, 45(1), 78–83. https://doi.org/10.1007/s40596-021-01399-x
Castillo, E. G., Isom, J., DeBonis, K. L., Jordan, A., Braslow, J. T., & Rohrbaugh, R. (2020). Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education. Academic Medicine, 95(12), 1817–1822. https://doi.org/10.1097/ACM.0000000000003559
DeSouza, F., Mathis, M., Lastra, N., & Isom, J. (2021). Navigating Race in the Psychotherapeutic Encounter: A Call for Supervision. Academic Psychiatry, 45(1), 132–133. https://doi.org/10.1007/s40596-020-01328-4
Friedman, J. R., & Hansen, H. (2022). Evaluation of Increases in Drug Overdose Mortality Rates in the US by Race and Ethnicity Before and During the COVID-19 Pandemic. JAMA Psychiatry, 79(4), 379. https://doi.org/10.1001/jamapsychiatry.2022.0004
Godkhindi P, Nussey L, O’Shea T. “They’re causing more harm than good”: a qualitative study exploring racism in harm reduction through the experiences of racialized people who use drugs. Harm Reduct J. 2022 Aug 25;19(1):96. doi: 10.1186/s12954-022-00672-y. PMID: 36008816; PMCID: PMC9406271.
Goldman, M. L., Swartz, M. S., Norquist, G. S., Horvitz-Lennon, M., Balasuriya, L., Jorgensen, S., Greiner, M., Brinkley, A., Hayes, H., Isom, J., Dixon, L. B., & Druss, B. G. (2022). Building Bridges Between Evidence and Policy in Mental Health Services Research: Introducing the Policy Review Article Type. Psychiatric Services, 73(10), 1165–1168. https://doi.org/10.1176/appi.ps.202100428
Hansen H, Jordan A, Plough A, Alegria M, Cunningham C, Ostrovsky A. Lessons for the Opioid Crisis-Integrating Social Determinants of Health Into Clinical Care. Am J Public Health. 2022 Apr;112(S2):S109-S111. doi: 10.2105/AJPH.2021.306651. PMID: 35349328; PMCID: PMC8965192.
Hughes M, Suhail-Sindhu S, Namirembe S, Jordan A, Medlock M, Tookes HE, Turner J, Gonzalez-Zuniga P. The Crucial Role of Black, Latinx, and Indigenous Leadership in Harm Reduction and Addiction Treatment. Am J Public Health. 2022 Apr;112(S2):S136-S139. doi: 10.2105/AJPH.2022.306807. PMID: 35349317; PMCID: PMC8965189.
Isom, J., & Balasuriya, L. (2021). Nothing About Us Without Us in Policy Creation and Implementation. Psychiatric Services, 72(2), 121–121. https://doi.org/10.1176/appi.ps.72202
Isom, J., Jordan, A., Goodsmith, N., Medlock, M. M., DeSouza, F., Shadravan, S. M., Halbert, E., Hairston, D., Castillo, E., & Rohrbaugh, R. (2021). Equity in Progress: Development of Health Equity Curricula in Three Psychiatry Residency Programs. Academic Psychiatry, 45(1), 54–60. https://doi.org/10.1007/s40596-020-01390-y
James K, Jordan A. The Opioid Crisis in Black Communities. J Law Med Ethics. 2018 Jun;46(2):404-421. doi: 10.1177/1073110518782949. PMID: 30146996.
Jordan, A., Mathis, M. L., & Isom, J. (2020). Achieving Mental Health Equity: Addictions. Psychiatric Clinics of North America, 43(3), 487–500. https://doi.org/10.1016/j.psc.2020.05.007
Jordan A, Babuscio T, Nich C, Carroll KM. A feasibility study providing substance use treatment in the Black church. J Subst Abuse Treat. 2021 May;124:108218. doi: 10.1016/j.jsat.2020.108218. Epub 2020 Dec 3. PMID: 33771290.
Lagisetty, P. A., Ross, R., Bohnert, A., Clay, M., & Maust, D. T. (2019). Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry, 76(9), 979. https://doi.org/10.1001/jamapsychiatry.2019.0876
Nweke, N., Isom, J., & Fashaw-Walters, S. (2022). Health Equity Tourism: Reckoning with Medical Mistrust. Journal of Medical Systems, 46(5), 27. https://doi.org/10.1007/s10916-022-01812-4
Portnoy, G. A., Doran, J. M., Isom, J. E., Wilkins, K. M., DeViva, J. C., & Stacy, M. A. (2021). An evidence-based path forward for diversity training in medicine. The Lancet Psychiatry, 8(3), 181–182. https://doi.org/10.1016/S2215-0366(21)00024-9
Roxas, N., Ahuja, C., Isom, J., Wilkinson, S. T., & Capurso, N. (2021). A Potential Case of Acute Ketamine Withdrawal: Clinical Implications for the Treatment of Refractory Depression. American Journal of Psychiatry, 178(7), 588–591. https://doi.org/10.1176/appi.ajp.2020.20101480
Townsend, T., Kline, D., Rivera-Aguirre, A., Bunting, A. M., Mauro, P. M., Marshall, B. D. L., Martins, S. S., & Cerdá, M. (2022). Racial/Ethnic and Geographic Trends in Combined Stimulant/Opioid Overdoses, 2007–2019. American Journal of Epidemiology, 191(4), 599–612. https://doi.org/10.1093/aje/kwab290
Wyatt JP, Suen LW, Coe WH, Adams ZM, Gandhi M, Batchelor HM, Castellanos S, Joshi N, Satterwhite S, Pérez-Rodríguez R, Rodríguez-Guerra E, Albizu-Garcia CE, Knight KR, Jordan A. Federal and State Regulatory Changes to Methadone Take-Home Doses: Impact of Sociostructural Factors. Am J Public Health. 2022 Apr;112(S2):S143-S146. doi: 10.2105/AJPH.2022.306806. PMID: 35349318; PMCID: PMC8965186.
Disclosures
The hosts and guests report no relevant financial disclosures.
Citation
Isom J, Jordan A, Cooper A, Krishnamurthy S, Pierce G, Calac A, Watkins A, Onuoha C, Lopez-Carmen VA, Nolen L, Williams J, Tsai J, Ogunwole M, Khazanchi R, Fields NF. “Episode 19: Reframing the Opioid Epidemic: Anti-Racist Praxis, Racial Health Inequities, and Harm Reduction”. The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. February 9, 2022.
Sukriti and Maani present a clinical unknown to Dr. Reza, followed by a brief discussion about addressing roadblocks that women in medicine face.
Dr. Nosheen Reza
Dr. Nosheen Reza is a cardiologist and translational researcher at the University of Pennsylvania focusing on advanced heart failure and transplant cardiology and cardiovascular genetics. She obtained her medical degree from the University of Virginia School of Medicine and completed internal medicine residency at the Massachusetts General Hospital. She then completed both her Cardiovascular Disease and Advanced Heart Failure and Transplant Cardiology fellowships at the University of Pennsylvania. At Penn, Dr. Reza pursued additional scholarship in genomic medicine as an NIH T32-funded postdoctoral fellow and in healthcare quality as a Penn Benjamin & Mary Siddons Measey Fellow in Quality Improvement and Patient Safety. Now, as an Assistant Professor of Medicine, she cares for patients in the Penn Center for Inherited Cardiovascular Disease and in the Section of Heart Failure, Transplantation, and Mechanical Support. Dr. Reza is also an Assistant Program Director of the Cardiovascular Disease Fellowship and the Director of the Penn Women in Cardiology program.
The spaced learning series team tackles the case of a patient with a non-resolving pulmonary inflammatory syndrome, found to have a cavitary lesion on lung imaging with glomerulonephritis.
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time,Valeria presents a case of headache and altered mental status to Joy and Mattia.
Valeria is a medical student at Universidad Peruana Cayetano Heredia. She was born and lives in Lima, Perú. She hopes to pursue Neurology residency. Her interests include neuro-infectious diseases, transgender health and medical education. Her work with CPSolvers involves being a part of the Virtual Morning Report team and serving on the Spanish schemas team. Outside of Medicine she loves running, hiking, cooking pasta and spending time with her dogs.
Joy Glanton
@joytibalan
Joy is a neuro enthusiast who has completed her neuroscience undergrad and medical studies in the Philippines. She is passionate about neurology and believes “the brain is everything; it’s what makes us who we are.” She is hoping to match into Neurology in 2023, and is currently in NYC completing clinical externships/rotations in neurology. Post residency, she aspires to do translational/clinical research work or pursue a career in academic/general neurology. Joy enjoys running, swimming, literary art, debates in neuroscience, and listening to rock and roll and classical music.
Mattia Rosso
@MattiaRosso3
Mattia Rosso is a neurology resident at the Medical University of South Carolina (MUSC) in Charleston, South Carolina. He is interested in movement disorders, behavioral neurology, and autoimmune neurology. He is also passionate about the intersection between the humanities and medicine. He started a Neurohumanities group at MUSC, which meets monthly and features internal and guest speakers. This group focuses on the role of the Arts, Cinema, Literature, Philosophy, and Music in medicine and neurosciences. Outside work, he enjoys photography, cinema, and discovering new music. Since starting residency, the Clinical Problem Solvers have been an irreplaceable source of learning and inspiration.
Episode 268: WDx #21 – Clinical Unknown with Dr. Rachael Lee
Dec 14, 2022
Dr. Lee joined the UAB Division of Infectious Diseases at UAB in 2016 and is currently an Associate Professor. She is the UAB Chief Healthcare Epidemiologist and in this role, she utilizes evidence based medicine to prevent the spread of healthcare-associated infections. Her research focuses on multi-drug resistant pathogens as they relate to infection prevention and control.
Reza and Rabih discuss a fascinating case of AMS, infection and polyuria.
rlrCPSOLVERS.COM
RLR have transitioned from Patreon to have their website rlrCPSolvers.com. Check out this virtual classroom full of bonus schemas, illness scripts, teaching videos and case challenges
Get a personalized clinical reasoning curriculum to take your skills to the next level AND support the CPSolvers while you are at it.
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, John presents a case of diplopia to Valeria and Madellena.
John Acquaviva is a fourth-year medical student attending Lake Erie College of Osteopathic Medicine in Erie, Pennsylvania. He has a passion for both clinical and academic neurology and will be starting neurology residency in the summer of 2023. He has special interests in neurophysiology, autoimmune neurology, and neuroimmunology, but is excited about all neurological fields. In his free time, he enjoys hanging out with friends, long-boarding, running, and martial arts.
Valeria Roldán
@valeroldan23
Valeria is a medical student at Universidad Peruana Cayetano Heredia. She was born and lives in Lima, Perú. She hopes to pursue Neurology residency. Her interests include neuro-infectious diseases, transgender health and medical education. Her work with CPSolvers involves being a part of the Virtual Morning Report team and serving on the Spanish schemas team. Outside of Medicine she loves running, hiking, cooking pasta and spending time with her dogs.
Madellena Conte
@MadellenaC
Madellena Conte was born and raised in San Francisco, CA. She completed her undergraduate degree at Dartmouth College. After college, she worked at Collective Health, a healthcare insurance technology company, and then completed her Master’s of Science in Global Health at UCSF where her research focused on understanding preferences for HIV care among people experiencing unstable housing. She is a MS4 at the Zucker School of Medicine at Hofstra/Northwell in New York and is currently taking a research year in the Division of HIV, ID, and Global Medicine at UCSF. Outside of medicine, Madellena loves to travel, meet new people, run, figure skate and really do anything outdoors. She plans on applying into internal medicine residency.
Episode 18 – Remedying Health Inequities Driven by the Carceral System
Show Notes by Ayana Watkins
October 18, 2022
Summary: This episode highlights the history and roots of the carceral system, as well as its far-reaching impacts on the health of women and children today. During this episode, we gain insight from special guests Dr. Jennifer James—a qualitative researcher, a Black Feminist scholar, and an assistant professor in the Institute for Health and Aging, the Department of Social and Behavioral Sciences, and the Bioethics program at the University of California San Francisco—and Dr. Nia Heard-Garris—a pediatrician and researcher in the Department of Pediatrics at Feinberg School of Medicine at Northwestern University and in the Division of Academic General Pediatrics and Mary Ann & J. Milburn Smith Child Health Research, Outreach, and Advocacy Center at the Ann & Robert H. Lurie Children’s Hospital of Chicago. This discussion is hosted by Sudarshan Krishnamurthy, Ashley Cooper, and Alec J. Calac.
Episode Learning Objectives
After listening to this episode, learners will be able to…
Understand the history of mass incarceration and its effect on health
Recognize how cultures of punishment and control within carceral spaces and within clinical settings impact health
Learn how to best care for and support those experiencing violence at the hands of the carceral system
Consider how we enact carceral structures and act as agents of the state in our clinical practices
Credits
Written and produced by: Sudarshan Krishnamurthy, Ashley Cooper, Alec J. Calac, Michelle Ogunwole MD, PhD, Ayana Watkins, Chioma Onuoha, Naomi F. Fields MD, Victor A. Lopez-Carmen MPH, Rohan Khazanchi MPH, Sudarshan Krishnamurthy, Utibe R. Essien MD, MPH, Jazzmin Williams, LaShyra Nolen, Jennifer Tsai MD, MEd, Zahada (Kiersten) Gillette -Pierce
Hosts: Sudarshan Krishnamurthy, Ashley Cooper, and Alec J. Calac
Infographic: Creative Edge Design
Audio Edits: Isabella Gau
Show Notes: Ayana Watkins
Guests: Dr. Nia Heard-Garris, MD, MSc and Dr. Jennifer James, PhD, MS, MSW
Time Stamps 00:00 Introduction of episode and guests 04:01 History of mass incarceration and its relationship with health 11:38 Understanding healthcare decision-making in carceral spaces 22:27 Substance Use and Treatment/Diversion vs. Incarceration of BIPOC mothers 29:30 Health Impacts on Children and Young Adults with History of Parental Incarceration 35:24 Remedying Health of Women and Children Impacted by the Criminal Legal System 45:55 Key takeaways
Episode Takeaways:
Prisons are not places of healing. Incarceration negatively affects the physical and mental health of people who are incarcerated as well as their family members and loved ones, and limits access to healthcare before, during, and after incarceration.
All healthcare professionals will have patients who are directly or indirectly impacted by the carceral system. Our guests remind us to think critically about our role in the carceral system and in imposing systems of control and punishment within clinical settings. Additionally, our guests urge us to recognize the ways in which our patients are impacted by incarceration and to ask our patients about these impacts in order to better care for them.
The ways to remedy the negative impacts of incarceration are to incarcerate fewer people and to invest in communities. Providing communities with the resources they need to survive, such as educational opportunities, jobs, and quality healthcare, will eliminate the need for incarceration. Additionally, decarceration and abolition will remedy the far-reaching health effects of the criminal legal system.
Pearls
“Prisons and jails are not healing spaces [. . .] They are not spaces designed for healing or care, they are designed for punishment and control.”
Dr. James explains that the culture of punishment, control, and violence within jails and prisons impedes healthcare for people who are incarcerated. People who are incarcerated are dehumanized and feel they are treated as inmates, rather than as patients. Correctional officers act as gatekeepers, deciding who does and does not need medical care. This means that people who are incarcerated are often not believed when they say they need medical care. As a result of this dehumanization and mistreatment, people who are incarcerated may forgo seeking medical care because they do not trust that the system and healthcare professionals will do anything but harm them further.
Dr. Heard-Garris draws parallels between the culture within the carceral system and that within hospitals and clinics. For clinicians who do not work within jails or prisons, it is important to recognize the presence of these same issues within other clinical spaces. Hospitals and clinics also have security, armed guards, and police whose roles are to impose control, and their presence can impact health outcomes for patients.
Dr. Heard-Garris also added that having a family member in the carceral system makes it more likely that a person will lose confidence in the medical system and will not seek care, so this mistrust in healthcare reverberates in generations post-incarceration.
Substance Use and Society’s focus on incarceration and punishment over treatment, diversion, and healing for BIPOC women
Dr. Heard-Garris explained that systems such as capitalism, politics, and white supremacy are the reasons our society focuses on incarceration and punishment rather than on substance use treatment. She discusses how it’s easier to incarcerate people than it is to invest in treatment because investment requires time, money, and the dismantling of our current systems.
Dr. James adds that reproductive justice and the rights to family, and having the resources and support to raise children have never existed for people of color and people experiencing poverty. Current-day familial structures reflect policies dating back to slavery, the forced displacement of Native Americans, and the way immigrant families have been treated. Today, the carceral system plays a pivotal role in modern-day eugenics and in reproductive and family control.
Health Impacts on Children and Young Adults with History of Parental Incarceration & Juvenile Justice Involvement
Dr. Heard-Garris explains that the health impacts that affect people who are incarcerated also impact children and adolescents with parents who have been incarcerated. This exposure to the carceral system negatively impacts the physical and mental health of these children and young adults and reduces their access to healthcare.
She also reminds us that children with parents who are incarcerated are not doomed to poor outcomes. Many of these children and young adults are resilient and are still able to thrive. However, they should not have to undergo these adverse childhood experiences and traumas. The carceral system needs to be changed and these children need to be supported and have their healthcare and education needs met.
Remedying the Health of Women and Children Impacted by the Criminal Legal System
Both Dr. James and Dr. Heard-Garris agree that the best way to remedy the health impacts of the carceral system is to incarcerate fewer people.
Dr. James discusses changes that can be made if we assume the current carceral system will remain. We need a system, such as a single-payer healthcare system, that provides people with consistent access to high-quality care before, during, and after incarceration. Additionally, we should provide people who are incarcerated with better ways to communicate with their families. For healthcare specifically, it is important to believe people when they say they need care and provide them with access to trauma-informed care.
Dr. Heard-Garris adds that a good place to start is to decarcerate people and offer them support. Additionally, we need to prevent incarceration by investing in communities and providing communities with resources, education, jobs, healthcare, etc. The goal is to create a society in which prisons and jails aren’t necessary because every person has what they need to survive.
Practices Clinicians can Incorporate to Reduce the Impacts of Mass Incarceration on Patients
Dr. James reminds us that no matter where we work or what specialty we work in, we will see people who are impacted by incarceration. As physicians and healthcare professionals, we should ask people about their histories of trauma and about the impact of incarceration on their lives. Additionally, we need to be cognizant of the ways we as providers enact a carceral state and think critically about the way these systems impact patient care.
Dr. Heard-Garris encourages us to ask patients about their interactions with the carceral system. Asking these questions provides us with an opportunity to better care for our patients. It can allow us to offer more support systems to patients and to connect patients with resources that have worked for others. We also have to be aware of our power and privilege and recognize that we do not treat all our patients equitably in order to change and do better.
References
Black Feminist Bioethics: Centering Community to Ask Better Questions. Hastings Cent Rep. 2022 03; 52 Suppl 1:S21-S23. James JE. PMID: 35470879.
Race, Racism, and Bioethics: Are We Stuck? Am J Bioeth. 2022 03; 22(3):22-24. James JE. PMID: 35258424.
Heard-Garris N, Sacotte KA, Winkelman TNA, Cohen A, Ekwueme PO, Barnert E, Carnethon M, Davis MM. Association of Childhood History of Parental Incarceration and Juvenile Justice Involvement With Mental Health in Early Adulthood. JAMA Netw Open. 2019 Sep 4;2(9):e1910465. doi: 10.1001/jamanetworkopen.2019.10465. PMID: 31483468.
Heard-Garris N, Winkelman TNA, Choi H, Miller AK, Kan K, Shlafer R, Davis MM. Health Care Use and Health Behaviors Among Young Adults With History of Parental Incarceration. Pediatrics. 2018 Sep;142(3):e20174314. doi: 10.1542/peds.2017-4314. Epub 2018 Jul 9. Pediatrics. 2019 May;143(5): PMID: 29987170.
Heard-Garris N, Johnson TJ, Hardeman R. The Harmful Effects of Policing—From the Neighborhood to the Hospital. JAMA Pediatr. 2022;176(1):23–25. doi:10.1001/jamapediatrics.2021.2936
Heard-Garris, N., Boyd, R., Kan, K., Perez-Cardona, L., Heard, N. J., & Johnson, T. J. (2021). Structuring poverty: how racism shapes child poverty and child and adolescent health. Academic pediatrics, 21(8), S108-S116.
Kaba, Mariame, et al. No More Police: A Case for Abolition. The New Press, 2022.
Roberts, Dorothy. Torn Apart: How the Child Welfare System Destroys Black Families–and How Abolition Can Build a Safer World. Basic Books, 2022.
Wilkerson, Isabel. Caste (Oprah’s Book Club): The origins of our discontents. Random House, 2020.
Disclosures
The hosts and guests report no relevant financial disclosures.
Citation
James J, Heard-Garris N, Krishnamurthy S, Cooper A, Calac A, Watkins A, Onuoha C, Lopez-Carmen VA, Krishnamurthy S, Calac A, Nolen L, Williams J, Tsai J, Ogunwole M, Khazanchi R, Fields NF, Gillette-Pierce K. “Episode 18: Remedying Health Inequities Driven by the Carceral System” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. October 18, 2022.
In this WDx episode, Sharmin and Dr Lekshmi Santhosh delve into the world of written evaluations: why are they important, implicit biases they can contain and how to do a better job in both writing and interpreting evaluations.
Dr. Lekshmi Santhosh
Dr. Lekshmi Santhosh is an associate professor of medicine at UCSF. She specializes in adult pulmonary and critical care medicine with a focus on medical education. She attends in the Medical ICU, the Neuro ICU, on the Internal Medicine teaching wards, and has clinic at the Pulmonary Outpatient Faculty Practice at UCSF-Parnassus. She is the founder and Medical Director of the multidisciplinary long-COVID/post-ICU OPTIMAL Clinic at UCSF Health.
She serves as the Associate Program Director for Curriculum for the Internal Medicine Residency and the Associate Program Director of the Pulmonary and Critical Care Medicine Fellowship. She also is the Director of the Department of Medicine Grand Rounds. She obtained her Master’s in Health Professions Education from UC-Berkeley. Her primary interests in medical education research are related to ICU transitions of care, women in leadership, clinical reasoning, and subspecialty career choice.
This episode is dedicated to the loving memory of Gabriel Talledo, we reflect on how greatly he touched our lives followed by his story, as told by him in the first episode of Queer Rounds.
Please consider donating here to the Gabriel Talledo’s Scholarship benefiting young medical students of the LGTBQIA community in hopes of financially helping them achieve their dreams.
Episode 258: Spaced Learning Series – Pulmonary Granulomas, Headache, and Hyponatremia
Sep 28, 2022
The SLS team tackles the case of a young woman presenting with a prolonged, inflammatory pulmonary syndrome is found to have pulmonary granulomas, headaches and hyponatremia. Join them as they apply CPSolvers schemas to real life Patient care to facilitate the diagnostic reasoning process.
Sharmin, Ann Marie, and Dan discuss a case that takes us on a journey through the pancreas and hepatobiliary systems with schemas at every stop of the way!
We cannot wait to share the new RLR website with you as our time on Patreon is coming to an end. The website is our dream project. You will be notified once the website is up before anyone else. We are a few weeks away!!!
And remember to reach out to us if there are any issues regarding refunds from Patreon as you cancel your annual subscriptions. It is very important to us that each of you are 100% satisfied with RR.
We hope you will continue to follow us and support our work once the new website is up and running. None of this is possible without you. We are so grateful for your support. For now, keep your monthly $5 Patreon subscription active b/c we are uploading audio as usual until the new website is up and running.
We will be offering so much more on the website. We think you will love it.
Enjoy this episode. We hope you don’t get a headache listening to it!!!
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, CPSolvers team member Rafael Medina presents a case of frequent falls for CPSolvers team member Yazmin and Alice.
