The Clinical Problem Solvers

https://clinicalproblemsolving.com/wp-content/uploads/2023/11/WDx-11.9.23-RTP.mp3Sharmin, Kaylin, and Jane are joined by Dr. Risheen Reejhsinghani, cardiologist extraordinaire, Clinical Associate Professor at Stanford, and Associate Program Director of the cardiology fellowship. They discuss her journey through medical training as an international medical graduate, how her love for cardiology developed, and how her career has evolved to allow her to combine her passions for medical education and mentoring into her daily work.
            Dr. Risheen Reejhsinghani is a Clinical Associate Professor in the Division of CardiovascularMedicine at Stanford. She was born in Mumbai, India, where she attended medical college, after spending her early school years in Sydney, Australia. Risheen moved to Boston for residency atSt. Elizabeth’s Medical Center and completed a cardiology fellowship at Baystate Medical Center, the western campus of Tufts University. She then completed an advanced echocardiography fellowship at the University of California, San Francisco.During fellowship, under combined cardiology and rheumatology mentorship, Risheen developed a clinical focus in cardio-rheumatology. This led to the creation of the StanfordCardio-Rheumatology Program, to provide specialized care to patients with cardiac pathology as a direct consequence of autoimmune disease. Risheen cares deeply about medical education and mentorship, and is an Associate Program Director for the CardiovascularMedicine Fellowship, where working closely with fellows is the absolute best part of her role. In the School of Medicine, she serves as an Associate Course Director for the pre-clerkshipPractice of Medicine Course, and is faculty co-lead for the cardiopulmonary block. Her scholarly work addresses curricular interventions and novel methods of teaching to improve education delivery, with the ultimate goal of increasing global access to education for medical trainees.Outside of medicine, Risheen enjoys writing and used to freelance for a newspaper in India.Along with her husband, she tries to travel as frequently as possible and loves learning about local cultures and traditions in the US and internationally. An ardent enthusiast of the alternative rock scene, Risheen has been an unwavering fan of the band Nirvana since well before she could read an EKG.   

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CPSolvers: Anti-Racism in Medicine Series

Episode 23 – Anti-Blackness, Anti-Fatness, and Food Shaming

Show Notes by Humza A. Siddiqui

October 31, 2023

 

Summary: This episode highlights the culture of food shaming and anti-fatness as it relates to anti-Blackness. During this episode, we hear from Da’Shaun L. Harrison, a community organizer and trans theorist, and Dr. Psyche A. Williams-Forson, an author and chair of the Department of American Studies at the University of Maryland. Together, our guests offer context around the history of anti-Blackness and how it is deeply intertwined with the culture around eating in America as well as the way anti-fatness manifests. Further, they expand on this to discuss how it relates to policing and the court systems in the U.S. This discussion is hosted by Sudarshan Krishnamurthy and Ashley Cooper. The show notes for this episode were written by Humza A. Siddiqui.

 

Episode Learning Objectives

After listening to this episode, learners will be able to

1. Explain how anti-fatness and food shaming culture in the U.S. is rooted in anti-Blackness.
2. Describe the intersection of policing and the court systems with anti-fatness and food shaming.
3. Identify ways to navigate clinical interactions with patients while respecting them and affirming their experiences with food and fatness.

 

Credits

• Written and produced by: Sudarshan Krishnamurthy, Ashley Cooper, Team
• Hosts: Sudarshan Krishnamurthy and Ashley Cooper
• Infographic: Creative Edge Design
• Audio Edits: Ashley Cooper and Noah Nakajima
• Show Notes: Humza A. Siddiqui
• Guests: Dr. Psyche A. Williams-Forson, Da’Shaun L. Harrison

 

Time Stamps

00:00 Opening

00:45 Introductions

03:07 Guest Introduction 1

04:46 Guest Introduction 2

08:15 On the Intersection of Black, Fat, and Trans Communities and the Medical-Industrial Complex

13:35 History and the Racial Underpinnings of Food Shaming in the U.S. Landscape

21:48 Policing, the Court Systems, Anti-Blackness, and Anti-fatness 

46:45: Language Matters: The War On Obesity

1:02:09 On Caring For Black, Fat, and Trans Patients

1:15:37 Fatness is Not Killing People and Other Pearls

1:21:25 Closing Remarks

 

Speaker biographies (Abbreviated)

• Dr. Psyche Williams-Forson is a Professor and Chair of the Department of American Studies at the University of Maryland College Park. She is the author of two award winning books:  Eating While Black: Food Shaming and Race in America (James Beard Foundation) and Building Houses Out of Chicken Legs: Black Women, Food, and Power (American Folklore Society); as well as the co-edited Taking Food Public: Redefining Foodways in a Changing Food World. Her work can also be found in several other publications and on podcasts and documentaries. Dr. Williams-Forson received her BA from the University of Virginia and her MA and PhD in American Studies from the University of Maryland.
  
  
• Da’Shaun Harrison is a trans theorist and Southern-born and bred abolitionist in Atlanta, Georgia. They are the author of Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness, which won the 2022 Lambda Literary Award for Transgender Nonfiction and several other media/literary honors. As an editor, movement media and narrative strategist, and storyteller, Harrison uses their extensive history as a community organizer—which began in 2014 during their first year at Morehouse College—to frame their political thought and cultural criticism. Through the lens of what Harrison calls “Black Fat Studies,” they lecture on blackness, fatness, gender, and their intersections. Harrison currently serves as Editor-at-Large at Scalawag Magazine, is a co-host of the podcast “Unsolicited: Fatties Talk Back,” and one third of the video podcast “In The Middle.” Between the years 2019 and 2021, Harrison served as Associate Editor—and later as Managing Editor—of Wear Your Voice Magazine.

 

Episode Takeaways

• Origin Stories – For Dr. Psyche A. Williams-Forson and Da’Shaun L. Harrison, the work that they do is deeply informed by the history of chattel slavery in the United States, through which eugenicists, white anthropologists, and racial realists created entire disorders to medicalize and bastardize enslaved folks who were interested in freedom. Natal alienation is, in part, the under-structure of the wider Medical-Industrial Complex and the gratuitous violence that fat, Black, trans folks experience. All of this contributes uniquely to social death.
  
  
• Soul Food – Food cultures are more complex, multilayered, and storied than Black stereotypes will lead even Black communities to believe. For this reason, labeling food in categories, and the moralizing that follows, can be extremely dangerous. A toxic cycle of disordered eating can emerge, and treatment for recovery can be rooted in anti-Blackness as physicians view the Black habitus as out of control, unruly, not in conformance with a wider racial project as described by Michael Omi and Howard Winant. The developing attitudes about food scarcity and deficit models, and mass media’s manufacturing consent, has to be challenged, especially because there is a deep and rich history of Black people as farmers, gardeners, and ranchers that belies what Chimamanda Ngozi Adichie calls the danger of a single story.
  
  
• Afterlife of Slavery – We are living in what Saidiya Hartman calls the Afterlife of Slavery, in where skewed life chances, limited access to health and education, premature death, and surveillance, incarceration, and impoverishment are overdetermined by slavery’s racial calculus. Da’Shaun L. Harrison explains the role of fatness in all of this and offers examples across medicine, law, and sociology that demonstrate fatness and Blackness cannot be divorced from each other. Dr. Williams-Forson expands on this history with respect to Black women, whose bodies are fetishized, and Black children, whose bodies are adultified, respectively. All of this contributes to various mental health challenges that are consistent with surveillance in not only a wider police-state but also the patient-physician relationship.
  
  
• The War on Obesity – We cannot make recommendations to our Black and Brown patients about diet and exercise without acknowledging that white supremacy is statistically more likely to kill Black and Brown patients than obesity. The conditions through which the United States’ socio-politico-economic apparatus is maintained, and the cultural mores that we encourage as a society, make it difficult for Black and Brown patients to eat a healthy diet or move their bodies freely.
  