Rafael Medina dos Santos is a Brazilian medical graduate. Before medicine, Rafael wanted to be a teacher. Unsurprisingly, he loves everything related to teaching and learning, so his passion for the CPSolvers’ mission was only natural. He’s applying this 2023 match season for internal medicine. Beyond medicine, Rafael loves fiction books/movies, pop music, and singing Disney songs.
Yazmin Heredia Allegretti
@minheredia
Yazmin is a Medical Graduate from Mexico, looking forward to applying to an Internal Medicine Residency in the U.S. She is passionate about medical education, health equity, and clinical reasoning and believes knowledge (as well as healthcare) must be accessible to everyone. She looks forward to collaborating with doctors and students worldwide to create the best evidence-based resources to impulse medical practice and patient care. Aside from medicine, you will find her taking care of her wide collection of plants, developing her skills in the fine arts, volunteering for any project she can find, or learning new languages.
Alice Falck
Alice is a 5th-year medical student from Berlin, currently working on her MD doctoral thesis to contribute to the pathophysiology of temporal lobe epilepsy. She aspires to be a neurologist and is interested in neuroscience, electrophysiology, and of course clinical reasoning. She is passionate about gender equality in general and especially in Medicine. In her free time, she loves discussing movies with friends and eating great food.
Dr. Rezigh presents a case of fever in a patient newly diagnosed with HIV to Dr. Woc-Colburn.
Dr. Alec Rezigh
Alec Rezigh is an academic hospitalist at Baylor College of Medicine in Houston, TX. He completed medical school at McGovern Medical School in Houston and his residency at The University of Colorado. His clinical interests include medical education and clinical reasoning. He loves all things basketball, CPSolvers, and playing with his human and doggy daughters.
Dr. Laila Woc-Colburn
Dr. Laila Woc-Colburn is an associate professor in the Division of Infectious Diseases at Emory University School of Medicine in Atlanta. She is a renowned medical educator and has a wide range of clinical interests including tropical medicine, HIV, and fungal diseases.
In this episode, Dr. Ashley McMullen, Dr. Simone Vais, and Jane Lock share stories of setbacks in medicine related to the theme, “I thought I was alone.” Session moderated by Madellena Conte.
Dr. Ashley McMullen is an assistant professor of medicine at the University of California, San Francisco, and a primary care internist based at the San Francisco VA Hospital. She is also a Houston, TX native and lifelong book nerd, who grew up nurtured by her mother, a pediatric nurse, and grandmother, an ordained minister. Dr. McMullen’s work focuses on the role of narrative and storytelling in medical education, and as a mechanism for healing, advocacy, and improving care across differences. She served as the host and producer of The Nocturnists: Black Voices in Healthcare Series, a 2021 Webby Award Honoree, and recently launched a new story-telling podcast with Dr. Kimberly Manning called, The Human Doctor.
Jane Lock
Jane Lock is an MD/PhD candidate at Boston University School of Medicine, currently in her M4 year applying into internal medicine. She was born in Malaysia and grew up in Taiwan before moving to the US for college and medical school. She has a strong interest in oncology research, particularly in mechanisms of DNA damage and repair in cancer. Her PhD thesis was focused on understanding alternative telomere maintenance mechanisms in osteosarcoma. She is also passionate about teaching and improving medical education. Outside of work and studying, she loves being the cool aunt to her 2 year old nephew, reading, crocheting and watching The Office with her husband.
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Valeria Roldan presents a case of tremors and myoclonus to Dr. Aaron Berkowitz.
Valeria is a medical student at Universidad Peruana Cayetano Heredia. She was born and lives in Lima, Perú. She hopes to pursue Neurology residency. Her interests include neuro-infectious diseases, transgender health and medical education. Her work with CPSolvers involves being a part of the Virtual Morning Report team and serving on the Spanish schemas team. Outside of Medicine she loves running, hiking, cooking pasta and spending time with her dogs.
Dr. Aaron Berkowitz
@AaronLBerkowitz
Aaron recently joined the founding faculty of Kaiser Permanente Bernard J. Tyson School of Medicine as a professor of neurology and director of global health. He previously served as an associate professor of neurology at Brigham and Women’s Hospital and Harvard Medical School, where he directed the Mind-Brain-Behavior course for first-year students and was a teaching attending on the neuro-hospitalist service and in the general neurology resident clinic. As a health and policy advisor to Partners In Health and senior specialist consultant to Doctors Without Borders, he has worked tirelessly to bring neurology care and education to regions where it is limited or non-existent, including co-developing the first neurology residency in Haiti. He is the author of Clinical Pathophysiology Made Ridiculously Simple, Clinical Neurology and Neuroanatomy: A localization-based approach, and most recently One by One by One, which tells the complex, moving, and inspiring stories of patients he and colleagues brought from Haiti to Boston for neurosurgery for brain tumors. When he is not trying to #EndNeurophobia, Aaron loves hiking, backpacking, and obsessively researching outdoor camping gear.
Pratik presents a case of dyspnea and RUQ pain to Fred.
Dr. Fred McLafferty
Fred McLafferty, MD is a fellow in the Division of Pulmonary and Critical Care at the University of California, San Francisco. His research interest is in how certain environmental particles and pathogens drive lung remodeling and pulmonary fibrosis. He is clinically interested in advanced lung disease and transplant, and will begin as the advanced fellow in lung transplant at UCSF in July 2022. Prior to fellowship, he graduated medical school from the David Geffen School of Medicine at UCLA and then completed both his internal medicine residency and chief residency at Northwestern University. Outside the hospital he enjoys skiing in Tahoe, riding his bike through San Francisco, or spending all day cooking a (sometimes) delicious dinner.
Dr. Pratik Doshi
Pratik Doshi, MD MS is a second-year Internal Medicine Resident at the University of Southern California. He completed medical school at Duke University School of Medicine. He is interested in delivering medical content in innovative ways and aspires to be a cardiologist. He is active on Twitter, follow him @PratikDoshiMD!
Dr. Jenn Davis presents a consult question to Dan, Doug, Emma, Sukriti, and Dr. Laila Woc-Colburn.
Dr. Laila Woc-Colburn
Dr. Laila Woc-Colburn is an associate professor in the Division of Infectious Diseases at Emory University School of Medicine in Atlanta. She is a renowned medical educator and has a wide range of clinical interests including tropical medicine, HIV, and fungal diseases.
Dr. Jennifer Davis
Dr. Jennifer Davis is a first year infectious diseases fellow at the Mass General Brigham combined infectious diseases fellowship in Boston. She’s interested in HIV and medical education.
Vale, Brodie, and Gabriel discuss basic terminology of the LGBTQ+ community, the importance of communication in healthcare, and pieces of advice when using gender-inclusive language.
Vale, Brodie, and Gabriel talk about their journey as LGBTQ+ members and the genesis of Queer Rounds, a platform that highlights the reality of gender and sexual diverse communities in healthcare.
Patreon exclusive: RLR 97_2 Cases (Anasarca, Hemoptysis) with Kirtan!!
Jun 22, 2022
Dear Patrons,
You don’t want to miss this episode. Two cases in one hour.
CPSolvers’ team member and extraordinary diagnostician, Kirtan, presents two fascinating cases to RR that have a similar theme.
We highly recommend you follow Kirtan on Twitter to enhance your diagnostic skills @KirtanPatolia.
Kirtan: We wish you the best as you start your IM residency. We are incredibly proud of what you have accomplished but are even more excited about what you are going to accomplish.
In this episode, Maani and Sharmin are joined by Dr. Tara Gadde who presents a clinical unknown case to Dr. Aimee Zaas followed by a discussion on leadership, mentorship, and career transition points.
Uttara (Tara) Gadde
Uttara (Tara) Gadde is an internal medicine resident at the University of Pennsylvania. She went to Cornell University for undergrad and completed a B.S. in Human Biology, Health & Society. She then worked for a year as a research analyst and public health advocate on a CDC funded HIV testing grant in the Bronx. She decided to pursue medicine and went to medical school at Rutgers NJMS and is completing her MPH from Johns Hopkins. Her career interests include infectious disease and global health. During her free time, she loves to cook (and eat!), curl up with a good book, or do anything active (running, hiking, HIIT workouts, yelling at the TV during Nets games).
Aimee K Zaas
Aimee K Zaas MD MHS is a Professor of Medicine in the Division of Infectious Diseases in the Department of Medicine at Duke University School of Medicine. She has served as the Program Director for the Duke Internal Medicine Residency since 2009, a job she considers to be both the best job ever and a continuous welcome challenge! She completed her medical school at the Northwestern Feinberg School of Medicine and her internal medicine residency and chief residency (ACS) at The Johns Hopkins Hospital. After completing her Infectious Diseases fellowship at Duke University, she joined the faculty at Duke where she has remained ever since, and has become a rather obnoxious Duke basketball fan in the process. Her husband David is also a physician and they have two boys, Jake (18) and Jonah (16) so have spent the majority of their family life at kids sporting events and traveling related to kids sporting events.
Summary: This episode centers the roles of reproductive justice and anti-racist action in rectifying inequities faced by Black and Indigenous birthing persons. This discussion is hosted by Naomi Fields, MD, Chioma Onuoha, and Victor Lopez-Carmen MPH, as they interview Dr. Joia Crear-Perry—a physician, policy expert, and highly sought-after birth equity and racial health disparities expert—and Dr. Katy B. Kozhimannil—the Distinguished McKnight University Professor in the Division of Health Policy and Management at the University of Minnesota and Director of the Rural Health Research Center. Our inspiring guests highlight liberation-oriented solutions to addressing inequities and contextualize how we can facilitate birthing experiences grounded in reproductive justice for Black & Indigenous women.
Episode Learning Objectives
After listening to this episode, learners will be able to…
Understand the magnitude of disparities faced by Black and Indigenous birthing persons and how forces of structural racism created and perpetuate these inequities
Define Reproductive Justice and understand how clinicians can promote reproductive justice during pregnancy and birth
Appreciate the importance of cultural reflexivity, community-centered initiatives, and midwifery and doula care in facilitating reproductive justice
Recognize the impacts of climate and land injustices on Black and Indigenous communities and know that climate justice, reproductive justice, and racial justice are all connected
Credits
Written and produced by: Naomi F. Fields MD, Chioma Onuoha, Victor A. Lopez-Carmen MPH, Rohan Khazanchi MPH, Sudarshan Krishnamurthy, Utibe R. Essien MD, MPH, Jazzmin Williams, Alec J. Calac, LaShyra Nolen, Michelle Ogunwole MD, PhD, Jennifer Tsai MD, MEd, Ayana Watkins
Hosts: Naomi F. Fields MD, Chioma Onuoha, and Victor A. Lopez-Carmen MPH
Infographic: Creative Edge Design
Audio Edits: David Hu, MD
Show Notes: Ayana Watkins
Guests: Dr. Joia Crear-Perry and Dr. Katy B. Kozhimannil
Time Stamps
00:00 Introduction
03:57 Magnitude of maternal health disparities for Black & Indigenous birthing people
09:31 Impact of guests’ identities and lived experiences on their work
25: 30 Defining reprodutive justice
29:42 Importance of community-centered initiatives and access to midwifery and doula care
35:15 Impact of Climate and Land Injustice on maternal health inequities
42:43 Role of family planning within reproductive justice
58:00 Key takeaways
Episode Takeaways:
We have a responsibility to unlearn the harmful hierarchies that unequally value people. The institutions of science, medicine, and academia perpetuate and codify racism. We all must recognize the codification of racism within our institutions and work to unlearn these hierarchies in order to better care for Black and Indigenous patients.
Be present in the birthing moment and see the full humanity of the birthing person and the life-changing nature of birth. Dr. Kozhimannil reminds us that birth is transformative and a gift to witness. As healthcare providers, we must listen to our patients and use the power of our presence to see birthing people’s full humanity and empowerment.
Pearls
Black and Indigenous birthing people are 3-13 times more likely to die in childbirth, with the rate varying by location and level of investment in communities.
Dr. Crear-Perry describes the magnitude of maternal health disparities faced by Black and Indigenous birthing people. The exact statistics vary by location and by the overall level of investment in each community. For example, in places that invest more into their communities through services such as childcare and parental leave, like in New York City, Black birthing persons are 8-12 times more likely to die in childbirth, while in areas with an overall lower level of investment, such as in areas in the Deep South, the increased likelihood of death in childbirth for Black birthing persons is lower, around 2-3x.
Dr. Kozhimannil reminds us to look past the statistics and zoom into the personal level. She urges us to recognize that maternal mortality changes the life trajectories of individuals and communities. These statistics not only reflect the number of birthing people dying in childbirth but also evince the number of children growing up without a parent and the number of families losing a loved one. She also reminds us that while mortality is the worst possible outcome, it is not the only thing we should be concerned about; that we must also ask the question: What are we doing to ensure that birth is as beautiful and empowering as possible?
“I have worked to imbue the credibility of my lived knowledge into the credibility that I now receive as a fancy person with a Ph.D. and a professor.”
Dr. Kozhimannil describes that her identity and her background—growing up in a rural area, having family living on tribal lands, and the intergenerational impact maternal mortality has had on her family and on her people—inform and motivate her work. She recognizes that academia and medicine traditionally do not listen to the people closest to the harm of structural racism and thus aims to use the credibility and privilege she receives from academia as a “Distinguished Professor” to persuade people with power to change the way they allocate power, resources, and opportunities.
Both Dr. Crear-Perry and Dr. Kozhimannil describe experiencing rejection when submitting their work to journals because of academia’s resistance to acknowledging racism as a cause of disparities.
Defining Reproductive Justice
Dr. Crear-Perry explains that the term “reproductive justice” was coined in 1994 by 12 Black women and is defined as the fundamental human right to personal bodily autonomy, to have children, to not have children, and to have safe and sustainable communities in which to parent children.
Reproductive justice first requires birthing people to be viewed as fully human. As Dr. Crear-Perry notes, Black women and other marginalized people in the United States have never been viewed as fully human. The second tenet of reproductive justice is the right to have children, and the third is the right to not have children. Certain policies have impeded birthing people’s ability to choose to not have children by taking away rights if people do not bear children. For example, at one time in Louisiana, only childbearing adults qualified for Medicaid. This policy reflects a societal belief that humans are not valuable unless they provide a service. Dr. Crear-Perry discusses a policy proposed in Michigan grounded in a similar notion: it required people living in urban areas to have a job in order to qualify for Medicaid. (To expand, this provision in Michigan was initially included in a State Senate bill for Medicaid expansion, but the work requirement was scrapped before the policy passed.) The final tenet of reproductive justice is the right to parent children in a safe, sustainable community. Parents deserve to raise their children in communities that value human life. For example, safe and sustainable communities have access to paid leave and equal pay, parks, and walkways, and lack dangerous aspects, like police violence and mass incarceration.
Impact of climate and land injustices on maternal health equity
Dr. Crear-Perry discusses previous research detailing the impact of climate injustice on maternal health transnationally. For example, Black babies born in communities that experienced redlining were more likely to die, and heat is known to cause premature birth. Additionally, scientists have used climate change to promote population control and to codify eugenics by falsely blaming climate change on high birth rates within poor, Indigenous communities around the world rather than uber-consumptive corporations.
Dr. Kozhimannil asserts that “climate justice and reproductive justice and racial justice are completely the same thing.” The climate crisis indicates a tear in the connection between humans and the earth and between us and one another. Dr. Kozhimannil believes the most powerful way to reconnect humans to each other and to the earth is through a good birth, in which we are connected to the land and are surrounded by loved ones.
Dr. Kozhimannil also describes an Indigenous philosophy of honoring the seven generations of ancestors that came before you and striving to be a good ancestor for the seven generations that will come after you. The process of childbirth is transformative for the birthing person and their community. Clinicians are able to shape the environment in which people give birth by caring for the earth and their patients.
The extent to which “family planning” fits within reproductive justice
Dr. Crear-Perry outlines the history of the term “family planning” and states that the idea of family planning stems from population control and eugenics. She urges us to remember that the abiltity to plan anything, is determined by generational access to power; and calls for discontinuing the use of this term. We should instead prioritize reproductive and sexual well-being and seeing Black and Indigenous birthing people as fully human.
Dr. Kozhimannil discusses her work on rural maternity care and the lack of hospital-based obstetric services. The places with the least access to hospitals in which they can give birth are also the places where people have experienced forced sterilization, where people do not have access to choices surrounding contraception, sexuality, or termination of pregnancies. Dr. Kozhimannil asks what moms and families can do if they do not have access to pregnancy prevention or termination and yet also have no place to give birth.
Asking the right questions, having the right intentions
Dr. Kozhimannil shares an important story about how her groundbreaking work showing maternity deserts in rural areas only came about by centering and engaging community members. In research we always begin with the research question and perhaps wonder if we are asking the “right” question. Dr. Kozhimannil offers a different approach, and stresses the importance of “answering the right question, from the people [communities impacted], who know the right question.”
Dr. Crear-Perry offers additional wisdom about interventions: “If your intention is off, your outcome is going to be off.”
Clarification: In this episode, Dr. Crear-Perry talks about eligibility for Medicaid expansion in Michigan requiring folks who lived in urban areas to have a job vs folks who lived in rural areas not needing to meet this requirement. What Dr. Crear-Perry mentions was a proposal that the State Senate wanted, but ended up doing away with before passing Medicaid expansion. See Reference 20 below for additional information.
References
Hardeman RR, Karbeah J, Kozhimannil KB. Applying a critical race lens to relationship-centered care in pregnancy and childbirth: An antidote to structural racism. Birth. 2020;47(1):3-7. doi:10.1111/birt.12462
Bekkar B, Pacheco S, Basu R, DeNicola N. Association of Air Pollution and Heat Exposure With Preterm Birth, Low Birth Weight, and Stillbirth in the US: A Systematic Review. JAMA Network Open. 2020;3(6):e208243-e208243. doi:10.1001/jamanetworkopen.2020.8243
Kozhimannil KB, Hardeman RR, Attanasio LB, Blauer-Peterson C, O’Brien M. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Am J Public Health. 2013;103(4):e113-e121. doi:10.2105/AJPH.2012.301201
National Birth Equity Collaborative. Dr. Joia on BMHW & Why Black Women & Birthing People Are Experiencing Poor Outcomes | NBEC.; 2021. https://youtu.be/GPAlyT8tuhE
Improving Equity in Birth Outcomes, a Community-based, Culturally-centered Approach. Robert Wood Johnson Foundation Interdisciplinary Research Leaders Program. Published January 16, 2019. https://irleaders.org/team/improving-equity-in-birth-outcomes/
Henning-Smith C, Kozhimannil KB. Missing Voices In America’s Rural Health Narrative. Health Affairs Blog. Published April 10, 2019. 10.1377/hblog20190409.122546
Hostetter M, Klein S. Restoring Access to Maternity Care in Rural America. Published online 2021. doi:10.26099/CYCC-FF50
Hardeman RR, Karbeah J, Almanza J, Kozhimannil KB. Roots Community Birth Center: A culturally-centered care model for improving value and equity in childbirth. Healthcare. 2020;8(1):100367. doi:10.1016/j.hjdsi.2019.100367
Kozhimannil KB, Henning‐Smith C, Hung P. The practice of midwifery in rural US hospitals.. Journal of Midwifery & Women’s Health. 2016;61(4):411-418. doi:10.1111/jmwh.12474
Lopez-Carmen VA, Erickson TB, Escobar Z, Jensen A, Cronin AE, Nolen LT, Moreno M, Stewart AM. United States and United Nations pesticide policies: Environmental violence against the Yaqui indigenous nation. The Lancet Regional Health – Americas. https://www.sciencedirect.com/science/article/pii/S2667193X22000722#bib0044
Kozhimannil KB, Casey MM, Hung P, Prasad S, & Moscovice IS. (2016). Location of childbirth for rural women: implications for maternal levels of care. American journal of obstetrics and gynecology, 214(5), 661.e1–661.e10. https://doi.org/10.1016/j.ajog.2015.11.030
The hosts and guests report no relevant financial disclosures.
Citation
Crear-Perry J, Kozhimannil KB, Fields NF, Onuoha C, Lopez-Carmen VA, Krishnamurthy S, Calac A, Nolen L, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 17: ‘Just’ Births: Reproductive Justice & Black/Indigenous Maternal Health Equity.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. May 31, 2022.
RLR discussed an intriguing case of a chronic consolidation
Thank you to our dear friend and colleague Dr. Kelley Chuang for her help with the production of this episode. (You are a legend, Kelley!) @kelleychuang
Patreon exclusive: RLR 93_Live from San Diego!!!
May 23, 2022
Dear Patrons!!!
We wish you a lovely week full of learning.
Huge shout out to our guest and dear friend, Anand, on this week’s episode. Anand is a trail blazer in making the invisible, in clinical reasoning, visible for undergradute medical trainees. https://twitter.com/AnandJag1
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time Dr. Doug Pet presents a case of slurred speech to Angelita and Diane.
Doug is a resident in neurology at UCSF. He grew up surrounded by cow farms and crab-apple trees in New Milford, CT. He completed a dual-degree program at Tufts and the New England Conservatory studying medical anthropology, community health, and jazz saxophone. He later worked for a non-profit in Berkeley, CA on bioethical and social justice issues related to genetic and reproductive technologies. Doug attended Vanderbilt University School of Medicine, after which he returned to the Bay Area for neurology residency at UCSF. He loves Brazilian music, playing Spikeball, and making custom wooden pens on his lathe.
Angelita Pusparani is a junior doctor (2ndY+) working in a small town in Indonesia. She is interested in discussing any cases (from neonate to geriatric), all patients inspire her. In her free time, Angelita is a basketball and marvel fan. She can also be found making a coffee or fried rice.
Diane Lebrun
Diane is an Internal Medicine Physician from Haiti. Her interest in Neurology started when she was a PGY-3 resident at Hopital Universitaire de Mirebalais (HUM), during her rotation in the Neurology Clinic. She has a special interest for Neuro-ICU, clinical reasoning, and medical education. In her free time, she enjoys spending quality time with family and friends, listening to faith-based music or podcasts, and dancing.
RR often discuss their fortune in finding such a supportive community.
We hope you enjoy the 2nd episode of the week. Huge shout out to the residents at Legacy Health in Portland. They are smart, kind, and hungry for diagnostic expertise. #Gratitude
Next Sunday we will learn what happened to part 2 of the Mathematician’s presentation – the patient w/ alc hep who returned with blood “per orum.”
Your grateful Mathematician and Magician (math + magic = RLR)
Patreon exclusive: RLR 90 w/ Krishna Ravindra
May 09, 2022
Hi Patrons,
You won’t want to miss this episode. Trust us. #EpicCase
Krishna is finishing his last week of MS3 year @ VCU School of Medicine. He did a PHENOMENAL job presenting the case.
Huge shout out to Dr. Patrick Fadden @ptfaddenMD, a superb clinician-educator, for guiding Krishna and being a great colleague to RR and CPSolvers.
RR are grateful to Krishna for his kindness, preparation, and stellar execution. Krishna, we will cheer on Madrid in the UEFA Champions League Final b/c we owe you for this special hour.
Episode 236: ARM Episode 16 – Live from SGIM: Best of Antiracism Research at the Society of General Internal Medicine’s 2022 Annual Meeting
May 03, 2022
Episode 16 – Live from SGIM: Best of Antiracism Research at the Society of General Internal Medicine’s 2022 Annual Meeting
Show Notes by Sudarshan Krishnamurthy
May 3, 2022
Summary: This episode was recorded in front of a live audience at the Society of General Internal Medicine’s 2022 Annual Meeting in Orlando, FL. In this episode, we gain insights from three antiracism scholars, Drs. Yannis Valtis, Ebi Okah, and Carine Davila, about research in their respective fields. Dr. Valtis is a 4th year Med-Peds Resident at Brigham & Women’s Hospital and Boston Children’s Hospital, and his research focuses on race and the utilization of security responses in the inpatient hospital setting. Dr. Okah is a family medicine clinician and NRSA research fellow at the University of North Carolina School of Medicine, and she studies the association between the use of race in medical decision-making and beliefs regarding the etiology of disparities in health outcomes. Dr. Davila is a palliative care physician at Massachusetts General Hospital and her work examines racial and ethnic inequities in patient-clinician communication. This episode was led by Rohan Khazanchi, and was hosted by Sudarshan Krishnamurthy and Utibe R. Essien.
Episode Learning Objectives
After listening to this episode learners will be able to:
Understand the association of race with the utilization of security responses in hospital settings
Understand the association between the use of race in medical decision-making and beliefs regarding the etiology of racial differences in health outcomes
Understand racial/ethnic inequities in trust-building healthcare experiences and describe the importance of improving trust in the healthcare system through trust-building experiences with historically marginalized communities
Credits
Written and produced by: Rohan Khazanchi MPH, Sudarshan Krishnamurthy, Utibe R. Essien MD, MPH, Jazzmin Williams, Alec J. Calac, Victor A. Lopez-Carmen MPH, Naomi F. Fields, LaShyra Nolen, Michelle Ogunwole MD, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins
Hosts: Sudarshan Krishnamurthy and Utibe R. Essien MD, MPH
Infographic: Creative Edge Design
Audio Edits: David Hu
Show Notes: Sudarshan Krishnamurthy
Guests: Drs. Yannis Valtis, Ebi Okah, and Carine Davila
Time Stamps
0:00 Introduction
4:20 Context and background of Yannis’ project
7:40 Framing of Ebi’s research
11:25 Inspiration for Carine’s work
14:50 Yannis’ explanation of his findings and potential next steps to intervene
25:45 Results from Ebi’s research
33:55 Carine’s findings from her work
40:00 Audience Questions
Episode Takeaways
Our Black patients are nearly twice as likely to experience a security utilization as our White patients.
Along with previous literature demonstrating a higher use of restraints in our Black patients in the emergency department setting, Yannis’ work shows a higher use of security responses in Black patients compared to White patients. Simulation-based training interventions are currently being studied to help combat these inequities.
Individuals who believe that genetic differences explain racial differences in health outcomes are more likely to practice race-based medicine.
Ebi’s research found that those physicians who possessed the belief that the etiology of racial differences in health outcomes was rooted in genetic differences were more likely to practice race-based medicine. On the other hand, those who believed that differences in social conditions explain racial differences in health outcomes were less likely to practice race-based medicine.
Our Black and Hispanic patients are less likely to have had trust-building experiences and more likely to have had trust-eroding experiences with the healthcare system.
Carine’s research illustrated the presence of trust-building experiences and trust-eroding experiences at every touchpoint with the health care system. Further, her research shows that Black and Hispanic patients are less likely to have had positive experiences and more likely to have had negative experiences. In addition to a need for culturally competent interpersonal communication, health systems and structures must actively work to build trust with historically marginalized communities.
Pearls
“When we heard the Code Gray bell go off in the hospital, all of us knew that there was a very high likelihood that we would be entering the room a Black patient.”
In the landscape of the murder of George Floyd, Yannis described how his team began to ask questions about how they could better protect their Black patients from police brutality. Although they began with a large focus on police brutality as a whole, they realized that the presence of police within the hospital had not been sufficiently examined. Although it had not been objectively measured, their clinical and personal experiences indicated that security responses were more often utilized for minoritized patients in the hospital.
“It did not make sense that an innate risk for poor health was attributed to Blackness, instead of thinking about how society assigns privileges and benefits by race that results in varying health outcomes.”
Ebi discussed the context behind what inspired her project, explaining that her journey began in medical school when students challenged race-based medical curricula and the use of race as a risk factor for disease. While starting residency, she was exposed to the use of race in clinical risk calculators and was confused by the rhetoric around the innate risk conferred by Blackness, instead of the influences of racism and inequitably distributed social determinants on health outcomes.
“There are known inequities in patient-clinician communication in historically marginalized populations that have immediate and downstream effects on health outcomes for these patients.”
Carine talked about her expertise in empathically communicating with patients as a palliative care physician. As she embarked on her project, she realized that improving serious illness care would require improving serious illness communication. She explained that the willingness for patients to engage in communication is rooted in how much they have been listened to in the past. Importantly, there is literature demonstrating inequities in patient-clinician communication with impacts on immediate outcomes, such as patient satisfaction and trust-building, along with downstream health outcomes
“… we found that the chance of having security called on our Black patients was nearly double that of our White patients.”
Yannis described previous studies demonstrating that Black patients have a higher likelihood of being restrained than White patients in the emergency department and psychiatric settings. However, there seemed to be a lack of literature exploring this in the inpatient hospital setting, where patient clinical presentations are more varied and management depends more on clinician behaviors. His team found that 1.5% of White patients had a security response called, in comparison to almost twice as many (2.8%) Black patients. Yannis posited that this difference was due to explicit and implicit biases rooted in racism in our broader societal context. When thinking about an intervention to combat these inequities, Yannis described a project at the Brigham leveraging simulation-based training on interacting with agitated patients followed by a debrief session to have clinicians reflect on their actions towards patients and the role of race.
“… we found that the belief in genetic differences explaining racial differences in health outcomes is associated with the practice of race-based medicine.”
Ebi’s work focused on how physicians think about race and how they engage in race-based medicine. Her project asks three main questions: 1) To what extent do racial differences in genetics explain racial differences in health outcomes? 2) How do values related to diet, exercise, and other cultural differences between racial groups explain racial differences in health outcomes? and 3) How do differences in social conditions, such as the environment and socioeconomic status, influence racial differences in health outcomes? Ebi found that the belief in genetic differences as an explanation for racial health disparities was associated with use of race-based clinical practices. Additionally, the belief that social inequalities explained racial health disparities was not associated with race-based practice.
“Our Black and Hispanic patients are less likely to have had positive experiences and more likely to have had negative experiences with the healthcare system.”
People engage in positive trust-building and negative trust-eroding experiences at every touch point or every interaction with someone in the healthcare system. Carine explains that this forms the framework for how experiences within the healthcare system can be evaluated. Unsurprisingly, it was found that Black and Hispanic patients were less likely to have had trust-building experiences and more likely to have had trust-eroding experiences with the healthcare system. Trust in the healthcare system is dependent on so many factors, and boils down to what the system has done to demonstrate that they are trustworthy. The onus is on us as a system to build and earn the trust of our patients through trustworthy behaviors, especially when the system has historically not done that. An important way of improving trust in the system within historically marginalized communities includes the recruitment of clinicians to the healthcare system from within these communities, to increase representation and better reflect the diversity of our patient population. The presence of these diverse clinicians also changes the inherent nature of the space that healthcare occupies.
References
Valtis YK, Stevenson K, Murphy E, Hong J, Ali M, Shah S, Taylor AD, Sivashanker K, Shannon E. Race and the Utilization of Security Responses in a Hospital Setting. Oral Presentation at Society of General Internal Medicine 2022 Annual Meeting. Orlando, FL.
Okah E, Cronholm P, Crow B, Persaud A, Westby A, Bonham V. The use of race in medical decision-making is associated with beliefs regarding the etiology of racial differences in health outcomes. Oral Presentation at Society of General Internal Medicine 2022 Annual Meeting. Orlando, FL.
Davila C, Ravicz M, Jaramillo C, Wilson E, Chan S, Arenas Z, Kavanagh J, Feltz B, McCarthy B, Gosline A. Talking the Talk: Examining racial and ethnic inequities in patient-clinician communication. Oral Presentation at Society of General Internal Medicine 2022 Annual Meeting. Orlando, FL.
Okah E, Thomas J, Westby A, Cunningham B. Colorblind Racial Ideology and Physician Use of Race in Medical Decision-Making. J Racial Ethn Health Disparities. 2021 Sep 7:10.1007/s40615-021-01141-1. doi: 10.1007/s40615-021-01141-1.
Ogunwole SM. Without Sanctuary. N Engl J Med. 2021 Mar 4;384(9):791-793. doi: 10.1056/NEJMp2030623.
Corbie-Smith G, Henderson G, Blumenthal C, Dorrance J, Estroff S. Conceptualizing race in research. J Natl Med Assoc. 2008 Oct;100(10):1235-43. doi: 10.1016/s0027-9684(15)31470-x.
Nash KA, Tolliver DG, Taylor RA, Calhoun AJ, Auerbach MA, Venkatesh AK, Wong AH. Racial and Ethnic Disparities in Physical Restraint Use for Pediatric Patients in the Emergency Department. JAMA Pediatr. 2021 Dec 1;175(12):1283-1285. doi: 10.1001/jamapediatrics.2021.3348.
Carreras Tartak JA, Brisbon N, Wilkie S, Sequist TD, Aisiku IP, Raja A, Macias-Konstantopoulos WL. Racial and ethnic disparities in emergency department restraint use: A multicenter retrospective analysis. Acad Emerg Med. 2021 Sep;28(9):957-965. doi: 10.1111/acem.14327.
The hosts and guests report no relevant financial disclosures.
Citation
Valtis Y, Okah E, Davila C, Krishnamurthy S, Essien UR, Calac A, Fields NF, Lopez-Carmen VA, Nolen L, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 16: Live from SGIM: Best of Antiracism Research at the Society of General Internal Medicine’s 2022 Annual Meeting” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. May 3, 2022
Dr. Blythe Butler presents a case to Dr. Alexandra “Jay” Teng, followed by a discussion about her experience as a woman in an Internal Medicine procedural subspecialty.
Alexandra “Jay” Teng
Alexandra “Jay” Teng hails from Berkeley and graduated from Harvard with a bachelor’s degree in history and science. After college, she worked at UCSF as a clinical research coordinator and patient navigator for women newly diagnosed with breast cancer, helping them prepare questions for their doctor and accompanying them to appointments. That experience helped convince her to pursue medicine. Dr. Teng earned her medical degree from UCSF, then completed internal medicine residency at UCLA. A competitive skier, she was originally interested in orthopedics, but she had a dramatic pivot at the end of her first year of medical school. “On the morning of my last final, I went into cardiac arrest and was admitted to Moffitt Hospital,” she said. The hospital team did an extensive workup, eventually diagnosing her with a rare condition called congenital long QT syndrome and implanting a cardiac defibrillator to prevent future life-threatening complications. “I was incredibly lucky, and feel a very personal connecting to cardiology,” she said. “I feel fortunate to train in the place and with the people who saved my life.”She completed Cardiology and Interventional Cardiology subspecialty fellowship at UCSF. She now works at Kaiser.
Blythe Butler
Blythe Butler is a first-year internal medicine resident at the University of California, San Francisco. She grew up in Spokane, Washington and attended Dartmouth College where she studied chemistry and mathematics. She went on to pursue a career in education and spent four years teaching general and AP chemistry as a high school teacher in San Jose, CA. She decided to switch careers to pursue medicine and completed medical school at UCSF. She enjoys running through Golden Gate Park, hiking and backpacking, and baking. Her career interests include medical education, communication in medicine, and health equity.
The only way we significantly grow is through reflection! Listen to this episode, reflect, and become better for the patient you treat tomorrow and the student you teach tomorrow.
We thank you for your support.
Is it Reza loves Rabih or Rabih loves Reza … it is the best palindrome …
In this case, Anna and Moses work through the schemas of dyspnea, AMS, HIV & infection, and lymphocytic pleocytosis as they discuss a case presented by Simone.
Episode 232: Anti-Racism in Medicine Series – Episode 15 – Housing is Health: Racism and Homelessness – Clinician + Community Perspectives
Apr 05, 2022
Episode 15: Housing is Health: Racism and Homelessness – Clinician + Community Perspectives
Show Notes by: Victor Anthony Lopez-Carmen, MPH
April 5, 2022
Summary: This episode highlights homelessness’ impact on health, the structural and racialized nature of homelessness, and practical interventions to address housing inequities. This is the last of three episodes interrogating the relationships between race, place, housing, and health. During this episode, we gained insight from special guests Dr. Margot Kushel and Mr. Bobby Watts about what brought them into their fields, how their work reaches the most marginalized, and what can be done at the community and structural level to address homelessness. Dr. Margot Kushel is a Professor of Medicine and Division Chief at the Division of Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center and Director of the UCSF Center for Vulnerable Populations and UCSF Benioff Homelessness and Housing Initiative. Mr. Bobby Watts is the chief executive officer of the National Health Care for the Homeless Council. This episode was hosted by Sudarshan Krishnamurthy, Jazzmin Williams, and Alec Calac.
Episode Learning Objectives:
After listening to this episode, learners will be able to:
Learn about non-stigmatizing language for healthcare providers when talking about individuals experiencing homelessness
Understand how systemic racism, including injust housing policies and over-policing, are at the root of homelessness and its disproportionate impact on Black and Brown communities
Understand the systemic factors that have increasingly led to the aging population experiencing homelessness today
Learn how homelessness contributes to adverse health outcomes, especially in the context of the COVID-19 pandemic
Describe the utility of medical respite care when working with patients experiencing homelessness
Credits
Written and produced by: Sudarshan Krishnamurthy, Jazzmin Williams, Alec J. Calac, Victor A. Lopez-Carmen, MPH, Naomi F. Fields, LaShyra Nolen, Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins
Hosts: Sudarshan Krishnamurthy, Jazzmin Williams, Alec J. Calac
Infographic: Creative Edge Design
Audio edits: David Hu
Show notes: Victor Anthony Lopez-Carmen, MPH
Guests: Dr. Margot Kushel and Mr. Bobby Watts
Time Stamps
00:00 Introduction
04:31 Guest career paths
11:58 Non-stigmatizing language around homelessness
19: 30 Structural racism and homelessness
33:09 Increasingly older population experiencing homelessness
42:01 Medical respite care
48:30 Criminalizing and over-policing homelessness
53:19 Key takeaways
Episode Takeaways
We must know the housing status of our patients, and how to ask about it.
Our guests remind us to ask our patients about their housing status using non-judgmental and non-stigmatizing language. If we do not know the housing status of our patients, then we do not know one of the most fundamental things that is going to affect their health and wellbeing.
2. Know your community resources.
Our guests emphasize that physicians must be familiar with community resources. Do you have a medical respite center? Do you have a coordinated entry system (CES) in your community? Can you refer your patient there?
3. If we are not part of the solution, we are complicit in structural injustice.
Dr. Kushel and Mr. Watts remind healthcare providers to speak out about the structural causes of homelessness. Push back against individual narratives that blame individuals for systemic injustice. Push back against dehumanizing language. Push back against discussions that homelessness is caused by substance use or mental health problems.
4. Disaggregated data on homelessness is vital.
Missing racial and ethnic data on homelessness is an example of structural racism. We must know who we are serving to truly be able to tackle the systemic injustices that cause disproportionate rates of homelessness in America.
Pearls
Formative Career Moments:
Dr. Kushel explained how discharging patients experiencing homelessness only for them to come back a few days later in worse shape was unacceptable. This pattern led Dr. Kushel towards work on solving the systemic failures causing “catastrophic” health outcomes in populations experiencing homelessness.
Mr. Watts added a tangible example where people experiencing homelessness would be dropped off by ambulances in front of the center for homelessness where he worked, which was not equipped to deal with their medical circumstances. They would eventually end up back at where the hospitals they came from. Experiences like this made him want to contribute to solutions in the community.
Speaking about Homelessness:
Dr. Kushel encouraged people to go past the textbooks and learn from people on the frontlines of homelessness. This humanizes the crisis and also centers the lived experiences of persons experiencing homelessness as the experts who can teach us more than any textbook.
Dr. Kushel emphasized that we should use person-first language because homelessness is an experience and there is no such thing as an inherently homeless person. Some people also prefer to use unhoused instead of homeless.
Mr. Watts encouraged use of the term neighbor, such as “neighbors without homes, unhoused neighbors, or neighbors experiencing homelessness. Another term he uses is “people with the lived expertise of homelessness,” which centers them as experts in solution-making.
Dr. Kushel detailed how the use of dehumanizing language equates to complicity in a narrative that systemically harms our neighbors with lived expertise in homelessness.
Dr. Kushel emphasized that we must speak to the structural racism at the root of disproportionate rates of homelessness in communities of color, instead of just focusing on mental health and substance use.
Restrictive Housing Policy and Homelessness Today:
Mr. Watts described how property tax laws give more public funding to school districts in higher socioeconomic neighborhoods than poorer neighborhoods, leading to worse educational outcomes and thus higher rates homelessness in low-income neighborhoods.
Dr. Kushel and Mr. Watts remarked that housing, especially expensive house ownership, is massively subsidized in comparison to apartment renting, meaning populations who are less likely to own houses receive less financial support from state and federal housing programs.
Dr. Kushel described how the wealth gap created by discriminatory housing policies also means that more racial minorities are renting properties, making them more vulnerable to gentrification and eviction, contributing further to the housing crisis.
Mr. Watts explained that predatory home or apartment lending targets Black and Brown people, leading to higher rates of poverty and homelessness in those communities. He also described how other policies like redlining and racist policing practices contribute to the mass incarceration of Black and Brown people, increasing homelessness in those communities.
Aging Compositions of the Population Experiencing homelessness across the US:
Dr. Kushel explained that in the early ’90s in San Francisco, 11% of those experiencing homelessness were 50 and older. By 2003, 37% were 50 and older. Now, among single adults experiencing homelessness, the median age is much closer to 50, meaning about half are under 50 and half are over 50. 44% had never once been homeless before the age of 50. So, the population experiencing homelessness is increasingly older.
Mr. Watts noted that the aging population experiencing homelessness came of age during mass incarceration, over policing, and thus many of them had histories with the prison system. Most were due to drug-related non-violent crimes that haunted them and limited employment opportunities throughout their lives.
Dr. Kushel also noted that housing became less and less affordable, adding on to the vulnerability of those in this generation who could not obtain well-paying jobs due to non-violent criminal histories.
Mr. Watts described how life expectancy among those experiencing homelessness is 20-30 years shorter than those with stable housing. This means they don’t benefit from social security because they are dying before they can receive it.
Health and Homelessness:
Dr. Kushel emphasized that people experiencing homelessness have elevated hospitalization rates and longer stays due to more comorbidities, and are more likely to be re-hospitalized.
Mr. Watts described how care for people experiencing homelessness needs to take into account the realities of being without a house, such as having medications stolen or going bad because of lack of refrigeration (e.g. insulin), greater decompensation after discharge because of a lack of a place to rest, and other factors that lead to poorer health outcomes.
Our guests explained that inpatient and outpatient treatment plans need to prioritize knowing the patients’ housing status, shared decision-making, and creating plans that take homelessness into account so treatment regimens are effective.
Dr. Kushel commented that in order to create systemic changes that will decrease rates of homelessness and improve the health outcomes of those experiencing homelessness we need disaggregated data to fully understand which groups in society are most impacted and why.
Medical Respite Care:
Mr. Watts advocated for medical respite, a safe place to heal and “short circuit” the street-emergency room-street-emergency room cycle as a way to treat people experiencing homelessness who are not sick enough for inpatient service, but too sick to send back out to the streets, only for their sickness to worsen. Because of less hospitalization return rates, Dr. Kushel emphasized that medical respite programs also save taxpayer money.
Dr. Kushel and Mr. Watts emphasized that respite medical care needs to be integrated into the continuum of care and homeless response systems.
Dr. Kushel explained that medical respite care via the National Institute for Medical Respite Care was very successful during the COVID-19 pandemic and is inspiring more and more communities to integrate respite care into their practices.
Policing:
Mr. Watts noted how the crack cocaine epidemic shifted the race demographics of homelessness in NYC from largely older, white drinkers to “50/50 young African American and Latinx”, with many cycling in and out of the carceral system due to over-policing and mass incarceration, which only made the crisis worse.
Mr. Watts emphasized that to this day, you are still more likely to be arrested for drug charges if you are Black or Brown, even though rates of drug use are equal across races. This is due to over policing of Black and Brown communities, which leads to higher rates of homelessness in those populations.
Mr. Watts and Dr. Kushel described how criminalizing homelessness is counter-productive and increases stigma, especially when the media focuses on one’s homelessness in the context of a crime. He states that people who are experiencing homelessness are actually more vulnerable to crimes happening to them, so they deserve more protection and service from the criminal justice system. Mr. Watts highlighted a program called CAHOOTS (Crisis Assistance Helping Out On The Streets) as a great, evidence-based mobile response model for addressing urgent needs among those experiencing homelessness.
Hahn JA, Kushel MB, Bangsberg DR, Riley E, Moss AR. BRIEF REPORT: the aging of the homeless population: fourteen-year trends in San Francisco. J Gen Intern Med. 2006;21(7):775-778. doi:10.1111/j.1525-1497.2006.00493.x
Semere W, Kaplan L, Valle K, Guzman D, Ramsey C, Garcia C, Kushel M. Caregiving Needs Are Unmet for Many Older Homeless Adults: Findings from the HOPE HOME Study. J Gen Intern Med. 2022 Feb 15:1–9. doi:10.1007/s11606-022-07438-z
Kushel M. Older homeless adults: can we do more?. J Gen Intern Med. 2012;27(1):5-6. doi:10.1007/s11606-011-1925-0
Disclosures
The hosts and guests report no relevant financial disclosures.
Citation
Watts B, Kushel M, Krishnamurthy S, Williams J, Calac AJ, Lopez-Carmen VA, Fields NF, Nolen L, Tsai J, Ogunwole SM, Onuoha C, Watkins A, Essien UR, Khazanchi R. “Episode 15: Housing is Health: Racism and Homelessness – Clinician and Community Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. April 5, 2022.
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Vijay presents a case of left upper extremity weakness to Vale and John.
Valeria is a medical student at Universidad Peruana Cayetano Heredia. She was born and lives in Lima, Perú. She hopes to pursue a Neurology residency. Her interests include neuro-infectious diseases, transgender health, and medical education. Her work with CPSolvers involves being a part of the Virtual Morning Report team and serving on the Spanish schemas team. Outside of Medicine, she loves running, hiking, cooking pasta, and spending time with her dogs.
John Acquaviva
@DrJAStrange
John Acquaviva is a third-year medical student attending Lake Erie College of Osteopathic Medicine in Erie, Pennsylvania. He has a passion for both clinical and academic neurological concepts and plans to practice neurology after medical school. He has a special interest in autoimmune neurology and neuroimmunology, but is excited about all neurological clinical presentations. In his free time, he enjoys hanging out with friends, long-boarding, and running while listening to neurology podcasts.
Vijay Balaji
@VijayBramhan
Vijay is currently a third-year internal medicine resident at Ramaiah Medical College & Hospital, Bangalore, India, and has interests in medical education and clinical reasoning. Outside academics, his interests include playing basketball, cooking, and philosophy.
Dr. Aisha Rehman, thank you for taking the time to present your patient’s case.
We are still awaiting a final diagnosis. Dr. Rehman and RR would appreciate any thoughts you might have regarding her patient. Please comment below or send us a private message. There will definitely be a part 2 as more data returns.
Patreon exclusive: RLR 80 with Uncle Bob – Hyperkalemia
Feb 28, 2022
It is hard to believe we are already at 80 episodes with 719 patrons. We cannot thank each of you enough for allowing RR to chase their dream of teaching/learning diagnostic reasoning. We all are on an epic journey together.
This episode is very special because we feature a mentor, advisor, and supporter of CPSolvers’ effort from day 1 and episode 2 (hyponatremia). We feel lucky to know Uncle Bob. He is a great human being, physician, and teacher.
Make sure to listen after our outro theme song for case updates by UB.