  
• Fatness is Not Killing Black People – Historically, what is killing Black people is a medical industry that is not primarily built to offer care and is otherwise disinterested in learning more about the experiences of Black bodies. Anti-obesity initiatives that aim to reduce weight and encourage healthy diet and exercise, while they may nudge choices on a population level and put pressure on corporations in their harmful advertising, may be reductive in their understanding of fatness as a function of obesity. Fat people can lead healthy lives, and we need to think about the structural issues that keep the populace from being healthy at all sizes. This demands teleological explanations and policy interventions. On one hand, we must not moralize food choices. On the other hand, we cannot let hyper-capitalism off the hook, especially those industries that target Black and Brown communities and seek to profit from the manufactured consent that lends itself to insecurities about weight loss or weight gain.

Pearls

• Respect cultural mores about diet and exercise. Acknowledge that Black and Brown patients understand their bodies at some level and what sustains them nutritionally. Be precise instead about the care we can offer beyond weight loss.

 

• Fatness is not killing Black people. However, consider that Black patients are navigating disordered eating as a function of moralizing their food choices under white supremacy and a standard of care that was created by eugenicists, white anthropologists, and racial realists that inappropriately value the heterosexual, cis-gender, white European male habitus.

 

References

 

Cox, J. (2020). Fat girls in Black bodies: creating communities of our own. North Atlantic Books.

 

Harrison, D. (2021). Belly of the Beast: the politics of anti-fatness as anti-blackness. North Atlantic Books.

 

Taylor, S. R. (2018). The body is not an apology: the power of radical self-love (First Edition). Berrett-Koehler Publishers.

 

Williams-Forson, P. A. (2022). Eating while Black: food shaming and race in America. The University of North Carolina Press.

 

Possley, M., & Armstrong, K. (1999, January 11). Part 2: The flip side of a fair trial. Chicago Tribune. https://www.chicagotribune.com/investigations/chi-020103trial2-story.html

 

Purkiss, A. (2017). “Beauty Secrets: Fight Fat”: Black Women’s Aesthetics, Exercise, and Fat Stigma, 1900–1930s. Journal of Women’s History, 29(2), 14–37. https://doi.org/10.1353/jowh.2017.0019

 

Waxman, O.B. (2022). “The White Supremacist Origins of Exercise, and 6 Other Surprising Facts About the History of U.S. Physical Fitness.” Time Magazine. https://time.com/6242949/exercise-industry-white-supremacy/ 

 

Harrison, D., Tovar, V. (2021, January 5). Fatphobia (& Foodphobia) is Anti-Blackness with Da’Shaun Harrison, Season 2, Episode 1. Rebel Eaters Club. https://podcasts.apple.com/us/podcast/fatphobia-foodphobia-is-anti-blackness-with-dashaun/id1495401238?i=1000504393373

 

Harrison, D., Young, R. (2023, September 21). Destruction w/ Da’Shaun Harrison. Episode 6. Weight for it. https://podcasts.apple.com/us/podcast/destruction-w-dashaun-harrison/id1686599391?i=1000628697389

 

Disclosures 

The hosts and guests report no relevant financial disclosures.

 

Citation

Harrison DL, Williams-Forson P, Cooper A, Krishnamurthy S, Siddiqui H, Calac A, Pitre A, Pierce G, Essien UR, Fields NF, Lopez-Carmen V, Nolen L, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Anti-Blackness, Anti-Fatness, and Food Shaming” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. November 7, 2023.

 

Show Transcript

 

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Episode description

Reza and Rabih discuss a case of a young woman with a fever of 105

 

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In this Infectious Disease Rafael Medina Subspecialty Episode, Dr. Navila Sharif presents a case to Dr. Natasha Spottiswoode of a patient presenting for fevers and chills.