Cardionerds, Tommy and Dinu, present a case to Dr. Vaidya, Lindsey, and Dan.
Dr. Anjali Vaidya
Dr. Vaidya is a heart failure and transplant cardiologist at the Lewis Katz School ofMedicine at Temple University, where she serves as the co-director of the Pulmonary Hypertension, right heart failure, and CTEPH program, as well as APD for the cardiology fellowship program and residency advisor for the internal medicine residency.
Episode 14: Race, Place, and Health: Clinician and Community Perspectives
Show Notes by Alec Calac
February 15th, 2022
Summary: This episode highlights how racism manifests in the built environment, and how community and individual-level efforts can mitigate these inequities. This discussion is the second of three planned conversations around the connections between race, place, and health. Our latest episode welcomes first-time guests Dr. Eugenia South, a physician-scientist and Vice Chair for Inclusion, Diversity, and Equity in the Department of Emergency Medicine at the Perelman School of Medicine, and Noelle Warford, Executive Director of the grassroots organization Urban Tree Connection. Hosted by team members Naomi Fields and LaShyra Nolen,our guests present their community-based work in Pennsylvania and lay bare the connections between race, place, and health.
Episode Learning Objectives:
After listening to this episode, learners will be able to…
Understand the historical and present-day role of land dispossession and property rights in determining health along lines of race and place.
Learn how advancing individual agency and distributive justice can empower community organizers and initiatives.
Understand the factors that promote and inhibit long-term resiliency and sustainability of place-based initiatives.
Learn how we can reimagine health by decolonizing wealth and philanthropy in modern society.
Credits
Written and produced by: Naomi F. Fields, LaShyra Nolen, Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Alec Calac, Victor Lopez Carmen, MPH, Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Sudarshan Krishnamurthy, Chioma Onuoha, Dereck Paul, MD, MS, Ayana Watkins, Jazzmin Williams
Hosts: Naomi F. Fields, LaShyra Nolen
Infographic: Creative Edge Design
Audio edits: David Hu
Show notes: Alec Calac
Guests: Dr. Eugenia South, MD, MSPH, and Noelle Warford, MSW
Time Stamps
00:00 Introduction
05:40 Built environments and structural racism
11:18 Agricultural perspective, land rights, and settler colonialism
15:00 Responsible community engagement and catalyzing individual agency
21:58 Engaging communities outside of the ivory tower
27:00 Scaling up interventions to the community level
32:29 Intervention sustainability
37:18 Decolonizing philanthropy and place-based investments
42:40 Navigating trade-offs and mitigating ethical tensions
49:20 Key takeaways
Episode Takeaways
1. Your “why” has to be clear before you engage in community-based work.
Ms. Warford reminds us that we need strong, sound ideological positions and guiding principles before engaging with the communities around us. She asks to think about what we are doing today to make it easier for people to live in the future. Our ancestors considered our present to be impossible, so how can we use our ideas and experiences to effect positive change in our communities? These movements require action, not passivity.
2. Take time to learn from your patients. Be curious.
Clinicians are incredibly privileged individuals. Dr. South reminds us that it is our great honor to talk to people in an exam room. Our patients are not just a list of problems. They are individuals who interact with environments that affect their health. She encourages us to see beyond these problems, and ask patients about their lives, challenges, and successes. Everything is important. Unfortunately, medical practice does not always allow us to slow down and take this time to listen. But, finding ways to do so can prove illuminating as well as rewarding.
Pearls
Built Environment, Physical Health, and Mental Health
Dr. South detailed that there are clear physical health benefits associated with place-based interventions, but unfortunately many lots and buildings sit vacant and destitute across the US. There’s also more. When interviewing community members in Philadelphia, she shared that longstanding disinvestments in their communities made them feel “unimportant” and “neglected” by society, which had effects on their mental health.
The 2021 Build Back Better Act recognized the impact that the built environment has on health, calling for environmental improvements such as planting trees.
Ms. Warford is the Executive Director of Urban Tree Connection, a grassroots organization in West Philadelphia that uses land-based strategies and urban agriculture as tools for fostering community leadership and power. She presented a powerful argument that connected settler colonialism, Indigenous genocide, and chattel slavery with modern-day property rights and tax codes. By preventing Black and Brown people from developing relationships with the land and using it as a way of forming social connection, as well as communal sustenance, structural racism manifests along lines of race and place.
Lash echoed this and also reaffirmed points made by Dr. South that the built environment changes how individuals see themselves, limiting their ability to push back on the status quo.
Individual Agency and Redistribution of Resources
Ms. Warford centered the conversation and reminded the audience that it is not just healthcare systems that are being pushed to the brink. Non-profit organizations are experiencing the same organizational stress. Working with Dr. South and others, Urban Tree Connection is helping community members realize their inherent agency and leadership capacity.
In the process of redesigning the Memorial Garden in West Philadelphia, Ms. Warford and Dr. South foregrounded the reality that spaces have to be rooted in people’s experiences. There is often a sentiment that “If you build it, they will come”; however, one should not make assumptions about what community members want. It is important to get their perspectives and figure out what the “little things” are. The vision for any community-informed project has to meet community members where they are. What are their priorities? What are their needs?
Continuing this conversation, Dr. South shared that “solutions have to be solutions, not fantasies.” Approaching community problems with an academic approach will not necessarily have community interests in mind (or prioritize them). By moving outside of this academic mindset, organizers and facilitators can work to effect meaningful, long-lasting change in the community.
Sustainability
Dr. South has studied a variety of place-based interventions including vacant lot greening, abandoned house remediation, tree planting, and structural repairs to homes. She was recently awarded a $10 million grant from the National Institutes of Health that will allow her and her team to conduct a randomized-controlled trial that combines many interventions instead of just one. A serious concern that she and many others have is the sustainability of interventions after grant funding ends. Funding structures, especially from government agencies, are not exactly permissive of this.
To promote sustainability, Dr. South and Ms. Warford encouraged the audience to confront the ethical tension between place-based interventions and long-term sustainability after funding streams dry up. It is important to educate and engage key stakeholders such as policymakers who can work to address these limitations.
Ms. Warford shared that funding priorities are not necessarily community priorities. In limited funding environments, non-profit organizations often apply for any and all available funding streams, which may gradually shift the organization’s priorities, a phenomenon often referred to as mission creep.
Decolonizing Wealth and Philanthropy
Our panelists detailed how much wealth is generated from the labor of Black and Brown people. Unfortunately, it is difficult for that wealth to be reinvested in those very same communities. Ms. Warford encouraged our listeners to think about how we can decolonize wealth and philanthropy, noting that place-based investments have to be gradual and intentional. She shared that funding entities must recognize the labor of community members and provide funds for their work. “People power” is a resource that must be cultivated, respected, and valued.
Recognizing Your Role
Naomi recapped much of the discussion and shared that it was clear that “there is no quick fix.” Much of the work involves education, finances, time, and people power. Dr. South shared that there are many ways to be a part of dismantling structural racism. Some people are more front-facing, while others work behind-the-scenes. All perspectives and skillsets are welcome in this process. Ms. Warford shared that it will take time to navigate away from capitalist structures and extractive economies. It is important to celebrate the small wins and strive for the greater vision. LaShyra shared some personal reflections to this effect. The goal for this work will always be liberation and agency. When you’re just trying to make it every day, you don’t always have the privilege to do anything else.
“A Randomized Controlled Trial of Concentrated Investment in Black Neighborhoods to Address Structural Racism as a Fundamental Cause of Poor Health.” National Institutes of Health RePORTER. Accessed January 2, 2022. https://reporter.nih.gov/project-details/10413510#description
The hosts and guests report no relevant financial disclosures.
Citation
South E, Warford N, Fields NF, Nolen L, Calac A, Lopez-Carmen V, Tsai J, Krishnamurthy S, Ogunwole M, Onuoha C, Watkins A, Williams J, Paul D, Essien UR, Khazanchi R. “Episode 14: Race, Place, and Health: Clinician and Community Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. February 15, 2022.
Patreon exclusive: RLR 77 – Jaundice and weight loss
Feb 03, 2022
Dear Patrons,
We enjoyed this tremendously. It was an honor to discuss a case at the University of Pittsburgh Medical Center.
We hope you enjoy it.
Ryan, we cannot thank you enough for being such an amazing friend and colleague. You put the case together expertly. You presented it flawlessly. You made it an experience we will cherish forever.
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Maria presents a case of increased drowsiness to Dr. Mathieu Brunet and Dr. Mattia Rosso.
Maria Jimena Aleman María Jimena Alemán was born and raised in Guatemala where she currently works in community and rural health care. After suffering from long standing neurophobia, she has embraced her love for neurology and will pursue a career in this field. She looks forward to dedicating her life to breaking barriers for Latin women in medical fields and improving medical care in her country. Maria is one of the creators of a medical education podcast in Spanish called Intratecal. Her life probably has a soundtrack of a mix between Shakira and Ella Fitzgerald. Outside of medicine she enjoys modern art, 21st century literature, and having hour long conversations over a nice hot cup of coffee or tequila.
Mathieu Brunet
Mathieu Brunet is an emergency physician and trauma team leader at the Hôpital du Sacré-Coeur-de-Montréal and an assistant professor of emergency medicine at Université de Montréal in Canada. After his emergency medicine training, he completed a Fellowship in Resuscitation & Reanimation at Queen’s University in Canada and a Master of Traumatology with the University of Newcastle in Australia. Mathieu has been a regular listener of the podcast and the daily Virtual Morning Reports. He finds The Clinical Problem Solvers to be an invaluable resource to progress and maintain motivation on the lifelong journey toward clinical reasoning expertise.
Mattia Rosso
Mattia Rosso is a neurology resident at the Medical University of South Carolina (MUSC) in Charleston. He is interested in movement disorders, behavioral neurology, and autoimmune neurology. He is also passionate about the intersection between the humanities and medicine, with a focus on the fields of medical history and bioethics. Outside work, he enjoys photography, cinema, and discovering new music. Since starting residency, Clinical Problem Solvers have been an irreplaceable source of learning and inspiration.
In this episode, Dr. Elliot Tapper discusses a clinical unknown case presented by Dr. Jennifer Mundell
Jennifer Mundell
Jennifer Mundell, MD FACP is the associate program director for Ascension St Vincent Internal Medicine Residency Program. She graduated from University of Louisville School of Medicine and completed IM residency at Ascension St. Vincent in 2016. The residents best know her for building differentials, baking cakes, and owning more cars than garage spaces. During her free time, she enjoys writing up interesting cases with residents, taking her family to a beach, and planning next year’s Halloween decorations.
Elliot Tapper, MD is an Assistant Professor in the Division of Gastroenterology at the University of Michigan in 2016. His clinical activity and research efforts focus on the outcomes of patients with cirrhosis, particularly those with hepatic encephalopathy. He did his residency and was resident, chief resident, and a fellow in gastroenterology and transplant hepatology, at Beth Israel Deaconess Medical Center where he served as Director of Quality Improvement for the Liver Center. He is very active on twitter and tweets at @ebtapper
Emma presents a case to Dr. Yao Heng, followed by a discussion about her experience as a woman in Internal Medicine procedural subspecialty.
Dr. Yao Heng
Dr. Yao Heng was born in Bangkok, Thailand. She immigrated to the US in her 20’s. After graduating from the University of California, Berkeley with a Bachelor of Arts in Biochemistry, she received her medical degree at the University of California, San Francisco. She completed her residency in Internal Medicine at the University of California, San Francisco and specialty fellowship in Gastroenterology at the University of Washington. She went to University of Brugmann in Brussel, Belgium for special training in biliary tract disorders. She has been practicing gastroenterology and hepatology at Kaiser Permanente since 1992. She is currently in charge of the capsule endoscopy and balloon enteroscopy programs at San Francisco Kaiser. She has a strong interest in small bowel disorders, the microbiome and gut directed hypnotherapy.
Doug presents an unknown case of vision loss to Dr. Cherayil, Lindsey and Dan.
Dr. Neena Cherayil. Dr. Cherayil is an Assistant Professor of Neurology in the Departments of Neurology and Ophthalmology at Northwestern University Feinberg School of Medicine in Chicago, Illinois. She completed her neurology residency followed by a neuro-ophthalmology fellowship at the University of Pennsylvania. She is currently associate clerkship director of the neurology clerkship at Feinberg as well as co-module leader for the MS2 Neurosciences course. She enjoys leading morning report every week with the neurology residents and students and seeing the fascinating spectrum of afferent and efferent neuro-ophthalmic complaints in clinic. Her particular academic interests include diagnostic reasoning and curricular development with a focus on neuro-anatomic localization. Her favorite cranial nerve is, of course, CN III – the oculomotor nerve.
Episode 215: Vaccine Hesitancy – with Dr. Davis and Dr. Villela
Dec 27, 2021
CPSolvers team members Rafael Medina and Simone Vais take a moment to reflect on what is going on in the world of medicine focusing on vaccine uptake with two incredible experts on the matter about what their experiences have been.
Dr. Davis is the Director of Health for the City of St. Louis. Dr. Hlatshwayo Davis received her medical degree from Cleveland Clinic Lerner College of Medicine and a Master’s in Public Health Degree from Case Western Reserve University. She completed her internal medicine residency at University Hospitals Case Medical Center. She went on to complete her Infectious Diseases fellowship at the Washington University School of Medicine (WUSM), also completing a one year HIV fellowship and a Sexually Transmitted Infections (STI) fellowship. She has held many, many positions throughout her illustrious career in medicine. Dr. Hlatshwayo Davis is now a national and international medical contributor on COVID-19 with a particular focus on marginalized populations, as well as the Director of Health for the city of St. Louis (among much else). Her career passions include community engagement, the care of people living with HIV and the impact of COVID-19 infection in marginalized populations.
Dr. Villela is a graduate of Tucson High School, Yale University, and the University of Connecticut School of Medicine. She currently serves as Chief of Family and Community Medicine at San Francisco General Hospital and is Professor and Vice Chair in the UCSF Department of Family and Community Medicine.
Her interests include chronic illness care, family medicine education, reproductive health, health of Latinxs in the U.S., and health care disparities. Her clinical practice includes inpatient adult medicine, short-term nursing home care, and ambulatory family medicine. She lives with her partner in the Mission district of San Francisco; they have a daughter who is a junior in college. All three are vaccinated against COVID and 2 of 3 have had boosters.
Patreon exclusive: RLR 73 – the case of a patient phone call…
Dec 26, 2021
Episode 13: Centering Asian Americans: Racism, Violence, and Health
Show Notes by Naomi F. Fields
December 21, 2021
Summary: This episode is about racism faced by Asian-Americans, why it often goes unrecognized, and how we can work to rectify these wrongs. This discussion is hosted by Jazzmin Williams, Rohan Khazanchi, MPH, and Jennifer Tsai MD, MEd, as they interview Thu Quach, PhD, an epidemiologist and galvanizing leader who has led the Asian Health Services (Oakland, CA) in addressing racial disparities in COVID-19, and Tung Nguyen, MD, a Professor of Medicine at the University of California, San Francisco, and a nationally-renowned health disparities researcher. Our inspiring guests help us to contextualize struggles faced by Asian-Americans even as they outline and energize within us a path forward – together.
Content Warning: This episode contains themes of violence, trauma-induced mental health concerns, and brief mentions of suicide. If you or someone you know is struggling with suicidal thoughts, please call the National Suicide Prevention Hotline at 800-273-8255, that’s 800-273-TALK.
Episode Learning Objectives:
After listening to this episode learners will be able to…
Define the myth of the “Model Minority” and explain how it impacts the racism experienced by Asian-Americans.
Describe how divisiveness amongst minoritized groups was and remains politically orchestrated, and how minority groups can work together in solidarity against White oppression.
Appreciate how intergenerational trauma may surface amongst Asian-Americans, and how these intergenerational relationships may also offer fertile ground for generating understanding.
Highlight how structural racism against Asian-Americans surfaces in clinical settings, and describe means of counteracting such structures.
Understand how engaged community-based work, centered on trust and accountability, has supported the health of communities served by Oakland, CA’s Asian Health Service.
Reckon with the health disparities that exist amongst Asian-Americans, how such disparities are related (in part) to insufficient data-gathering, inequitable clinical settings, and violence, and how they were further exacerbated by the COVID-19 pandemic.
Credits
Written and produced by: Jazzmin Williams, Rohan Khazanchi, MPH, Jennifer Tsai MD, MEd, Alec Calac, Victor Lopez-Carmen, MPH, Utibe R. Essien, MD, MPH, Sudarshan Krishnamurthy, Naomi F. Fields, LaShyra Nolen, Chioma Onuoha, Ayana Watkins, and Michelle Ogunwole, MD
Hosts: Jazzmin Williams, Rohan Khazanchi, MPH, and Jennifer Tsai MD, MEd
Infographic: Creative Edge Design
Audio edits: David Hu
Show notes: Naomi F. Fields
Guests: Thu Quach, PhD, and Tung Nguyen, MD
Time Stamps
00:00 Introduction
04:00 How Dr. Thu Quach’s and Dr. Tung Nguyen’s journeys shape their work
11:40 Policy work as a way of mitigating burnout
12:55 Balancing individual and communal focus (include?)
16:35 Impact of the COVID-19 pandemic on Asian communities in Oakland
17:40-17:50 Content Warning: Mention of suicide
22:25 Forms of Anti-Asian racism
25:17 The danger of gaslighting Asian-Americans and of comparing oppressions
27:51 Explanation of the model minority myth and a deeper dive into comparative oppressions
30:03 Engaging with community members via validation, and operationalizing means of working against anti-Asian racism
33:58 Dr. Jennifer Tsai reflecting on her father’s experience
37:10 Dr. Nguyen on pathways to intergenerational connection and combatting erasure
39:45 Dr. Quach on intergenerational trauma and reconciliation
43:56 Rohan Khazanchi reflecting on Asian-American disparities in Nebraska and community strength
46:30 Data collection and disaggregation: strengths, challenges, and insufficiencies
56:14 Structural anti-Asian racism in clinical settings
59:22 Clinical tools and takeaways
Episode Takeaways:
Recognize that structural barriers can embed anti-Asian racism into clinical settings.
Insufficient language services (i.e., provision in only English +/- Spanish), limitations of medical technology (i.e., difficulty of sending patient messages through the electronic medical record in languages other than English), limited healthcare literacy, and English-only signage on healthcare campuses are just a few of the structurally racist barriers faced by many Asian folks seeking healthcare. Dr. Nguyen encourages us to recognize how such barriers represent assumptions about people’s capabilities, how they can worsen people’s healthcare, and how they communicate exclusion to our Asian patients.
See the world through others’ eyes, and act.
Dr. Nguyen calls us to ask ourselves: “If [my] mother and father were like this person, how would they negotiate the system that I’m in? What can I do to either ameliorate those problems, or to fix those problems behind the scenes, so they don’t have to deal with them on a day to day basis?” This can help us reach the goal of taking care of patients in the ways that they want to be taken care of, by operationalizing the vision Dr. Quach shared for “letting lived experiences guide us.”
Create spaces to have conversations about the broader contexts affecting patients.
Dr. Quach reminds us that environmental factors and the political landscape affect patients’ wellbeing everyday. Creating spaces where these experiences can be shared by patients as well as by practitioners can highlight the structural nature of seemingly individualized problems. By appreciating the impact of factors affecting entire communities, we can be better positioned to act upon them.
Remember that more deeply understanding your patients can provide meaning!
Seeking to more deeply understand your patients is not an additional burden: ultimately, it is an additional benefit. Dr. Nguyen describes that in his experience, striving for understanding deepens the patient-provider relationship over time and offers fulfillment to him as well as to his patients.
Pearls
Case study: Oakland, CA’s Asian Health Services’ origin, ethos, and lessons
Dr. Quach describes the community- and advocacy-based origins of Asian Health Services, a Federally Qualified Health Center in Oakland, CA. She also describes their role in detecting and relaying the double-bind of challenges (COVID-19 and racism) being faced by community members throughout the pandemic, and how her team generated solutions that signaled their ongoing responsibility to the communities they served.
Asian-Americans face both apparent and enshrouded forms of racism, both of which have directly related health effects.
Dr. Nguyen goes on to expand on these forms. One form includes the eye-catching racist acts that explicitly manifest anti-Asian sentiments, such as violence toward elders, verbal abuse, and gun violence. In addition to the physical wrongs done to the victims, these acts function as community stressors that harm the mental, emotional, and physical wellbeing of so many others.
Another more insidious form of racism is erasure. This often manifests in a glaring lack of recognition of many of the problems faced by many Asian Americans. In the healthcare space, it can also result in a lack of data collection to demonstrate and understand issues faced by these groups. As a result, there are often failures to address their unique needs.
The “Model Minority” myth engenders both the racist erasure of Asian-Americans and division amongst minority groups.
Created in the 1960s by conservatives seeking to divide minority groups during the Civil Rights Movement, the model minority myth projects the relative success of some Asian-Americans onto all Asian-Americans; and subsequently casts them as an “ideal” group unaffected by the problems and negative stereotypes that plague other minority groups. In so doing, the model minority myth obscures how White supremacy actually affects Asian-Americans, and perpetuates a zero-sum game which pits minority groups against each other rather than alongside each other in solidarity.
Data on the problems faced by Asian Americans is lacking. This perpetuates further erasure of Asian-American health disparities, and there are multiple needed interventions to redress this injustice disparity.
Erasure often conceals the need for the collection of information that would spotlight challenges/inequities faced by Asian-Americans. For instance, Dr. Nguyen describes how the National Academy of Medicine and the Centers for Disease Control, amongst other major health organizations, issued valid and needed statements about the impact of COVID-19 on other minority groups, but did not mention the problems faced by Asian- Americans – nor the fact that the data was insufficient. The resulting message implied to the public was that no problems existed.
Additionally, data collection practices often do not capture all experiences due to usage of inaccessible language, or neglecting to spotlight voices from the most marginalized community members.
Data disaggregation, which seeks to spotlight specific ethnic groups within the Asian diaspora, can be a helpful step in better understanding the experiences unique to Asian-American communities we serve. It requires recognizing the diversity of experiences and gaining buy-in from community members.
“You don’t fight fire with fire, you fight fire with water.” – Fred Hampton
Dr. Nguyen mentioned this quote, and expounded upon it to say, “You don’t fight racism, with more racism you fight racism with solidarity and partnership and coalition building.” Although the Model Minority myth has generated divisiveness amongst minority groups, true power can come from folks turning away from gaslighting and the wrly named “Oppression Olympics” to recognize that we all need to work together against the real enemy: Oppression writ large by White supremacy.
Within Asian-American communities, intergenerational relationships can be a critical strength.
Multiple members of this episode describe challenging experiences with bridging understanding of their elder family members that may mirror dynamics within Asian-American communities more broadly.
On the one hand, these relationships convey the intergenerational traumas (of migration, of racism, and the like) that impact elders’ experiences, yet may differ from those of younger individuals.
Simultaneously, these relationships present opportunities to connect interpersonally as “genuine human beings,” and to find solution-generating commonalities.
Relatedly, our guests both describe experiences acting as “cultural brokers” to assist with healthcare needs of their elders that impacted their own journeys into medicine. These insights primed them to understand what challenges community members might be facing now.
Public Broadcasting Service. “Asian Americans: The history of identity, contributions, and challenges experienced by Asian Americans.” https://www.pbs.org/show/asian-americans/
Chu JN, Stewart SL, Gildengorin G, et al. Effect of a media intervention on hepatitis B screening among Vietnamese Americans. Ethn Health. 2019;1-14. doi:10.1080/13557858.2019.1672862
Quach T, Von Behren J, Tsoh J, et al. Improving the knowledge and behavior of workplace chemical exposures in Vietnamese-American nail salon workers: a randomized controlled trial. Int Arch Occup Environ Health. 2018;91(8):1041-1050. doi:10.1007/s00420-018-1343-2
Yan BW, Hwang AL, Ng F, Chu JN, Tsoh JY, Nguyen TT. Death Toll of COVID-19 on Asian Americans: Disparities Revealed. J Gen Intern Med. 2021 Nov;36(11):3545-3549. doi: 10.1007/s11606-021-07003-0.
Jones CP, Maybank A, Nolen L, Fields N, Ogunwole M, Onuoha C, Williams J, Tsai J, Paul D, Essien UR, Khazanchi, R. “Antiracism in Medicine – Episode 5: Racism, Power, and Policy: Building the Antiracist Health Systems of the Future.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/antiracism-in-medicine/. January 19, 2021.
Kawai, Yuko. (2005). Stereotyping Asian Americans: The Dialectic of the Model Minority and the Yellow Peril, Howard Journal of Communications, 16:2, 109-130, DOI: 10.1080/10646170590948974
Smith, Andrea. “Chapter Six: Heteropatriarchy and the Three Pillars of White Supremacy: Rethinking Women of Color Organizing”. Color of Violence: The INCITE! Anthology, edited by INCITE! Women of Color Against Violence, New York, USA: Duke University Press, 2016, pp. 66-73. https://doi.org/10.1515/9780822373445-008
The hosts and guests report no relevant financial disclosures.
Citation
Quach T, Nguyen T, Williams J, Tsai J, Fields NF, Calac A, Lopez-Carmen V, Krishnamurthy S, Nolen L, Onuoha C, Watkins A, Williams J, Essien UR, Ogunwole M, Khazanchi R. “Antiracism in Medicine – Episode 13: Centering Asian Americans: Racism, Violence, and Health.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/antiracism-in-medicine/. December 21, 2021.
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Maria presents a case of episodic transient loss of consciousness to Gabriel and Ravi.
Maria Jimena Aleman was born and raised in Guatemala where she currently is a medical student in Universidad Francisco Marroquin. After suffering from long standing neurophobia, she has embraced her love for neurology and will pursue a career in this field. She also looks forward to dedicating her life to breaking barriers for Latin women in medical fields and improving medical care in her country. Maria is one of the creators of a medical education podcast in Spanish called Intratecal. Her life probably has a soundtrack of a mix between Shakira and Louis Armstrong. Outside of medicine she enjoys modern art, 21st century literature and having hour long conversations over a nice hot cup of coffee or tequila.
Gabriel Talledo
Gabriel is a MS2 student from Cayetano Heredia University. When it comes to medicine, he enjoys dermatology, infectiology, and LGBTQ+ health. He fell in love with his career when he understood medicine not just as a concept of knowledge but a combination of knowledge and social justice pursuit. He loves cooking Peruvian cuisine (one of the best in the world), eating, jogging and watching TV series. Recently he is doing a transgender education program at his university and a volunteering of sexual education in Lima schools.
Dr. Kushal Vaishnani is a Hospitalist at Atrium Health. He finished his medical school at B.J. Medical College, Ahmedabad, India. He completed his transitional year at Brandon Regional Hospital and Internal Medicine residency at LSUHSC – University Hospital and Clinics in Lafayette. His academic interests include clinical reasoning, medical education, high value care, and infectious diseases.
Saman is from Tucson, AZ. He graduated from the University of Arizona College of Medicine, finished internal medicine residency at Columbia, and his infectious diseases fellowship at Johns Hopkins. He is now working as a transplant ID physician at the University of Arizona. He is also completing his Master’s of Education in the Health Professions. He enjoys cooking with Reza and washing the dishes. In his spare time, he loves to watch PJ Masks with his wife and son, who was featured in Episode 42 as AstroBoy.
Brandon Pearce is a third-year Internal Medicine resident at Ascension St. Vincent in Indianapolis. His medical interests include pulmonary critical care and clinical education. In his spare time, he enjoys basketball, hiking with his fat Labradors, and traveling.
Episode 209: Antiracism in Medicine Series – Episode 12 – Our Land is Our Health: Addressing Anti-Indigenous Racism in Medicine
Nov 22, 2021
Episode 12: Our Land is Our Health: Addressing Anti-Indigenous Racism in Medicine
Show Notes by LaShyra Nolen
November 23rd, 2021
Summary: This episode is about the ways we can combat anti-Indigenous sentiments and actions in our efforts to promote anti-racism in medicine and public health. This discussion is hosted by our new team members Alec Calac and Victor Lopez-Carmen, as they interview Dr. Tom Sequist, member of the Taos Pueblo Tribe and Chief Patient Experience and Equity Officer at Mass General Brigham, and Dr. Sophie Neuner, proud member of the Karuk Tribe, and a Research Associate at the Johns Hopkins Center for American Indian Health. Together, these two phenomenal guests help us understand the structural and individual challenges of Indigenous peoples in academic medicine, public health, and beyond.
Episode Learning Objectives:
After listening to this episode learners will be able to…
Understand the historical and present-day role of settler colonialism behind health disparities in Indigenous populations.
Learn ways to address the lack of representation of Indigenous peoples in academia and how to create safe learning environments for Indigenous peoples in these academic spaces.
Understand the importance of disaggregated health data and how the burden of proof for “blood quantum” requirements can be detrimental to Indigenous peoples.
Learn the ways COVID-19 and climate change have exacerbated health inequities within Indigenous populations.
Learn tangible ways to center the Indigenous communities in advocacy efforts at the interpersonal and institutional level.
Credits
Written and produced by: Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Alec Calac, Victor Lopez Carmen, MPH, Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Sudarshan Krishnamurthy, Naomi F. Fields, LaShyra Nolen, Chioma Onuoha, Dereck Paul, MD, MS, Ayana Watkins, Jazzmin Williams
Hosts: Alec Calac and Victor Lopez Carmen, MPH
Infographic: Creative Edge Design
Audio edits: David Hu
Show notes: LaShyra Nolen
Guests: Dr. Tom Sequist, MD, MPH and Dr. Sophie Neuner, MD, MPH
Time Stamps
00:00 Introduction
05:25 What do I call you?
10:37 “Blood quantum” and the burden of proof
18:05 Challenges of Indigenous Peoples in medical spaces
24:50 COVID-19 and climate change’s impact on Indigenous Peoples
30:27 Racism in academia and creating safe spaces
41:22 “Data genocide”
50:11 What can listeners do going forward?
62:10 Key takeaways
Episode Takeaways:
Take the time to learn about how Indigenous Peoples influence the world around you.
From the street names of the cities in which we live to the nature that surrounds us, Dr. Sequist reminds us of the importance of taking the time to learn about how Indigenous Peoples have influenced and continue to influence every aspect of our lives. He encourages us to learn about the original inhabitants of lands on which we reside and to do the work to learn about the ongoing contributions from tribes around us. This is especially important when we consider the lasting role colonialism, genocide, and racism has played in attempted erasure of these communities and their culture.
Learn about the good and the ugly when it comes to the history of Indigenous Peoples.
Victor reminds us that we can hold two truths at the same time. Dr. Sequist also encourages us to, in addition to learning about the rich cultural traditions and invaluable contributions of Indigenous Peoples, to also acknowledge the historical and ongoing oppression these communities face. Indigenous Peoples continue to suffer disproportionately from health inequities, mental illness, poverty, climate change and police brutality, all of which have been exacerbated by the COVID-19 pandemic. We must recognize these struggles were born out of settler colonialism and learn this history while actively working to undo present harms.
Do not exclude Indigenous peoples in your research narratives. If you’re going to, acknowledge your limitations.
Dr. Neuner reminds us of the importance of centering Indigenous Peoples in our research and data because this information helps drive policy and health initiatives that can address barriers to health in the community.
Pearls
Common Terms Used to Refer to Indigenous Peoples
Our guests and hosts remind us of the importance of not making assumptions about someone’s identity. It is often preferable to use tribal affiliation when referring to Indigenous Peoples rather than terms like Indigenous or Native American. By not doing so, we obscure critical knowledge about relationality, Indigenous clans, and communal origins.
The term “American Indian or Alaska Native” is a legal racial and ethnic identifier which is why we might see it used in legal documents and research manuscripts. Many manuscripts have moved towards using Black, Indigenous, People of Color (BIPOC), but this term may be doing more harm than good for Indigenous Peoples. Read III.A.I-2 of Why BIPOC Fails (Deo, M., 2021) to understand why.
The term “Native American” is frequently used but does not cover Indigenous Peoples from across the world
The Burden of Proof
Dr. Sequist discusses “blood quantum”, which is an attempt by the federal government to reduce one’s identity as an Indigenous person to a percentage of blood affiliated with specific Tribes in the US. This flawed measure can be harmful for many reasons. It notably creates a burden of proof for Indigenous trainees to prove their identity, which can provide additional stress during application and interview cycles.
COVID-19 and Indigenous Peoples
Alec reminds us that Indigenous Peoples represent 6% of the global population across more than 70 countries, but around 15% of the global population experiencing poverty.
Many of the health inequities we have seen for Indian Country during COVID-19 are directly linked to settler colonialism. This is further exacerbated by poverty, lack of cell phone coverage, food insecurity, broadband internet, and a shortage of trusted messengers with appropriate training in Tribal communities.
Dr. Neuner reminds us that many Native communities live in multigenerational housing (over 65% of communities have elders living with them) which made it challenging to socially distance during the pandemic.
Data Genocide
Dr. Neuner reminds us about the importance of data for advocacy for Indigenous communities, especially during COVID-19. More background here from the Urban Indian Health Institute.
“Without data you can’t change anything.”
Some of the challenges with data collection discussed were:
Limited availability disaggregated data and how being listed as “other” on surveys leads to compounded distrust in medical systems
Limited accessibility to that data for Tribal communities being surveyed
Logistical challenges of collecting necessary data, including the training and funding of community members
Ways to Help Uplift Indigenous Peoples in Academia
Our guests share some ways we can help support and uplift Indigenous peoples:
Community-based participatory research that benefits Tribal communities in meaningful ways
Working towards making education free for Native students
Promoting Tribal sovereignty
Advocating for climate justice
Aligning institutional missions to support Indigenous peoples locally, nationally, and globally
Creating Supportive Spaces
Our guests remind us of the importance of thinking beyond addressing the “pipeline” to increase representation of Indigenous Peoples in medicine, but also emphasize the importance of creating safe spaces for these students to thrive.
This includes being mindful of language and the etiology of the words we use in academic and medical spaces (e.g., “low on the totem pole”, “let’s have a powwow”)
This also includes understanding the unique challenges Indigenous students face when away from their communities in predominantly white institutions, which can often affect their mental health and wellbeing.
Perspective by Dr. Tom Sequist “Paving the Way — Providing Opportunities for Native American Students” N Engl J Med 2005; 353:1884-1886. doi:10.1056/NEJMp058218
The hosts and guests report no relevant financial disclosures.
Citation
Sequist T, Neuner S, Calac A, Lopez-Carmen V, Tsai J, Krishnamurthy S, Ogunwole M, Fields NF, Nolen L, Onuoha C, Watkins A, Williams J, Paul D, Essien UR, Khazanchi R. “Episode 12: Our Land is Our Health: Addressing Anti-Indigenous Racism in Medicine.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. November 23, 2021.
Anisha B. Dua MD, MPH is an Associate Professor of Medicine in the Division of Rheumatology, Rheumatology Fellowship Program Director and Director of the Northwestern Vasculitis Center at Northwestern University Feinberg School of Medicine. Dr. Dua interests are in rheumatology, education, and vasculitis. She completed her Rheumatology fellowship at Rush University as well as fellowships in medical education at The University of Chicago and Integrative Medicine at Northwestern. She is a former member of the Committee on Training and Workforce for the American College of Rheumatology, worked with the ACGME to develop the new subspecialty milestones for Rheumatology, and is currently the Chair of the ACR In-Training-Exam committee. Dr. Dua currently leads a multidisciplinary team in the clinical management of vasculitis patients. She recently assisted in the development of the American College of Rheumatology (ACR) Guideline for the Treatment and Management of Vasculitis, is on the Board of Directors for the Vasculitis Foundation and a member of the Scientific Advisory Council for the Rheumatology Research Foundation. She has served in leadership capacities both locally and nationally through the American College of Rheumatology, the Vasculitis Foundation, and the ACGME in the areas of education as well as vasculitis. You can follow her on twitter @anisha_dua
Patreon exclusive: RLR 69 – Power of the frame
Nov 14, 2021
In the diagnostic journey, nothing is more important than the frame. The wrong frame leads to the wrong diagnosis. However, sometimes you need multiple frames with the flexibility to pivot from one frame to another like Lionel Messi and his left foot. Rabih shows us the power of the frame in this episode.
Happy Sunday!
And consider advertising RLR to a friend. We thank you.
Sharmin and Dr. Kaylin Nguyen delve deeper into the imposter phenomenon. They discuss the origin of the term, the problems with the mainstream definition, and how it should be reframed.
Dr. Kaylin Nguyen was born in Vietnam and grew up in Southern California. After graduating from UCLA, she completed both medical school and Internal Medicine residency at UCSF. She is currently a second year Cardiology fellow at Stanford and has interests in cardiovascular imaging, health disparities, and digital health. She enjoys hiking, drinking copious amounts of herbal tea, and well-timed puns.
Episode 205- Global VMR Special Episode – The Mock Interview – The Do’s and Don’ts with Dr. Ravi Singh – Part 2
Nov 04, 2021
Dr. Ravi Singh interviews CPSolvers team members Rafael Medina, Sukriti Banthiya, and Rabih Geha who illustrate the Do’s (Rafael and Sukriti) and Don’ts (Rabih) of a residency application interview. This is for anyone interviewing, but especially for IMGs.
Doctor Ravi Singh graduated from the University Medical School of Debrecen in Hungary. He did residency at the MedStar Health Internal Medicine Residency program in Baltimore, Maryland. He then moved to Sinai hospital/Johns Hopkins internal medicine residency program as an academic hospitalist. Dr Singh is currently an associate Program Director Internal Medicine Residency Program at Sinai Hospital, in Baltimore and also a clerkship site director at Sinai for Johns Hopkins School.
Episode 205- Global VMR Special Episode – The Mock Interview – The Do’s and Don’ts with Dr. Ravi Singh – Part 1
Nov 04, 2021
Dr. Ravi Singh interviews CPSolvers team members Rafael Medina, Sukriti Banthiya, and Rabih Geha who illustrate the Do’s (Rafael and Sukriti) and Don’ts (Rabih) of a residency application interview. This is for anyone interviewing, but especially for IMGs.
Doctor Ravi Singh graduated from the University Medical School of Debrecen in Hungary. He did residency at the MedStar Health Internal Medicine Residency program in Baltimore, Maryland. He then moved to Sinai hospital/Johns Hopkins internal medicine residency program as an academic hospitalist. Dr Singh is currently an associate Program Director Internal Medicine Residency Program at Sinai Hospital, in Baltimore and also a clerkship site director at Sinai for Johns Hopkins School.s
Patreon exclusive: RLR 67 – Not so fast
Nov 02, 2021
We hope you enjoy! And as always, thank you for your support. The RLR series is only possible because of you.
In this episode, Simone & Emma review the schemas of Altered Mental Status and Microangiopathic Hemolytic Anemia as they work through a case presented by Moses.
Lisa Sanders, MD, founder and writer of the popular Diagnosis column for New York Times Magazine, and Laura Glick, MD, STUMP RR through a very exciting case.
We hope you enjoy it as much as we enjoyed being stumped.
Join us on Patreon for more cases with Dr. Sanders, and 5 bonus episodes a month with RLR.
Episode 202: Global VMR Special Episode – Residency Applications for IMGs Part 2
Oct 19, 2021
CPSolvers team members–Rafael Medina (lead organizer),Valeria Roldán, Gabriel Talledo, and Andrea Guzman facilitate a conversation with Drs. Gallo and Singh who shared authentic, practical, and inspirational insight into the IMG journey to apply to residency in the USA.
Dr Alice Gallo
Doctor Alice Gallo graduated from the Medical School of the Pontifícia Universidade Católica do Rio Grande do Sul in Brazil. She did residency at the Hospital Nossa Senhora da Conceição, repeated it at the University of Miami Miller School/Jackson Memorial Hospital/VA Hospital. She did a Pulmonary and Critical Care Fellowship at Mayo Clinic in Rochester, and joined the Critical Care staff at Mayo in 2017. Dr. Gallo is an Associate Professor of Medicine and Associate Program Director for the Internal Medicine Residency Program Mayo Clinic in Rochester.
Dr Ravi Singh
Doctor Ravi Singh graduated from the University Medical School of Debrecen in Hungary. He did residency at the MedStar Health Internal Medicine Residency program in Baltimore, Maryland. He then moved to Sinai hospital/Johns Hopkins internal medicine residency program as an academic hospitalist. Dr Singh is currently an associate Program Director Internal Medicine Residency Program at Sinai Hospital, in Baltimore and also a clerkship site director at Sinai for Johns Hopkins School.
CPSolvers team members–Rafael Medina (lead organizer),Valeria Roldán, Gabriel Talledo, and Andrea Guzman facilitate a conversation with Drs. Gallo and Singh who shared authentic, practical, and inspirational insight into the IMG journey to apply to residency in the USA.
Dr Alice Gallo
Doctor Alice Gallo graduated from the Medical School of the Pontifícia Universidade Católica do Rio Grande do Sul in Brazil. She did residency at the Hospital Nossa Senhora da Conceição, repeated it at the University of Miami Miller School/Jackson Memorial Hospital/VA Hospital. She did a Pulmonary and Critical Care Fellowship at Mayo Clinic in Rochester, and joined the Critical Care staff at Mayo in 2017. Dr. Gallo is an Associate Professor of Medicine and Associate Program Director for the Internal Medicine Residency Program Mayo Clinic in Rochester.
Dr Ravi Singh
Doctor Ravi Singh graduated from the University Medical School of Debrecen in Hungary. He did residency at the MedStar Health Internal Medicine Residency program in Baltimore, Maryland. He then moved to Sinai hospital/Johns Hopkins internal medicine residency program as an academic hospitalist. Dr Singh is currently an associate Program Director Internal Medicine Residency Program at Sinai Hospital, in Baltimore and also a clerkship site director at Sinai for Johns Hopkins School.
Any topic in medicine is more enjoyable once you learn the topic. I did not have a systematic approach to ataxia one year ago and it was a tough day at work. I used that energy to create an approach with a dear friend.
We hope you are kind to yourselves and use such reminders as a stimulus to grow rather than defeat.
Episode 11: Racism, Redlining, and the Path Towards Reconciliation
Show Notes by Sud Krishnamurthy, Michelle Ogunwole, Chioma Onuoha
October 12th, 2021
Summary: This episode is part of a 3-part series on Race, Place, and Health. In this episode, we invite Mr. Richard Rothstein, distinguished Fellow of the Economic Policy Institute and acclaimed author of the book, The Color of Law: A Forgotten History of How Our Government Segregated America, and Professor Fernando De Maio, PhD director of research and data use at the AMA’s Center for Health Equity, professor of sociology at DePaul University, and co-editor of the recently published book, Unequal Cities: Structural Racism and the Death Gap in America’s Largest Cities, to share their expertise on structural racism, neighborhood segregation, and health inequities.
Episode Learning Objectives:
After listening to this episode learners will be able to…
Explain the differences between de jure and de facto segregation
Explore the historical and present-day implications of neighborhood redlining and housing segregation on health disparities
Explain the importance of precise definitions when discussing structural racism
Explore short and long term remedies to segregation
Credits
Written and produced by: Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Sudarshan Krishnamurthy, Naomi F. Fields, LaShyra Nolen, Chioma Onuoha, Dereck Paul, MD, MS, Ayana Watkins, Jazzmin Williams
Hosts: Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Rohan Khazanchi, MPH
Infographic: Creative Edge Design
Audio edits: David Hu
Show notes: Sudarshan Krishnamurthy, Michelle Ogunwole, Chioma Onuoha
Guests: Richard Rothstein, Fernando De Maio, PhD
Time Stamps
00:00 Introduction
02:29 De Jure and De Facto Segregation: The Color of Law
06:45 Health Inequities and Segregation: Unequal Cities
12:07 Defining Structural Racism
18:05 Federal Policy and Suburbanization
24:50 The Racial Wealth Gap and its Consequences
30:27 The Role of Health Equity Promoting Policy
32:00 Potential Remedies for Past Harms
39:45 Segregation of Medical Care
41:20 What Can Listeners Do Going Forward?
Episode Takeaways:
1. Terminology and Definitions of de jure and de facto segregation: The myth that segregation in modern societies has to do with private activities (e.g individual bias or bigotry that leads to a failure to sell a home to a person of color) and personal choices ( e.g. Black people prefer to live among other Black people) is referred to as de facto segregation. Adopting this worldview removes any obligation to remedy the consequences of segregation. In contrast, de jure segregation refers to the involvement of federal, state, and local governments in creating, structuring, designing, reinforcing, and perpetuating segregation. This reality of de jure segregation helps us understand that we have an obligation to remedy this constitutional violation.
2. Segregation relates to crucial public health outcomes that ultimately have an effect on life expectancy: The average life expectancy across the United States is 78.6 years; however, there exists a 10 year gap in life expectancy among the 30 largest cities in the US, from 72.9 years in Baltimore to 82.9 years in San Francisco and San Jose. Across the country, we see a 4 year gap in life expectancy between Black and White Americans; and this gap between and Black and White individuals ranges from 12 years in Washington DC, more than 8 years in Chicago, to no gap in El Paso. These gaps are not a product of lifestyle choices, biology or individual behaviors. They are a product of deep-rooted man-made policies that extend to many sectors (healthcare, education, criminal justice etc). These policies have systematically disadvantaged some groups, and have advantaged others. These policies are woven deeply into the fabric of the United States, and are intimately related to residential segregation, life expectancy, and mortality.
3. Unconstitutional housing policy in the mid-20th century led to the present day wealth gap and has implications for disparities: Discriminatory policies prohibited African Americans from being homeowners, while allowing White Americans to purchase homes and accumulate generational wealth. These policies established the wealth gap between Black and White Americans that persists today. Nationally, African Americans’ income is 60% of that of White Americans. Although one would think this leads to a 60% wealth gap as well, household wealth of African Americans is 5% (95% wealth gap) of that of White Americans. This extreme disparity between the 60% income ratio and the 5% wealth ratio is attributable to consequences of federal housing policy practiced in the mid-20th century. You can draw a line from these discriminatory housing policies, to the wealth gap, to disparities in education, health, and police brutality.
Pearls
On the importance of considering place based inequities
Variability of health inequities between communities in a single city or across different cities is critical to consider when discussing health inequity.
“We tend to think of health inequities as big, monolithic, deeply entrenched patterns, and they are, but their variability is really important. It gives us a sense of how different things can be.”-Professor Fernando De Maio
On language and the use of the term ‘structural racism’
Structural racism is a word that is used often, however many people do not know what it really means. Professor DeMaio notes that confusion around terminology is not a reason to shy away from discussions around it. He declares that one of our greatest challenges, and also one of our obligations, is to address structural racism head on.
“It’s our collective responsibility to explain it, to define it, to communicate it in effective ways to physicians, to healthcare systems, to the public at large and in detail, with data and with narratives, all the ways through which racism impacts our health.” -Professor Fernando De Maio
On Remedies to segregation
Mr. Rothstein shares two examples of potential remedies to segregation. The first would specifically address the constitutional violation that prohibited African Americans from becoming homeowners. The remedy would be for the government to buy up homes at market value in neighborhoods where African Americans were not allowed to buy homes, and sell them back to qualified African American buyers at deeply discounted rates.