 

Session facilitator: Youssef Saklawi

The goal of this series is to provide greater access to subspecialty, primary care, and internal medicine-adjacent specialty education for learners worldwide. For those interested in participating as a case presenter or discussant (or to nominate an educator or attending), the nomination form is available here. 

 

Case Discussant: Natasha Spottiswoode, MD, PHD

Natasha is a fellow in the Division of Infectious Diseases at the University of California, San Francisco. Her interests include the use of combined host-pathogen metagenomics to diagnose and treat critically ill patients, and the development of better treatments for patients with rare infectious syndromes. She also loves climbing, trail running and backcountry skiing.

 

 

Case Presenter: Navila Sharif, MD

Navila is a second year internal medicine resident at Emory University in Atlanta, GA. She is passionate about health equity and advocacy, and is interested in general hospital medicine and gastroenterology, with a keen interest in transplant hepatology. Outside of work, she enjoys exploring coffee shops, binging reality TV, and any hike with the promise of a view.

To join us live on Virtual Morning Report (VMR), sign up HERE. 

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Sharmin, Jack, and Maddy discuss their approaches to severe acute liver injury, abdominal pain, and hyperferritinemia as they talk through a case presented by Ann-Marie. 

Frameworks: 

Severe Acute Liver Injury

Abdominal Pain

To join us live on Virtual Morning Report (VMR), sign up HERE. 

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Episode 305: Neurology VMR – Shallow breathing

Episode description: We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Vaness presents a case of shallow breathing to Maria and Sridhara.

Neurology DDx Schema

 

Vanessa Roque

 

Vanessa, a proud Filipino through and through, has dedicated herself to medicine. She has been serving her countrymen since earning her medical degree. Practicing in areas of limited resources, she has sharpened her clinical eye allowing her to realize her passion for neurology where localizing lesions is as intellectually stimulating and satisfying as a daily crossword puzzle. Her interests include cognitive neurology, vascular neurology, and neurocritical care. A true “jill of all trades”, she is always down for a new adventure. She has explored dance and theater, film and photography, various musical instruments, different languages, and swimming. At home, you are most likely to find her in the kitchen preparing your new favorite meal

 

Maria Jimena Aleman

@MariaMjaleman

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.

Sridhara Yaddanapudi

@syaddana_neuro

 

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.

 

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Episode description: 

The spaced learning series team discusses a case of a patient with hyperbilirubinemia secondary to acute alcoholic hepatitis, who then developed hypoxia and hemolysis.

Featuring: Anna Fretz
Priyanka Athavale
Kirtan Patolia Schemas
HyperbilirubinemiaHypoxemiaHemolysis 

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Sharmin & Kaylin are joined by María Jimena Alemán, CPSolvers co-director of internal operations & future neurologist with a passion for global health. They discuss how her upbringing has informed & shaped her passions & values, how she got involved with CPSolvers, the growth that comes from being a leader, the power of community & good mentor-mentee relationships. 

 

 

 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 the medical field and improving neurology care around the world. She loves being a part of The Clinical Problem Solvers where she serves as the co-director of internal operations alongside Madellena Conte. Her life soundtrack is a mix between Shakira and Ms. Lauryn Hill. Outside of medicine, she enjoys contemporary art, crossword puzzles, and having hour-long conversations over a nice hot cup of coffee or tequila.

 

 

 

 Kaylin Nguyen is a non-invasive cardiologist with interests in medical education, women in medicine, and health disparities. She was born in Vietnam and grew up in Southern California. She completed medical school and Internal Medicine residency at UCSF. She then made her way down the peninsula to Palo Alto, where she completed cardiology fellowship at Stanford, serving as a chief fellow. She is super excited to be back in Los Angeles and to help care for the underserved community as a clinician-educator at Olive View-UCLA Medical Center. Outside of medicine, you can find her hiking with her dog, making (and eating) baked goods, and buying and neglecting plants*.

 

*Her plants are alive & well. We promise.