The second remedy would correct a policy– the low-income housing tax credit– that reinforces segregation. Currently, low-income housing tax credit is a federal program distributed to housing developers who build housing for low-income families. However, this program reinforces segregation as developers are more inclined to build low-income housing in low-income neighborhoods. This can be reversed by placing a priority on use of these tax credits in higher-opportunity communities and prohibiting the use of this credit for creating more segregated communities.
Mr. Rothstein notes that the challenge is not in thinking of ideas or potential remedies…
“ We know what the policies are to create equality, a more equal society and a non-segregated society. What’s missing is not policy ideas. What’s missing is a new civil rights movement that’s going to create the political environment where those policies have to be implemented.”-Mr. Richard Rothstein
On being a citizen and the collective effort needed to change the status quo
Mr. Rothstein leaves us with these wise words to consider as we head back into our professional roles in medicine.
“In addition to being a physician, you’re a citizen. And I think the most important thing you can do is align yourself with other citizens in whatever profession they are, because this is going to take a community effort” -Mr. Richard Rothstein
References
Rothstein, R. (2017). The Color of Law: A Forgotten History of How Our Government Segregated America.
Benjamins MR, De Maio F. Unequal Cities: Structural Racism and the Death Gap in America’s 30 Largest Cities. Baltimore: Johns Hopkins University Press; 2021.
De Maio F, Ansell D. “As Natural as the Air Around Us”: On the Origin and Development of the Concept of Structural Violence in Health Research. Int J Health Serv. 2018;48(4):749-759. doi:10.1177/0020731418792825
Benjamins MR, Silva A, Saiyed NS, De Maio FG. Comparison of All-Cause Mortality Rates and Inequities Between Black and White Populations Across the 30 Most Populous US Cities. JAMA Netw Open. 2021;4(1):e2032086. doi:10.1001/jamanetworkopen.2020.32086
Metzl JM, Maybank A, De Maio F. Responding to the COVID-19 Pandemic: The Need for a Structurally Competent Health Care System. JAMA. 2020;324(3):231-232. doi:10.1001/jama.2020.9289
Liao TF, De Maio F. Association of Social and Economic Inequality With Coronavirus Disease 2019 Incidence and Mortality Across US Counties. JAMA Netw Open. 2021;4(1):e2034578. doi:10.1001/jamanetworkopen.2020.34578
Krieger M, Boyd R, De Maio F, Maybank A. “Medicine’s Privileged Gatekeepers: Producing Harmful Ignorance About Racism And Health, ” Health Affairs Blog, April 20, 2021. doi: 10.1377/hblog20210415.305480
Wilkinson RG. Unhealthy Societies: The Afflictions of Inequality. London: Routledge; 2005.
Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126-133. doi:10.1016/j.socscimed.2013.06.032
The “Redress Project,”, i.e. the New Movement to Redress Racial Segregation, will launch early next year. For anyone who wants to receive more information about the launch of the New Movement to Redress Racial Segregation, please click here NMRRS.
The hosts and guests report no relevant financial disclosures.
Citation
De Maio F, Rothstein R, Khazanchi R, Tsai J, Krishnamurthy S, Ogunwole M, Fields NF, Nolen L, Onuoha C, Watkins A, Williams J, Paul D, Essien UR. “Episode 11: Racism, Redlining, and the Path Towards Reconciliation.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. October 12, 2021.
We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Gabriela presents a case of impairment of speech to Gabriel and Valeria.
Gabriela has graduated from Medical School at Unicamp and recently finished her neurology residency at Unesp, both in Brazil. She is interested in Medical Education and Clinical Reasoning and has obviously fallen in love with CPSolvers and VMRs since day 1. In her free time, she likes to practice pilates, play with her dogs, binge-watch Netflix comedy series, read biography books, go out with her friends (pre-COVID), drink wine, and cook (still learning).
Gabriel Talledo
Gabriel is a MS2 student from Cayetano Heredia University. When it comes to medicine, he enjoys dermatology, infectiology, and LGBTQ+ health. He fell in love with his career when he understood medicine not just as a concept of knowledge but a combination of knowledge and social justice pursuit. He loves cooking Peruvian cuisine (one of the best in the world), eating, jogging and watching TV series. Recently he is doing a transgender education program at his university and a volunteering of sexual education in Lima schools.
Valeria Roldan
Valeria is a medical student at Universidad Peruana Cayetano Heredia. She was born and lives in Lima, Perú. She hopes to pursue Neurology residency. Her interests include neuro-infectious diseases, transgender health and medical education. Her work with CPSolvers involves being a part of the Virtual Morning Report team and serving on the Spanish schemas team. Outside of Medicine she loves running, hiking, cooking pasta and spending time with her dogs.
On this episode, Rabih presents two cases at once for Reza.
We truly hope you enjoy these cases.
If you are not driving or doing an activity that needs your full attention, pause after each aliquot and share your thoughts out loud. Then compare your thoughts to RR’s thoughts. Think like no one is watching and get better one rep at a time!
Thank you as always.
RR
Episode 198: HumanDx Unknown with Laura, Stef, and Jack – hematochezia and abdominal pain
Sep 22, 2021
Alec presents a case of abdominal pain and hematochezia to Laura, Stef, and Jack.
Laura Geiszler
Laura Geiszler is a third-year Internal Medicine resident at Lankenau Medical Center in Wynnewood, Pennsylvania.
Laura completed her medical school at Philadelphia College of Osteopathic Medicine. She has a passion for humanizing medicine and promoting health and wellness to prevent disease.
Outside of work she is a proud cat mom, fitness lover, fiction book enthusiast, and fashion addict.
Stefanie Gallagher
Stefanie is a PGY-3 internal medicine resident at Lankenau Medical Center, located in Wynnewood, PA.
She earned her medical degree from the Philadelphia College of Osteopathic Medicine, with a dual-degree in Bioethics from the University of Pennsylvania.
She is an aspiring gastroenterologist and has a passion for disorders of the gut-brain axis.
Outside of medicine, she enjoys her English bulldog (Boomer), cycling, and reading non-fiction.
Alec Rezigh
Alec Rezigh is an academic hospitalist at Baylor College of Medicine in Houston, TX.
He completed medical school at McGovern Medical School in Houston and his residency at The University of Colorado.
His clinical interests include medical education and clinical reasoning.
He loves all things basketball, CPSolvers, and playing with his human and doggy daughters.
Dr. Titer, Dr. Williams, Maani and Lindsey discuss macro/microaggressions in the clinical setting.
Dr. KeAndrea Titer
Dr. KeAndrea Titer is an Assistant Professor in the Division of General Internal Medicine at University of Alabama at Birmingham. She was born and raised in Tampa, Florida. She received her Bachelor of Science in Biology from Oakwood University in Huntsville, Alabama. She went on to earn her medical degree from Loma Linda University School of Medicine in Loma Linda, California. She completed her residency and chief residency at the University of Alabama at Birmingham Tinsley Harrison Internal Medicine Residency Program. Her academic interests include physical exam-focused medical education where she co-directs the Enhanced Clinical Skills Residency Track and serves as Investigator for the AMA Reimagining Residency Grant awarded to John Hopkins, Stanford, and UAB focused on studying clinical skills as it relates to resident wellness. She is also passionate about diversity, equity, and inclusion and serves as the Assistant Director of Diversity and Inclusion for the Tinsley Harrison Internal Medicine Residency Program where she works to design initiatives and curriculum focused on recruitment, education, and building community.
Dr. Karla Williams
Dr. Karla Williams is an assistant professor in the Division of General Internal Medicine and Hospital Medicine at UAB in Birmingham, AL. She serves as an assistant program director and the director of diversity and inclusion for the Tinsley Harrison Internal Medicine Residency Program. She has a passion for advancing diversity, equity and inclusion in graduate medical education and care delivery and was recognized as a recipient of the 2020 Dean’s Excellence Award in Diversity. She has recently worked with colleagues to develop a formal curriculum, Supporting Trainees by Addressing Inappropriate Behaviors by Patients, to address microaggressions and other inappropriate behaviors in the medical environment. This initiative has created a platform to have safe and honest discussions about the presence and effect of bias, including racial and gender derogations, in the medical environment and has been presented and implemented at numerous academic institutions at the UME and GME levels. The ultimate goal is to bring awareness to our implicit and explicit biases in an effort to cultivated more inclusive learning and clinical environments for trainees, faculty and patients.
Patreon exclusive: RLR 62 – Lisa Sanders, MD, presents a case to R&R
Sep 13, 2021
Lisa Sanders, MD, founder and writer of the popular Diagnosis column for New York Times Magazine, and Laura Glick, MD, STUMP RR through a very exciting case.
We hope you enjoy it as much as we enjoyed being stumped. There will be exclusive schema(s) and/or illness script(s) with this episode for tier 2 and tier 3 Patrons. We thank you for your continued support.
RLR are back on the podcast with a fascinating case. Over the summer, they’ve been releasing a lot of cool content on Patreon. Check it out here for much more RLR content.
Gabriela has graduated from Medical School at Unicamp and recently finished her neurology residency at Unesp, both in Brazil. She is interested in Medical Education and Clinical Reasoning and has obviously fallen in love with CPSolvers and VMRs since day 1. In her free time, she likes to practice pilates, play with her dogs, binge-watch Netflix comedy series, read biography books, go out with her friends (pre-COVID), drink wine, and cook (still learning).
Maria Jimena Aleman
Maria Jimena Aleman was born and raised in Guatemala where she currently is a medical student in Universidad Francisco Marroquin. After suffering from long standing neurophobia, she has embraced her love for neurology and will pursue a career in this field. She also looks forward to dedicating her life to breaking barriers for Latin women in medical fields and improving medical care in her country. Maria is one of the creators of a medical education podcast in Spanish called Intratecal. Her life probably has a soundtrack of a mix between Shakira and Louis Armstrong. Outside of medicine she enjoys modern art, 21st century literature and having hour long conversations over a nice hot cup of coffee or tequila.
Kirtan Patolia
Kirtan is a final year medical student from B.J. Medical College, Ahmedabad, Gujarat, India. He is looking forward to joining Internal Medicine Residency in the USA by applying through this year’s Match Cycle.
He loves to solve clinical cases and was delighted when he got the opportunity to join the CPSolvers team. He is so grateful to Dr. Geha and Dr. Manesh for this opportunity. Clinical reasoning is his biggest passion and he strives to enhance his diagnostic skills every day. Discussing and sharing clinical cases with his friends gives him distinct pleasure. Outside of medicine, I like to read Agatha Christie and Nancy Drew novels. He also loves kite-flying, as he finds the various techniques and maneuvers to fly kites fascinating.
Patreon exclusive: RLR 55 – Headache + Support Rabih’s Internet Bill
Aug 10, 2021
Dr. Marion Stanley is a hospitalist and an internal medicine residency associate program director at Northwestern Memorial Hospital. She completed medical school at University of Chicago, Pritzker School of Medicine and graduated from University of California, San Francisco for residency. She spends her clinical time on the general medicine teaching services as well as the general medicine and oncology hospitalist units. She enjoys spending time with her husband and two daughters, ages 4 and 1.
Dr. Geralyn Palmer
Dr. Geralyn Palmer is a first year internal medicine resident at the University of Wisconsin. She completed her undergraduate and medical education in her home state of South Dakota. After residency, Geralyn hopes to pursue a career in medical education, and is currently considering a broad specialty differential. In her free time she enjoys long walks outside (preferably with dogs), experimenting in the kitchen, and The Great British Bake Off.
Dr. Julia Armendariz presents a clinical unknown to Dr. Laura Huppert.
Dr Laura Huppert
Laura Huppert, MD, is a third year Hematology/Oncology Fellow at the University of California, San Francisco (UCSF). Her clinical interest is in solid tumor malignancy, including the treatment of breast cancer and melanoma. She is also interested in medical education, and recently published a handbook for internal medicine entitled “Huppert’s Notes”, published by McGraw Hill. Dr. Huppert earned her M.D. from Harvard Medical School. She completed her Internal Medicine Residency and Chief Residency at UCSF.
Dr. Julia Armendariz
Julia Armendariz, MD is a general medicine hospitalist. Her interests lie in medical education, trainee wellness, and effective communication. She is a faculty member of the Stanford Internal Medicine Residency Wellness Committee and the Stanford GME Women in Medicine group. Dr. Armendariz earned her M.D. from Oregon Health and Science University in Portland, OR and completed her Internal Medicine Residency at Stanford.
Shanthi presents a clinical unknown to Sam, Michael, and Jack.
Want to test your learning? Take our episode quiz here
Michael Vu
Michael Vu is a second year Internal Medicine resident at Methodist Dallas. He completed his undergraduate education at the University of Texas at Dallas and his medical training at the University of North Texas Health Science Center – Texas College of Osteopathic Medicine. His current career interests include clinical reasoning, medical education, and cardiology. In his free time, he enjoys working out, cooking, and spending time with his wife.
Samantha Etienne
Sam is a PGY3 and chief resident at Methodist Dallas Medical Center in Dallas, TX. She attended the University of Texas Medical Branch at Galveston and is an aspiring hematologist/oncologist. Outside of medicine, she enjoys spending quality time with friends and family and has a real passion for food. She is considered by many a connoisseur of tacos.
Shanthi Kappagoda
Shanthi Kappagoda was born in United Kingdom and grew up in the UK and Canada. She graduated from UC Davis School of Medicine and completed her internal medicine residency at Brigham and Women’s Hospital in Boston. She completed her Infectious Disease fellowship at the Stanford School of Medicine and after fellowship remained at Stanford as a clinical faculty member. She works primarily on the ICU-ID consult service. In her free time, she enjoys spending time with her two children, growing vegetables and hiking around California State parks.
In this episode, we invite the powerful sister duo Oni Blackstock, MD, MHS and Uché Blackstock, MD to share their experiences on leaving public health and academia to become social entrepreneurs, creating their own organizations in health equity.
Episode Learning Objectives
After listening to this episode learners will be able to…
Recognize some common factors that influence Black women’s decisions to leave traditional health careers
Define counterspaces and understand their value
Apply tools to combat burnout that could be applied to traditional or alternative health careers
Credits
Written and produced by: Michelle Ogunwole, MD, Naomi F. Fields, LaShyra Nolen, Chioma Onuoha, Rohan Khazanchi, MPH, Dereck Paul, MD MS, Utibe R. Essien, MD, MPH, Jazzmin Williams, and Jennifer Tsai MD, M.Ed
Hosts: Michelle Ogunwole, MD, Naomi Fields, and LaShyra Nolen
Infographic: Creative Edge Design
Audio edits: David Hu
Guests: Oni Blackstock, MD, MHS and Uché Blackstock, MD
Time Stamps
00:00 Introduction
03:49 Defining “CounterSpaces”
5:22 Why Drs. Uché and Oni Blackstock created their counterspaces
17:54 Value gained outside of academia, public health
24:08 Finding balance in racial equity opportunities
34:17 On challenging the self-sacrificing mentality in medicine
42:26 On “doing the work” within academia
49:01 The meaning of sisterhood
52:20 Closing Remarks
Episode Takeaways:
Definition of CounterSpaces: CounterSpaces are academic and social safe spaces that allow underrepresented faculty to promote their own learning, wherein their experiences are validated and viewed as critical knowledge; they have space to vent frustrations by sharing stories of isolation, microaggressions or overt discrimination; and they can challenge the deficit notion of people of color and establish and maintain a positive collegial racial climate for themselves.
Root causes of the exodus Black women physicians from academia and public health: In many academic and public health institutions, Black women feel undervalued, untitled, underfunded, and undersupported. Their contributions to diversity, equity, and inclusion efforts are expected, but not compensated or rewarded. They are disproportionately passed over for promotions and opportunities despite quality work. These factors directly contribute to the growing trend of Black women physicians leaving these fields to pursue nontraditional health careers.
You are gifted!: “Sometimes you’re in these environments [academic, public health] for so long where you’re undervalued and underappreciated, you’re not supported the way that you should be, that you actually start thinking that– or start forgetting that you’re actually someone with gifts to share.” — Dr. Uché Blackstock
Self-sacrifice is not the highest virtue: Medicine is its own subculture where people are expected to make sacrifices of their time, personal and family life, and finances in order to demonstrate that they are good physicians. It is okay to say that you don’t want that for yourself, and work to actively counter this cultural norm in order to live a fulfilling personal and professional life.
There are opportunities to advance racial equity inside and outside of academia: For those who feel driven to pursue racial and health equity work within academia and/or public health: (1) understand what you value from working at an academic institution and recognize that there may be options to do that work outside of academia (e.g. research), and (2) build a support structure that enables you to stay true to your values as you work to create change from within.
For those having a hard time deciding if they should stay in academia or other traditional research or public health roles, Dr. Oni Blackstock offers important advice about listening to and trusting oneself:
“… just listening to your intuition, that’s like our main form of knowing. We have all these other forms of knowledge in books and what we’re taught in school, but really many times, the answer lies within us. So, again, just making sure that we’re in tune and listening to what we feel like our needs are. And if they’re telling us to leave, that we are true to those voices and we leave. And if they’re saying there’s work for us to do here, we want to stay and we have the support to be able to do that, then do that.” — Dr. Oni Blackstock
Pearls
“The work of liberation is the work of freeing the soul to be exactly who we were meant to be.” — GirlTrek
The role of an abundance mindset in achieving work/life balance
Many of us operate from a scarcity mindset; we feel that opportunities are limited and therefore take all opportunities that come our way without regard for our genuine interest in the opportunity or our true time availability. Especially for people early in their careers, there is an unspoken pressure to accept all opportunities that could possibly advance one’s career. It is impossible to achieve work/life balance when operating from this mindset, and as a consequence, it leads to burnout.
However, with an abundance mindset, one recognizes that opportunities are not finite and that saying no to one opportunity frees up our ability to say yes to a better opportunity that comes along later down the line. Dr. Uché Blackstock shared an example of how she experienced a tension between a scarcity mindset and an abundance mindset when deciding whether to continue part-time clinical work or to devote full-time effort to the organization she founded. When she embodied an abundance mindset and let go of her clinical career, she was free to say yes to even more fulfilling opportunities that came her way.
Relatedly, Dr. Oni Blackstock discussed the importance of pausing before committing to opportunities. White supremacy culture creates an artificial sense of urgency so we often respond reflexively. By taking a moment to pause and reflect, one can take on opportunities that align with one’s values and that one has adequate time for without sacrificing personal responsibilities. Taking a moment to pause ensures that we react from our authentic self and not from institutional culture.
Cultivate tools to sustain a career in traditional and alternative health careers
Cultural norms rooted in white supremacy and capitalism create an environment that extracts goods, time, and energy from people without providing a source from which to renew those resources. Dr. Oni Blackstock advises listeners to be “cognizant of the day to day ways in which these systems work against us,” and to actively fight against this culture with things that replenish ourselves. Tools that Dr. Oni Blackstock uses include: daily meditation, creating a gratitude list of 3 things each morning, and yoga and exercise several times a week. Additionally, she spoke about the importance of mentorship and a strong support network so you have people to turn to for advice and encouragement.
Finding effective strategies to replenish oneself is important for anyone advancing racial equity work in their careers as social entrepreneurs, academicians, public health officials.
Dr. Oni Blackstock shared a treasured quote around this idea: “ Learn to drink as you pour, so the spiritual heart cannot run dry and you always have love to give”-Ma Jaya
Self-reflection is a vital component of professional development
It is easy to become consumed by various career opportunities that are presented to us. In order to maintain one’s ability to effectively transform the existing culture of medicine into an anti-racist one, it is important to find time to reflect on one’s journey and direction. Below are some questions that CPSolvers ARM host Dr. Michelle Ogunwole synthesized after this conversation with Drs. Oni and Uché Blackstock.
What are the things (situations, contexts, people) that are making you question your gifts?
What are the wake up calls that we need in our life? How can they help you in your next step?
Who are you taking advice from?
What is keeping you from being your authentic self?
References
National Academies of Sciences, Engineering, and Medicine 2020. Promising Practices for Addressing the Underrepresentation of Women in Science, Engineering, and Medicine: Opening Doors. Washington, DC: The National Academies Press. https://doi.org/10.17226/25585.
National Academies of Sciences, Engineering, and Medicine 2021. Impact of COVID-19 on the Careers of Women in Academic Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press. https://doi.org/10.17226/26061.
Doll KM, Thomas CR Jr. Structural Solutions for the Rarest of the Rare – Underrepresented-Minority Faculty in Medical Subspecialties. N Engl J Med. 2020;383(3):283-285. https://www.nejm.org/doi/full/10.1056/NEJMms2003544
The hosts and guests report no relevant financial disclosures.
Citation
Blackstock O, Blackstock U, Ogunwole M, Fields NF, Nolen L, Onuoha C, Williams J, Tsai J, Essien UR, Paul D, Khazanchi R. “Episode 10: CounterSpaces in Medicine: Finding Safe Spaces and Redefining Value.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. July 15, 2021.
Dr. Frederick Weber is a Clinical Professor of Medicine at the University of Alabama Birmingham in the Division of Gastroenterology and Hepatology. He is the former Medical Director of the Division.
Want to test your learning? Take our episode quiz here
Gabriela Pucci
Gabriela has graduated from Medical School at Unicamp and recently finished her neurology residency at Unesp, both in Brazil. She is interested in Medical Education and Clinical Reasoning and has obviously fallen in love with CPSolvers and VMRs since day 1. In her free time, she likes to practice pilates, play with her dogs, binge-watch Netflix comedy series, read biography books, go out with her friends (pre-COVID), drink wine, and cook (still learning).
Kirsten Austad MD, MPH is an Assistant Professor of Family Medicine at Boston University School of Medicine and a hospitalist at Boston Medical Center. She earned her undergraduate degree in English Literature and Medical Microbiology and Immunology from the University of Wisconsin-Madison and her medical degree from Harvard Medical School in the New Pathway Program. She completed her residency in Family Medicine at Boston Medical Center, the largest safety-net hospital in New England. Following residency, she completed a research fellowship at Brigham and Women’s Hospital in Global Women’s Health and earned a Masters in Public Health from the Harvard T.H. Chan School of Public Health. During this time she worked clinically as a nocturnist at Brigham and Women’s Hospital / Dana Farber Cancer Institute. After fellowship she returned to Boston Medical Center where she is a hospitalist and the Medical Director of the HealthNet Inpatient Family Medicine service, one of the largest family medicine hospitalist services in the country.
Her research focuses on global implementation science aimed at improving the delivery of women’s health care in low-resource settings, including respectful maternity care and family planning. In addition to global health research, she also has extensive experience in program development, having spent 6 years as the Director of Women’s Health for Maya Health Alliance, a non-profit providing care to indigenous Maya patients in the highlights of Guatemala, where she trained and supervised a team of over 20 nurses and doctors to provide community-based patient-centered women’s health care.
Mohit is a current Chief Resident in the Department of Internal Medicine at WashU. He is from Huntington, West Virginia and attended Marshall University School of Medicine in his hometown. He loves clinical reasoning and has a special interest in Hospital Medicine. Outside of work, he enjoys cooking new recipes, hiking, walks in the park, and has recently developed a green thumb with over 30 house plants and a garden.
Kai Jones
Kai Jones is from Tulsa, Oklahoma and studied Biology and Anthropology at Washington University in St. Louis. She attended Washington University for medical school and is now a second-year resident in Internal Medicine at Barnes-Jewish Hospital. She is interested in Endocrinology, and community based participatory research. Her hobbies include golf, and cooking.
Bronson Knuzler
Bronson Kunzler was born and raised in Salt Lake City, Utah, he studied finance at Utah State University and is currently an MS3 at Penn State University College of Medicine. He is interested in Internal Medicine with hopes to become a Cardiologist. In his free time he enjoys cheering for the Utah Jazz, barbeque, and visiting museums.
Nicholas Hornstein is a PGY-3 at UCLA Ronald Reagan Medical Center. He was born and raised in Los Angeles, earned his undergraduate degree from Brandeis University, and graduated from Columbia University with an MD and a PhD in Computational Biology. He has a passion for climbing, cooking, furry animals, and the advancement of medical genomics/technology. He will be furthering his education next year with a Fellowship in Hematology Oncology at MD Anderson Cancer Center and couldn’t be more excited.
Suellen Li
Suellen Li is a PGY-2 internal medicine resident at Massachusetts General Hospital. She grew up in Roanoke, VA and attended Duke University, where she studied Environmental Sciences & Policy and Global Health. She then moved to Chicago to complete medical school at the University of Chicago Pritzker School of Medicine. After finishing residency, she hopes to pursue a career in hospital medicine. In her free time, she enjoys reading, eating chips and being a cat mom.
Jennifer Plotkin
Jennifer Plotkin is a PGY2 in internal medicine at UCLA. She was born and raised in Los Angeles. She attended MIT for undergrad where she majored in Chemistry. She completed her medical school training at Johns Hopkins. She loves internal medicine for its problem solving and meaningful therapeutic relationships with patients. Her interests include primary care, endocrinology, and medical education, particularly in the veteran population. Outside of medicine, she enjoys running, rooting for the Lakers and Dodgers, and exploring restaurants.
In this special episode of the Antiracism in Medicine Series, originally recorded for the 2021 Society of General Internal Medicine Annual Meeting, the CPSolvers Antiracism team discusses what must be done to make medical education more antiracist. The conversation spans stages of academic medical career progression, ranging from recruitment to training to retention. The ARM team draws upon their own research and personal experiences to provide listeners with recommendations and actionable next steps.
Learning Objectives
After listening to this episode, listeners will be able to…
Explore the common barriers to entering the medical profession that minoritized trainees face and discuss strategies that trainees and institutions can adopt to overcome them.
Recognize how racist ideologies are often perpetuated in medical education and ways that academic medical centers can revise their curricula to prepare a physician workforce that is invested in recognizing and addressing the root cause of health disparities.
Understand the “minority tax” that minoritized trainees and faculty experience in diversity, equity, and inclusion reform efforts; identify models to properly compensate individuals for their time and expertise.
Credits
Written and produced by: Dereck Paul, MD, MS; Chioma Onuoha, Utibe R. Essien, MD, MPH; Rohan Khazanchi, MPH; LaShyra Nolen; Naomi F. Fields; Michelle Ogunwole, MD; Jazzmin Williams; and Jennifer Tsai MD, M.Ed
Host: Chioma Onuoha
Infographic: Creative Edge Design
Guests: Rohan Khazanchi, MPH; Naomi F. Fields; Michelle Ogunwole, MD; Utibe R. Essien, MD, MPH; Jazzmin Williams
Timestamps:
00:00 Introduction
02:15 Barriers to Entry in Medicine
05:15 How to Identify an Uplifting Institutional Home
11:40 Racism Ingrained in Medical Education
15:10 Imagining an Ideal Medical School Curriculum
17:40 A Roadmap to Engaging Hyperlocal Communities in Medical Education
20:30 Moving Beyond Ahistorical Conversations about Health Disparities
27:05 Engaging All Learners as Stakeholders for Health Equity and Antiracism
33:40 Re-examining Who the Experts Are
42:40 Recognizing Privilege and Positionality
45:25 Patient Safety Analogy and “Racism Saps the Strength of the Whole”
49:44 Where Do You Find Your Hope?
Takeaways:
Reimagining the learning environment: Creating a more antiracist learning environment will require institution-level commitments and broader reforms in the medical education regulatory environment (i.e. board examinations and mandated competencies).
Valuing health equity work: antiracism and health equity work must be properly compensated at all levels of training. Such compensation could be monetary or come in the form of academic currency, like co-authorship of publications.
How to be a good ally and co-conspirator: Power and access are needed to sustain and amplify antiracist justice within medicine. Many times, granting this power and access will require that individuals with privileged identities historically possessing a disproportionate amount of power transfer that power to individuals from marginalized backgrounds. Rather than centering the importance of individual advancement, we can remember that whenever racism is operational, as Dr. Camara Jones says, it “saps the strength of the whole society.” Using justice to guide our distribution of power will improve everyone’s livelihood.
Advancing beyond ahistorical teaching on racial health disparities: Health equity education must include racism as a driver of health inequities. As prior podcast episodes have highlighted, misleading theories of racialized biological differences cannot be presented as the cause of racial health disparities.
Pearls:
Acculturation to Medical Education
While the process of medical education is exciting, progressing through clinical training involves acculturation for all. This acculturation can differentially affect learners based on their own backgrounds and experiences. It is important for learners to reach out to mentors and peers who can offer insight into learning the ropes, and a safe place to land; it is also important for educators to recognize this and offer this to their learners. Additionally, it is important that institutions create environments where students have educators and faculty of similar backgrounds as theirs to learn from.
For trainees: What to consider when evaluating medical schools and residency programs
It can be challenging for students and residents to decide if an institution is truly committed to antiracism, social justice and equity. While time and action are true measures of this commitment, some things to consider include:
Is there diversity, which is more than skin deep, in the leadership?
Does the institution involve community members in training?
What is the relationship between community members and the academic medical center?
How does the institution respond to issues of injustice that affect trainees?
Is advocacy celebrated or at least respected and encouraged?
Does the institution recognize past historical transgressions? What have they done to address a painful history if one exists?
Does the curriculum equip learners with a vocabulary to discuss racism?
Does the curriculum include historical context about the communities served by the academic medical center?
Engaging All Students as Stakeholders
Antiracism education can seem relegated to students with niche interests. Nevertheless, there are ways to engage all students as stakeholders.
Board exam writers can shape their learning objectives toward antiracism based on our evolving knowledge base and more accurate paradigms of racism-as-the-risk factor, given that board exams shape what educators include in their curricula.
On an institutional level, we can incentivize scientifically accurate, ethically responsible, justice-based means of representing and incorporating race, racism, and health equity within faculty members’ work. These are the people that learners often look up to and after whom they model their careers.
Finally, we might eschew the idea that learners are disinterested in these topics, and commit to deep education regarding race/racism in medicine. Learners are often intellectually curious with a heart to learn what is needed to provide the best care for their patients.
Curricular Reforms to Operationalize Antiracism
Curricula seeking to address health inequities cannot be ahistorical. Health disparities are not created in a vacuum; thus, discussion of disparate outcomes should include conversations about the systemic and structural underpinnings of inequity.
Similarly, medical curricula must become comfortable reframing who the “experts” are on health disparities topics. In brief, community stakeholders are crucial experts on the lived experiences and health of their neighbors. Community engagement, as well as prioritization of hyperlocal issues impacting communities proximate to academic institutions, can and should be integrated in health equity curricula.
References:
Amutah C, Greenidge K, Mante A et al. Misrepresenting Race — The Role of Medical Schools in Propagating Physician Bias. New England Journal of Medicine. 2021;384(9):872-878. doi:10.1056/nejmms2025768
Nolen L. How Medical Education Is Missing the Bull’s-eye. New England Journal of Medicine. 2020;382(26):2489-2491. doi:10.1056/nejmp1915891
Sharma M, Pinto A, Kumagai A. Teaching the Social Determinants of Health. Academic Medicine. 2018;93(1):25-30. doi:10.1097/acm.0000000000001689
Phelan S, Burke S, Cunningham B et al. The Effects of Racism in Medical Education on Students’ Decisions to Practice in Underserved or Minority Communities. Academic Medicine. 2019;94(8):1178-1189. doi:10.1097/acm.0000000000002719
Khazanchi R, Keeler H, Marcelin J. Out of the Ivory Tower: Successes From a Community-Engaged Structural Competency Curriculum. Academic Medicine. 2021;96(4):482-482. doi:10.1097/acm.0000000000003927
Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education. Academic Medicine. 2016;91(7):916-920. doi:10.1097/acm.0000000000001232
Jones C. Toward the Science and Practice of Antiracism: Launching a National Campaign Against Racism. Ethn Dis. 2018;28(Supp 1):231. doi:10.18865/ed.28.s1.231
Tsai J, Lindo E, Bridges K. Seeing the Window, Finding the Spider: Applying Critical Race Theory to Medical Education (MedCRT) to Make Up Where Biomedical Models and Social Determinants of Health Curricula Fall Short. Front Public Health. 2021. doi: 10.3389/fpubh.2021.653643
Mr. Khazanchi is a member of the American Medical Association’s Council on Medical Education, but the views presented herein represent his own and not necessarily those of the AMA or the Council. The hosts and guests report no other relevant financial disclosures.
Citation
Onuoha C, Khazanchi R, Fields N, Ogunwole M, Williams J, Essien UR, Tsai J, Nolen L, Paul D. “Episode 9: Moving Towards Antiracism in Medical Education.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. June 10, 2021.
Episode 180: Clinical Unknown – Global VMR
Jun 03, 2021
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Dr. Hernán Carrillo
Hernán Carrillo is Head of the Internal Medicine Department at Las Higueras Hospital in Talcahuano, Chile. He’s also an Assistant Professor at Concepción’s University. He is passionate about his work in public health care and is specially crazy about diagnostic process. Loves to play guitar and singing, and he’s learning a little bit of piano. Also enjoys photography. He is totally in love with his family!
Description: We continue our campaign to #EndNeurophobia led by Aaron Berkowitz! This time, Doug presents a case of headache and blurry vision to Hannah and Dhruv.
Dhruv Srinivasachar is a soon-to-be 1st year Medicine-Pediatrics resident at Western Michigan University and a graduate of Virginia Commonwealth University School of Medicine (the Medical College of Virginia for all the veteran attendings out there). Introduced to medicine through research, Dhruv has shifted his passions to empathetic clinical care and medical education, as a contributor to the CPSolvers (especially through VMR as a case presenter, discussant, and compiler of cases) and team member for the Not Just Little Adults podcast (CPedsSolvers, if you will). When he’s not looking for apartments or stressing about intern year, he can be found biking, gardening, and cooking.
Hannah Roberts
Hannah is currently finishing medical school in Arizona with plans for emergency medicine. She graduated from the US Naval Academy and completed active duty before starting med school. Her interests in medicine include nuclear weapons safety, medical education, and clinical applications of evolutionary biology. Outside of medicine she is a dog person and loves being outside mountain biking, running, and camping.
Doug Pet
Doug Pet is a resident in neurology at UCSF. He grew up surrounded by cow farms and crab-apple trees in New Milford, CT. He completed a dual-degree program at Tufts and the New England Conservatory studying medical anthropology, community health, and jazz saxophone. He later worked for a non-profit in Berkeley, CA on bioethical and social justice issues related to genetic and reproductive technologies. Doug attended Vanderbilt University School of Medicine, after which he returned to the Bay Area for neurology residency at UCSF. He loves Brazilian music, playing Spike ball, and making custom wooden pens on his lathe.
Dr. Katrina Armstrong and Dr. Vineet Arora join the #bosslady Wdx team to discuss navigating negotiations as women in medicine
Dr. Katrina Armstrong
Dr. Katrina Armstrong is the Jackson Professor of Clinical Medicine at Harvard Medical School, Chair of the Department of Medicine and Physician-in-Chief of Massachusetts General Hospital. She is an internationally recognized investigator in medical decision making, quality of care, and cancer prevention and outcomes, an award winning teacher, and a practicing primary care physician. She has served on multiple advisory panels for academic and federal organizations and has been elected to the American Society of Clinical Investigation and the Institute of Medicine. Prior to coming to Mass General, she was the Chief of the Division of General Internal Medicine of the Robert Wood Johnson Clinical Scholars Program at the University of Pennsylvania.
Dr. Vineet Arora
Vineet Arora, MD, MAPP is an academic hospitalist and Associate Chief Medical Officer for Clinical Learning Environment and Assistant Dean for Scholarship & Discovery at the University of Chicago. Through her role, she bridges educational and hospital leadership to engage frontline staff into the institutional quality, safety, and value mission. An accomplished researcher, she is PI of numerous NIH grants to evaluate novel interventions that combine systems change with learning theory to improve care which has resulted in publications that have been cited over 11,000 times. She is an elected member of the National Academy of Medicine and the American Society of Clinical Investigation. As an advocate for women in medicine, she was featured in the New York Times for an editorial that called to end the gender pay gap in medicine. She is a founding member of the 501c3 Women of Impact dedicated to advancing women leaders in healthcare. She is on the leadership group of the National Academy of Science Engineering and Medicine’s Action Collaborative to End Sexual Harassment in Higher Education.
“There’s nothing new under the sun, but there are new suns” – Octavia E. Butler
Summary: We invite social justice champion and acclaimed scholar of race, gender, and the law, Dorothy E. Roberts, JD, to discuss the history of race-based medicine and the movement for health equity and justice.
Episode Learning Objectives
After listening to this episode learners will be able to…
Understand race as a social construct and political invention
Explore the history of race as a proxy for genetics and ancestry
Explore the history of race-based pharmaceuticals
Explore the history of race-based clinical algorithms
Credits
Written and produced by: Naomi Fields, Rohan Khazanchi, LaShyra Nolen, Michelle Ogunwole, MD, Chioma Onuoha, Jenny Tsai, MD, Jazzmin Williams, Dereck Paul, MS, and Utibe R. Essien, MD, MPH
13:40 Responses to Common Race Based Medicine Arguments
20:40 Race as a Proxy for Racism
31:00 BiDiL and Race Based Medicine Definition
42:00 Dr. Duana Fullwiley and the “African Gene”
49:30 Debunking Folklore Health Narratives
53:30 Slavery Hypertension Hypothesis
57:00 Importance of Intentional and Plausible Research Methods
1:00:00 Race in Medical Algorithms
1:12:00 Moving Away from Relying on Simplistic Biological Concepts of Race
1:15:48 Advice for Listeners
1:21:00 Closing Remarks
Takeaways:
Definition of Race: Race is not a biological category, instead it is a permeable, flexible, and unstable social construction and political invention that facilitates political and economic inequality. However it is important to remember that this political invention DOES affect biology because of the way that it creates social inequity.
Historical Context: Historically, laws such as interracial marriage bans have protected established structures of white supremacy and reinforced the social construct of race.
Race is a Poor Proxy for Genetics: Diseases with genetic or population associations are often evolutionary adaptations to specific geo-environments. Race, a social construction, groups people from large swaths of of global territory based on superficial phenotype is often a poor proxy for these genetic associations with disease.
Race is a proxy for Racism: race was invented as a way to classify people into subordinate groups and support the political sanctioning of inequity. The very function of race is thus to support and uphold racism. When we evaluate race in medicine we have to recall this origin story and not rely on race as a placeholder for anything else except racism.
The Root of Inequities: Health inequities are overwhelmingly caused by differences in social status, living conditions, and experiences of discrimination. When we cling to race as the cause of health inequities, we obscure and divert attention away from these social factors that need to be addressed.
Intersectionality: Race and racism intersect with socioeconomic status, education, geography, sexual orientation, religion, immigration status, gender and other identities with differential impact.
Our responsibility in medicine: “What we have to do is include medicine in the political movement to bring down the structures of racism and white supremacy and the way in which medicine incorporates those and promotes those. And [this] HAS to be in conjunction with broader social movements…that are dedicated to radically transforming our world into one in which human beings are equally valued…”-Dorothy E. Roberts JD
For the patient I see tomorrow: Beyond recognizing that race is not a proxy for biology, we can all ask ourselves “What way is structural racism affecting my patient and what can I do about it?” The answer to this question may not be easily answered and may not always be found in the clinical setting.
Pearls:
“Genetics is not the end all be all of understanding disease” – Dorothy E. Roberts JD
An Emphasis on Genetics is Not the Solution to Race-Based Medicine
Being antiracist in medicine does not mean being more precise in our understanding of genetics. Rather we need a deeper and broader understanding of the influence of the structural and political determinants of health inequities. Part of the problem with focusing on race in medicine is that it limits our perspectives and encourages research practices that lack the rigor required to identify root causes of racial health inequities. We should be focusing on root causes rather than proxies. It does not mean that we should stop exploring genetic causes of disease, but rather that we should not pretend that understanding genetics is the solution to addressing disparities. Dr. Roberts put it expertly: “to be anti-racist, it doesn’t mean, well, then let’s just be more precise in our genetics. It means being anti all the things that race and racism do.”
Medicine Must Move Beyond Othering Black People
All too often in medicine, Black people are singled out from all other human beings as having different bodies from the norm, aka whiteness. Examples of this include: BiDiL, the blood pressure drug marketed solely to black people; arguments for race-based medicine that cite sickle cell, a disease that is most common in Black people because of geographic varietion rather than innate difference; and the slavery hypertension hypothesis which posits that hypertension disparities observed in Black people are a result of the stress of slavery and the middle passage rather than the longitudinal impacts of structural racism. Rather than searching for obscure explanations for inequalities, we must instead recognize the ways that racism impedes health at both individual and structural levels.
Race-based algorithms can produce inequity and there is a moral dilemma we must attend to
There is a persistent question about whether race-based clinical algorithms disadvantage patients and how we should think through use of them in clinical medicine. Professor Roberts offers some guidance: whenever you are stuck, go back to the origin story- what is race? Then you can ask yourself, how is race being used and does that use further inequity?
Professor Roberts also offers a few scenarios.
Race-based algorithms: Race is being used as a biological construct AND it can produce harm. For example, GFR- race correction for Black patients. The use of race is based on a false/biological concept of race AND many studies show that this can harm patients ( i.e. clinical resources are withheld based on results of algorithm). This is the rationale for NOT using these kinds of race-based algorithms.
Race “neutral” algorithms, which are used for allocation of resources for most fit patients. Race is not included in the algorithm, however because of the experiences of structural racism, certain groups will have worse scores. These worse scores may lead to the withholding of resources and ultimately further inequity. For example, the proposal of race neutral ventilator algorithms that were set up to allocate ventilators to the most fit patients during the COVID-19 pandemic. This race neutral algorithm could disadvantage Black patients, who because of structural racism may have lower fitness scores. This could worsen existing disparities in COVID-19 outcomes among Black patients.
Moral dilemma: Including race as a biological construct in clinical algorithms can lead to inequity. However whenever structural racism isn’t included in clinical algorithms, we also risk denying a group who has experienced structural racism access to much needed resources. We have not thought about this enough in medicine and we don’t have a gold standard of how to include race as a proxy for structural racism in our clinical algorithms. As we move forward we must continue to think critically about the ethical and just way to include race or rather structural racism in clinical algorithms and ensure that our algorithms do not further inequity.
References:
Lindo E, Nolen L, Paul D, Ogunwole M, Fields N, Onuoha C, Williams J, Essien UR, Khazanchi R. “Episode 140: Dismantling Race-Based Medicine, Part 1: Historical & Ethical Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. November 17, 2020.
Eneanya A, Tsai J, Williams J, Essien UR, Paul D, Fields NF, Nolen L, Ogunwole M, Onuoha C, Khazanchi R. “Episode 4: Dismantling Race-Based Medicine, Part 2: Clinical Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. December 17, 2020.
Roberts D. Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-first Century. The New Press: 2012.
Roberts D. “The problem with race-based medicine.” TEDMED 2015. Link to talk.
Roberts DE. What’s Wrong with Race-Based Medicine?: Genes, Drugs, and Health Disparities. Minnesota Journal of Law, Science & Technology. 2011;12(1):1-21.
Yudell M, Roberts D, DeSalle R, Tishkoff S. NIH must confront the use of race in science. Science. 2020;369(6509):1313-1314. doi:10.1126/science.abd4842
Roberts DE. Is race-based medicine good for us?: African American approaches to race, biomedicine, and equality. J Law Med Ethics. 2008;36(3):537-545. doi:10.1111/j.1748-720X.2008.302.x
Taylor AL, Ziesche S, Yancy C, Carson P, D’Agostino R Jr, Ferdinand K, Taylor M, Adams K, Sabolinski M, Worcel M, Cohn JN; African-American Heart Failure Trial Investigators. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med. 2004 Nov 11;351(20):2049-57. doi: 10.1056/NEJMoa042934.
The Slavery Hypertension Hypothesis: Dissemination and Appeal of a Modern Race Theory. (2003). Epidemiology, 14(1), 111-118. Retrieved May 9, 2021, from http://www.jstor.org/stable/3703292
Roberts, Dorothy E. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York: Pantheon Books, 1997.
Sjoding MW, Dickson RP, Iwashyna TJ, Gay SE, Valley TS. Racial Bias in Pulse Oximetry Measurement. N Engl J Med. 2020 Dec 17;383(25):2477-2478. doi: 10.1056/NEJMc2029240.
Hansen H, Netherland J. Is the Prescription Opioid Epidemic a White Problem?. Am J Public Health. 2016;106(12):2127-2129. doi:10.2105/AJPH.2016.303483
Bibbins-Domingo K, Fernandez A. BiDil for heart failure in black patients: implications of the U.S. Food and Drug Administration approval. Ann Intern Med. 2007 Jan 2;146(1):52-6. doi: 10.7326/0003-4819-146-1-200701020-00009. Erratum in: Ann Intern Med. 2007 Apr 17;146(8):616. PMID: 17200222.
Roberts DE. Abolish race correction. Lancet. 2021 Jan 2;397(10268):17-18. doi: 10.1016/S0140-6736(20)32716-1. PMID: 33388099.
The hosts and guests report no relevant financial disclosures.
Citation
Roberts, DE, Onuoha C, Khazanchi R, Nolen L, Fields N, Tsai J, Essien UR, Paul D, Ogunwole M,. “Episode 8: Dismantling Race Based Medicine Part 3: Towards Justice and Race-Conscious Medicine.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. May 10, 2021.
Episode 175: The Consult Question #2: Back pain & double vision
Apr 29, 2021
Kaitlyn Thomas is a 3rd year medical student at Lake Erie College of Osteopathic Medicine at their Seton Hill campus in Greensburg, Pennsylvania. She is interested in medical education, advocacy and assisting underserved populations. She has contributed to the CPSolvers on Virtual Morning Report on several occasions and produced a few videos for their illness scripts. In her free time, she enjoys hiking, spending time with family, and finding new recipes to cook.
Sherry Chao
Sherry Chao is a 4th year medical student at University of North Carolina at Chapel Hill. She is interested in medical education and is also an aspiring physician-scientist hoping to apply computational systems biology to understanding hematologic diseases. In her free time, she likes to travel and explore outdoors with her husband, try out new escape rooms, and play with her bearded dragon, Toothless.
Gabriela Pucci
Gabriela has graduated from Medical School at Unicamp and recently finished her neurology residency at Unesp, both in Brazil. She is interested in Medical Education and Clinical Reasoning and has obviously fallen in love with CPSolvers and VMRs since day 1. In her free time, she likes to practice pilates, play with her dogs, binge-watch Netflix comedy series, read biography books, go out with her friends (pre-COVID), drink wine, and cook (still learning).
Episode 173: Clinical unknown with Reza and Rabih at VMR: Dyspnea and finger swelling
Apr 21, 2021
Dr. Usha George, MBBS (MAHE India), MSc (Respiratory Medicine) Imperial College University of London, FRCP London, is at present attached to Sunway Medical Centre, Malaysia. It is a 650 bedded private tertiary hospital, also involved in training medical students. I practice as a Respiratory and General Medicine Physician. My special interest is in clinical and diagnostic reasoning.
Ana Clara Miranda is a 4th-year medical student from Brazil. She grew up in Belo Horizonte and moved to Rio de Janeiro in 2017 to attend medical school. Her medical interests are Pediatrics and Infectious Diseases. Today, she intends to go to the United States for an international clinical experience as a visiting student and, in 2023, apply for a Residency Program. Outside medical environment, she loves going to the beach with friends, enjoying nature and baking cakes.
Elena Vasti
Elena Vasti is a second year resident at Stanford in the department of Internal Medicine. She attended UC Davis to study Human Development and Exercise Biology and went on to UCLA Fielding School of Public Health to complete an MPH in Epidemiology and Community Health Sciences. She decided to switch careers to pursue clinical medicine and matriculated at UCSF School of Medicine in 2015. She enjoys running every day, analyzing movie trailers and both listening to and joining the CPSolvers any chance she gets! She plans to pursue a career in academic cardiology.
Episode 171: Human Dx Unknown with Sharmin – Face and leg weakness
Apr 08, 2021
Shub Agrawal is a PGY-2 at Emory’s J. Willis Hurst Internal Medicine Residency. She grew up in Athens, GA and attended New York University for undergraduate degrees in neuroscience and anthropology. She attended the AU UGA Medical Partnership for medical school where she first became passionate about medical education. She is currently doing medical education research about how to best use podcasts in UME and GME curriculum. She hopes to spend her career teaching and designing curriculum in academic medicine. Outside of medicine, she enjoys spending time with her family, friends and imagining all the trips she will take once it is safe to travel again!
Dr. Sadjadi
Raha Sadjadi is a PGY2 internal medicine resident at Emory University School of Medicine. She grew up in the San Francisco Bay Area and attended UC Berkeley for undergrad. After spending her whole life in the Bay Area, she moved to Atlanta to complete medical school at Emory University. At Emory she pursued her passion for caring for underserved populations while rotating at Grady Hospital and she found wonderful mentors invested in her growth as a physician and human. For these very reasons, she remained at Emory to complete her internal medicine residency. She is interested in transplant hepatology and in reducing healthcare disparities.
Dr. Rubiano
Carlos Rubiano is an Inpatient Medicine chief at UNC Hospitals where he also completed his internal medicine residency training. Prior to moving to North Carolina with his wife with whom he couples matched with, he completed his medical school training at Florida State University and undergraduate training in Biology at Florida Gulf Coast University. In medicine, he has a particular interest in medical education and hopes to be a clinician-educator as a soon-to-be hospitalist and one day as an ID clinician. Outside of medicine he loves playing pickleball and invites everyone to try this booming sport.
Episode 170: Human Dx Unknown with Jack – generalized itching
Apr 06, 2021
Eamonn hails from Charleston, West Virginia. He attended Marshall University for medical school and is currently in his final year of Dermatology residency at SLU. He will complete a Complex Medical Dermatology fellowship at NYU next year and hopes to practice with a focus on cutaneous lymphomas, connective tissue diseases, and immunobullous disorders. Outside of work he enjoys jiu jitsu, playing soccer, and spending quality time with his wife.
Ashley Boerrigter
Ashley Boerrigter is a third-year OBGYN resident at St. Louis University, where she will be Administrative Chief Resident for the 2021-2022 academic year. She attended medical school at the University of Kentucky and her academic interests include medically complex pregnancies and curriculum development. Hobbies include tennis, sailing, and alternating between beach sunning and mountain skiing.
In this episode of Clinical Problem Solvers: Anti-Racism in Medicine, we are joined by Michelle Morse, MD, MPH, Deputy Commissioner for the Center for Health Equity and Community Wellness (CHECW) and the inaugural Chief Medical Officer at the NYC Department of Health and Mental Hygiene (NYCDOHMH), and Paul Farmer, MD, PhD, Kolokotrones University Professor of Global Health and Social Medicine at Harvard University. Together, we discuss what global health equity looks like in the age of COVID-19.
Learning Objectives
After listening to this episode listeners will be able to…
Recognize that global health equity and global vaccine equity are everyone’s responsibility
Understand what decolonizing global health really means
Appreciate the importance of solidarity and human interconnectedness
Credits
Written and produced by: Dereck Paul, MS, Chioma Onuoha, Utibe R. Essien, MD, MPH, Rohan Khazanchi, LaShyra Nolen, Naomi Fields, Michelle Ogunwole, MD, Jazzmin Williams, and Jennifer Tsai MD, M.Ed
Guests: Michelle Morse, MD, MPH (@michellemorse) and Paul Farmer, MD, PhD
Timestamps
00:00 Introductions
04:00 What Brought You to Global Health Work?
11:50 Why is Global Health Equity Everyone’s Problem?
23:40 How has COVID-19 Changed Global Health Work and Perspectives?
40:30 The Role of Identity in Global Anti-Racism Work
49:00 Decolonize Global Health Movement
1:02:49 Hope for the Future
Takeaways
1. The Global COVID-19 Response Must Be Anti-Racist
An anti-racist COVID-19 response means that quality care, quality vaccines, and quality public health information must be provieded to all. From social distancing to contact tracing to vaccin distribution, every step should be considered through an anti-raicst framework. This includes financing vaccine acquisition for all countries and avoiding the global north vaccine hoarding that is happening today. It is important that we avoid vaccine tunnel vision and recognize the broader social context and need for social support systems worldwide.
2. The Four S’s
As Dr. Paul Farmer often says, an effective infectious disease global health response requires:
Staff – caregivers with the knowledge and passion to address health concerns
Stuff – the physical materials required for effective treatment or intervention
Space – places where people can safety receive appropriate care
Systems – policies and institutional systems that facilitate needed health responses
3. Why should everyone care about global vaccine equity?
“Unless everyone is safe, no one is” – Dr. Paul Farmer
The world is incredibly interconnected and, as COVID-19 has shown, we have to recognize the idea of collective survival. Health and well being is a global endeavor and an interdependent fight. Furthermore, we must reclaim the heart and soul of medicine: caretaking, healing, and the creative aspects of the profession that oftentimes get pushed to the side. American physicians and health professionals have immense power and a duty to use that power for the greater good to interrupt, and interrogate the colonial and imperial practices perpetrated by our own government. We must hold our government accountable. At the heart of this is a need for global solidarity.
Pearls
The Importance of this Moment
Both of our guests highlighted the HIV/AIDS movement as a catalyst for their continuing passion for global health equity. The COVID-19 pandemic provides a similar opportunity today for us to scale up our critical consciousness and re-examine the functioning of our society. People are naming racism, settler colonialism, and imperialism more than ever. In this current moment we can build on that momentum, shift perspectives and work towards long lasting equitable and anti-racist change.
Dangers of American Exceptionalism
It is imperative that we look beyond the walls of our nation and the privileges that living in the United States afford us in order to recognize the danger of American exceptionalism and how it impacts people across the world. For example, currently the United States, and other wealthy countries, are hoarding COVID-19 vaccines making it difficult for other countries to vaccinate their populations. Considering the interconnectedness of our world, by preventing equitable vaccine distribution we will only lengthen the current pandemic. As a country, we must expand our global critical consciousness and strive towards global equity by financing vaccine acquisition, investing in our education systems, interrogating American privilege and more.
Decolonizing Global Health – Allow the Global South to Lead
Part of decolonizing global health means being willing to take a backseat when it comes to defining, researching, and executing global south health priorities. This is especially true for large outside universities and institutions that habitually fail to engage domestic stakeholders in research and health decision making processes. We must trust the communities we serve to teach us and to guide initiatives.
Richardson, E. T., Malik, M. M., Darity, W. A., Mullen, A. K., Morse, M. E., Malik, M., . . . Jones, J. H. (2021). Reparations for Black American descendants of persons enslaved in the U.S. and their potential impact on SARS-CoV-2 transmission. Social Science & Medicine, 113741. doi:10.1016/j.socscimed.2021.113741
The hosts and guests report no relevant financial disclosures.
Citation
Morse M, Farmer PE, Onuoha C, Khazanchi R, Nolen L, Fields N, Ogunwole M, Tsai J, Essien UR, Paul D. “Episode 7: Anti-Racism, Global Health Equity, and the COVID-19 Response.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. April 1, 2021.
Episode 168: Clinical unknown with Reza and Rabih at VMR
Mar 24, 2021
Dr. Usha George (MBBS (MAHE India), MSc (Respiratory Medicine) Imperial College University of London, FRCP London) is at present attached to Sunway Medical Centre, Malaysia. It is a 650 bedded private tertiary hospital, also involved in training medical students. I practice as a Respiratory and General Medicine Physician .My special interest is in clinical and diagnostic reasoning.
Episode 167: Unilateral sensory changes
Mar 23, 2021
Maria Jimena Aleman was born and raised in Guatemala where she currently is a medical student in Universidad Francisco Marroquin. After suffering from long standing neurophobia, she has embraced her love for neurology and will pursue a career in this field. She also looks forward to dedicating her life to breaking barriers for Latin women in medical fields and improving medical care in her country. Maria is one of the creators of a medical education podcast in Spanish called Intratecal. Her life probably has a soundtrack of a mix between Shakira and Louis Armstrong. Outside of medicine she enjoys modern art, 21st century literature and having hour long conversations over a nice hot cup of coffee or tequila.
Mohamed Elashwal
Mohamed is a senior medical student at Alfaisal University in Riyadh Saudi Arabia. He was born in Egypt before he moved with his family to Saudi. Mohamed is interested in adult neurology; his neurophilia started in one morning report during his neuroscience rotation when he could feel his heart racing and his brain twisting thinking about the cases. He plans to apply to neurology residency next year. In his free time, Mohamed enjoys baking, and cooking; he also likes playing the piano (level: very amateur).
Kannu Bansal
Kannu is a junior resident at All India Institute of Medical Sciences, New Delhi, India working in the Kidney Transplant Wing. Despite my current affiliation with transplantation, I love to explore everything related to medicine. My passions include quizzing, teaching, and learning, and that’s how I came to know about CPSolvers. I plan to pursue Internal Medicine Residency in United States. Outside of medicine, I like to watch soccer, Formula 1, and sketch pencil portraits.
Patreon Exclusive: RLR 41- Bilateral vision loss
Mar 23, 2021
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Dr Ann Marie Kumfer is a new residency graduate and academic hospitalist at UNC. After completing medical school at Texas Tech University, she moved up to North Carolina for residency. She liked UNC so much, she decided to stay as an academic hospitalist after completing residency in June. She also serves as a section editor for the Human Diagnosis project. She is passionate about diagnostic reasoning, teaching, and guacamole.
Dr. Debra Bynum is the Director for the Internal Medicine Residency Program at the University of North Carolina. Originally from eastern North Carolina, she graduated from Davidson in 1990 with a degree in Biology and a focus on ecology and marine biology. From there, she came to Chapel Hill for medical school and stayed at UNC for residency training. After completing a year as Chief Resident, she joined the faculty at WakeMed hospital where she worked in the clinic caring for Raleigh’s underserved, attended on the inpatient service with UNC residents and students, and helped to found one of the first hospitalist programs in the area.
After three years at WakeMed, she returned to UNC for further training as a fellow in the Geriatric Medicine program and was appointed to a faculty position in 2001. During the subsequent fourteen years, she held multiple leadership positions within the School of Medicine, the Department of Medicine, and the Geriatric Medicine Fellowship and Internal Medicine Residency programs. She directed the Acting Internship for senior students as well as co-directed the clinical skills course for second year students, served on the School of Medicine education committee, and helped to design, implement, and co-direct both a transition course for new third year students as well as a teaching elective for fourth year students. She served as the Program Director for the Geriatric Medicine Fellowship from 2008-2014 and was selected to lead the Internal Medicine residency program in May of 2014.
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Episode 164: Spaced Learning Series – Abdominal pain and hypotension
Mar 04, 2021
Scott Walker grew up in Knoxville, Tennessee (Go Vols) where he completed his Bachelors in Kinesiology and Nutrition. He currently attends The University of Central Florida College of Medicine as a third year medical student. He is interested in entering the field of Emergency Medicine and is passionate about medical education and medical mission trips. He spends his spare time watching The Office with his wife or weight lifting.
Dr. Devika Gandhi
Devika Gandhi is a third-year internal medicine resident at Indiana University. She is originally from Dayton, Ohio and received her undergraduate degree from the University of Akron. She earned her medical degree from Northeast Ohio Medical University in Rootstown, Ohio (Go Walking Whales!). After residency she will be an incoming gastroenterology/hepatology fellow at Loma Linda University in California. During her free time, she enjoys reading, cooking, and going out to trivia with friends.
Episode 162: Antiracism in Medicine Series – Episode 6 – Racism, Trustworthiness, and the COVID-19 Vaccine
Feb 25, 2021
In Episode 6 of the Antiracism in Medicine series, “Racism, Trustworthiness, and the #COVID19 vaccine,” we are joined by two forces in the field of health equity and academic medicine, Dr. Giselle Corbie-Smith and Dr. Kimberly Manning, to discuss why the pandemic is the moment to ensure trust in medicine.
Learning Objectives
After listening to this episode listeners will be able to…
Recognize the importance of yielding privilege and power to better center marginalized voices and communities through individual, interpersonal, institutional, and systemic actions.
Understand the importance of looking beyond isolated and individual instances of mistrust, in recognition that the continued and ubiquitous insults of structural and systemic racism are the primary forces perpetuating mistrust among minoritized communities.
Identify potential individual, institutional, and policy-level actions to address COVID-19 vaccine inequities.
Credits
Written and produced by: Utibe R. Essien, MD, MPH, Rohan Khazanchi, LaShyra Nolen, Naomi Fields, Dereck Paul, MS, Michelle Ogunwole, MD, Chioma Onuoha, Jazzmin Williams, and Jennifer Tsai MD, M.Ed
Show Notes – Episode 6: Racism, Trustworthiness, and the COVID-19 Vaccine
Rohan Khazanchi
February 23rd, 2021
Summary
In this episode of Clinical Problem Solvers: Anti-Racism in Medicine, we are joined by Dr. Kimberly Manning, Professor of Medicine and Associate Vice Chair for Diversity, Equity, and Inclusion at Emory University, and Dr. Giselle Corbie-Smith, the Kenan Distinguished Professor of Social Medicine and Director of the Center for Health Equity Research at University of North Carolina-Chapel Hill. We dig into Dr. Manning’s leading perspectives on trust in the Black community and Dr. Corbie-Smith’s longstanding community-engaged research agenda, and we discuss implications for ongoing discourse about COVID-19 vaccine equity.
Timestamps
00:00 Music/Intro
1:25 Guest Introductions
02:34 Reflecting upon the current “moment of hope” in the COVID-19 pandemic
07:46 Why is Mistrust the “Tip of a 400-Year-Old Iceberg”?
12:04 Getting to the Individual “Why” of Declining the COVID-19 Vaccine
13:01 Is Mistrust the True Root Cause?
16:28 Moving past our preconceptions about vaccine mistrust
19:01 “When your immune system is knuckin’ and buckin’, it’s gonna be a little raucous!”
22:43 Shifting our framing from “vaccine hesitant” to vaccine deliberations
27:58 Recognizing our biases, centering the margins, and avoiding diluted generalizations
37:20 Valuing diversity rather than classifying minoritized groups as monoliths
43:34 Why Dr. Manning chose to participate in the Moderna vaccine trial
49:20 The “allostatic load” of the minority tax in a white supremacist system
55:45 Performative advocacy and the “musical chairs” of representation in medicine
58:12 The fallacy of the meritocracy
59:10 What can health systems do to reduce vaccine disparities?
1:06:20 Takeaways and conclusions
1:08:51 Outtakes Takeaways
Medical Mistrust in the Black Community is More than Tuskegee
Framing medical mistrust solely around watershed incidents like the U.S. Public Health Service Study of Untreated Syphilis at Tuskegee is harmful. It treats Black Americans as a monolith, when there is an enormous diversity and heterogeneity within the Black community. It treats mistrust as an isolated construct, when medical mistrust is intertwined with broader societal injustices. Lastly, our rhetoric often treats mistrust as an individual failing or “uninformed belief”, rather than a consequence of structural inequity.
In contrast, scholarship and clinical care which acknowledges within-group differences and shifts from a deficit-based to an asset-based view of marginalized groups can help us better serve our minoritized patients. Dr. Manning reaffirmed what Dr. Camara Jones told us last episode– that solutions lie in simultaneously emphasizing the importance of individual humanity and value in “hard to reach” (hardly reached) communities and dismantling the structures which push those communities down.
“Black Why’s Matter”
“Simply telling people what to do doesn’t work on your children, and it doesn’t work on your patients.” – Dr. Kimberly Manning
Every person who declines a COVID-19 vaccine has a reason to do so which is theirs, and theirs alone. As clinicians, we need to slow down and demonstrate our willingness to hear the “why’s” of our patients, colleagues, neighbors, and community members. In particular, racial concordance is a key piece of doing this work; authentic communication styles from people who personally understand the needs of their community and can better help motivate a “slow yes” through shared decision-making.
Addressing Racial Vaccine Inequities Requires Race and Community-Informed Solutions
This pandemic has highlighted a faultline between public health and medicine. Crossing that breach must involve organizing with faith-based and community-based organizations, community health workers, and beyond. Geographically-based interventions need to prioritize individuals from those communities, rather than allowing outsiders to take designated slots. Scapegoating mistrust can no longer be an excuse for not meeting people where they are and addressing longstanding, long-understood barriers.
Pearls
Reframe “Vaccine Hesitancy” as “Vaccine Deliberations”
“Vaccine hesitancy” is a symptom of a larger, chronic issue about the way Black and Brown people are treated in the United States. Yet, our narrow focus on the individual drives us to assign blame to those who decline a vaccine as “hesitant” or “distrusting” when there are a plurality of reasons why. Deliberating on big decisions is quite normal, especially when the lived experiences of individuals in historically marginalized groups inform their reasonable apprehension about inequities in U.S. systems writ large.
Minority Tax and the “Musical Chairs” of Representation in Medicine
“My taxation is not without representation… [musical chairs] is all fun and games until somebody has to give up their seat. If everything has been built on privilege, you have to be willing to give something up” – Dr. Kimberly Manning
Dr. Manning presented an analogy to us about a game of musical chairs, in which everyone is happy to participate and speak up for marginalized groups until the music stops and only one seat is left. Minoritized clinicians and researchers face the allostatic burden of stepping up to fix a broken system designed within a white supremacist culture. Performative activism only goes so far; when our colleagues with privilege aren’t willing to give up that power, the needle doesn’t get moved.
“I’m not interested in changing hearts and minds; I’m interested in seeing behavior change and changes in policies, practices, and norms.” – Dr. Giselle Corbie-Smith
References Mentioned
08:14
Manning KD. More than medical mistrust. The Lancet. 2020 Nov; 396(10261): 1481-1482. doi:10.1016/S0140-6736(20)32286-8.
13:01
Corbie-Smith G, Thomas SB, St George DM. Distrust, race, and research. Arch Intern Med. 2002 Nov 25;162(21):2458-63. doi: 10.1001/archinte.162.21.2458. PMID: 12437405.
32:18
Corbie-Smith G, Miller WC, Ransohoff DF. Interpretations of ‘appropriate’ minority inclusion in clinical research. Am J Med. 2004 Feb 15;116(4):249-52. doi: 10.1016/j.amjmed.2003.09.032. PMID: 14969653.
33:56
Corbie-Smith G, Thomas SB, St George DM. Distrust, race, and research. Arch Intern Med. 2002 Nov 25;162(21):2458-63. doi: 10.1001/archinte.162.21.2458. PMID: 12437405.
Corbie-Smith G, Thomas SB, Williams MV, Moody-Ayers S. Attitudes and beliefs of African Americans toward participation in medical research. J Gen Intern Med. 1999 Sep;14(9):537-46. doi: 10.1046/j.1525-1497.1999.07048.x. PMID: 10491242; PMCID: PMC1496744.
39:42
Wilkerson, I. (2020). Caste: The origins of our discontents.
Sengupta S, Corbie-Smith G, Thrasher A, Strauss RP. African American elders’ perceptions of the influenza vaccine in Durham, North Carolina. N C Med J. 2004 Jul-Aug;65(4):194-9. PMID: 15481486.
Quinn SC, Jamison A, An J, Freimuth VS, Hancock GR, Musa D. Breaking down the monolith: Understanding flu vaccine uptake among African Americans. SSM Popul Health. 2017 Nov 14;4:25-36. doi: 10.1016/j.ssmph.2017.11.003. PMID: 29349270; PMCID: PMC5769118.
Disclosures
The hosts and guests report no relevant financial disclosures.
Citation
Manning KD, Corbie-Smith G, Khazanchi R, Nolen L, Fields N, Ogunwole M, Onuoha C, Tsai J, Paul D, Essien UR. “Episode 6: Racism, Trustworthiness, and the COVID-19 Vaccine.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. February 23, 2021.
Patreon Exclusive: RLR 39 – Fever, dyspnea, and back pain
Feb 22, 2021
Rabih and Reza tackle a case of fever, dyspnea, and back pain presented by guest presenter Lawrence Yuen.
We kick off our new series, “The Consult Question”, aimed at highlighting the clinical reasoning of our subspecialty colleagues, with a case of hypoglycemia presented to master endocrinologist Dr. Elizabeth Murphy.
Dr. Elizabeth Murphy is a professor of Medicine at the University of California, San Francisco, where she serves as the Deborah Cowan Endowed Professor of Endocrinology and chief of the Endocrinology and Metabolism Division at Zuckerberg San Francisco General Hospital.
Episode 160: Neurology VMR: Hiccups + vertigo
Feb 16, 2021
Dhruv Srinivasachar is a 4th year medical student at Virginia Commonwealth University School of Medicine (the Medical College of Virginia for all the veteran attendings out there). Introduced to medicine through research, Dhruv has shifted his passions to empathetic clinical care and medical education, as a contributor to the CPSolvers (especially through VMR as a case presenter, discussant, and compiler of cases) and team member for the Not Just Little Adults podcast (CPedsSolvers, if you will). When he’s not interviewing for Med-Peds residency, he can be found biking around Richmond, VA, gardening, and cooking.
Elena Vasti
Elena Vasti is a second-year resident at Stanford in the Department of Internal Medicine. She attended UC Davis to study Human Development and Exercise Biology and went on to UCLA Fielding School of Public Health to complete an MPH in Epidemiology and Community Health Sciences. She decided to switch careers to pursue clinical medicine and matriculated at UCSF School of Medicine in 2015. She enjoys running every day, analyzing movie trailers and both listening to and joining the CPSolvers any chance she gets! She plans to pursue a career in academic cardiology.
Patreon Exclusive: RLR 38 – Dyspnea (with guest presenter Sean Carter!)
Feb 16, 2021
Sean presents a case of dyspnea to Rabih and Reza.
Maani, Priyanka, and Lindsey discuss a clinical unknown with Dr. Jori May.
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Dr. Jori May
Jori May, MD, is Assistant Professor of Medicine in the Division of Hematology/Oncology at the University of Alabama at Birmingham (UAB). Her clinical interest is non-malignant hematology, focusing on the care of patients with thrombosis and coagulation disorders. Additionally, she focuses on systems-based hematology, which works to improve hematologic care delivery across health systems. Dr. May earned her M.D. from Washington University School of Medicine in St. Louis. She completed her residency, chief residency, and fellowship in Hematology/Oncology at UAB.
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Dr. Ashita Tolwani, Professor of Medicine at the University of Alabama at Birmingham (UAB). She was the Nephrology Fellowship Training Program Director from 2004-2010 and is now the Associate Program Director. She is also the Director for ICU Nephrology at UAB. (Twitter: luck_urine)
Dr. Vipul Kumar MD PhD is a hematology-oncology fellow at UCSF. He is currently in his second year of fellowship and has a clinical interest in oncology of all forms as well as a passion for teaching. 
Dr. Anand Patel is an assistant professor of medicine at University of Chicago where he treats patients with leukemia and myeloid malignancies. He also serves as medical director of the inpatient leukemia service. His research focuses on the development of clinical trials to help improve the standard of care for patients with high risk leukemias and myeloid malignancies.