 

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Episode description

Reza and Rabih discuss a curious case of Anasarca

 

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In this Gastroenterology Rafael Medina Subspecialty episode, Dr. Allyson Richardson presents a case to Dr. Ryan Flanagan of a 68 year old woman presenting with chronic diarrhea. 

Session facilitator: Şeyma Yıldırım

The goal of this session 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 (or nominate an attending/educator), fill out the form HERE.

Case discussant: Dr. Ryan Flanagan is a gastroenterologist and faculty member at the Brigham and Women’s Hospital and Instructor in Medicine at Harvard Medical School in Boston. He has a clinical focus on the inpatient GI consult service and is the Associate Program Director for the Gastroenterology Fellowship Program.

Case presenter: Dr. Allyson Richardson is a second year Gastroenterology/Hepatology fellow at Brigham and Women’s Hospital. 

Presented images from flexible sigmoidoscopy

     

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Jack, AMK, and Maddy discuss their approaches to cytopenias and DVTs as they talk through a case presented by Sharmin.

Frameworks:

Pancytopenia

Thrombocytopenia

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Episode 299: Neurology VMR – Clumsiness

Episode description: We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, María presents a case of clumsiness to Andrea and Sridhara.

Neurology DDx Schema

Andrea Mendez Colmenares

@andreamendez92

Andrea is a Venezuelan medical doctor and cognitive neuroscientist specializing in advanced white matter imaging. She recently completed a Ph.D. in Cognitive Neuroscience from Colorado State University, USA, and is currently a postdoctoral researcher at the BRAiN Lab in Colorado. Andrea is also actively involved in initiatives supporting neurology applicants (e.g., @NMatch2024) and research career development for international medical graduates. In her free time, she is usually playing guitar or climbing a mountain!

Sridhara Yaddanapudi

@syaddana_neuro

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.

  Maria Jimena Aleman

@MariaMjaleman

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. 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.

 

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https://clinicalproblemsolving.com/wp-content/uploads/2023/08/8.10.23-SLS-RTP.mp3Episode description: The spaced learning series team discusses a case of nausea, vomiting and right upper quadrant pain in a pregnant patient. Featuring: Simone Vais
Moses Murdock
Valeria Roldan Schemas
Nausea & VomitingAbdominal Pain
Severe Acute Liver Injury 

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In this episode of WDx, Dr Casey Albin joins Kiara, Jane, & Sharmin to discuss a clinical unknown. Presented by Kiara, the case starts with the chief concern of difficulty recognizing family members.

 

Casey Albin, MD is an Assistant Professor at Emory University School of Medicine where she is a member of the department of Neurocritical Care. She completed both her neurology residency and a fellowship in Medical Simulation at Harvard Medical School/Partners Neurology before completing a fellowship in Neurocritical Care at Emory. Dr. Albin’s research interests focus on educational innovations in acute neurologic emergencies and neurocritical care. In addition to running simulation courses, she is the editor of The Acute Neurology Survival Guide and is passionate about open access neurologic education through Twitter, EMCrit, and podcasts.

 

 

 

 

 

 

 

 

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Episode description

RR discuss a grounding case of chest pain

 

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In this Infectious Disease Rafael Medina Subspecialty episode, Dr. Jorge Salazar presents a case to Dr. Monica Gandhi of a transgender woman with a recent diagnosis of HIV presenting with fatigue and weight loss. 

Session facilitator: Maddy Conte

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 (or nominate an attending/educator), fill out the form HERE.

 

Case discussant: Monica Gandhi MD, MPH is Professor of Medicine and Associate Division Chief of the Division ofHIV, Infectious Diseases, and Global Medicine at UCSF/San Francisco General Hospital. She also serves as the medical director of the HIV Clinic at SFGH (“Ward 86”).

Case presenter:  Jorge Salazar is an Infectious Disease Fellow at the University of California, San Francisco. He also serves as an AIDS Research Institute Clinical Fellow and provides integrated HIV care for patients at Ward 86.

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Maddy presents a case to Jack, Sharmin, and Ann Marie of a patient who is found to have a mediastinal mass on imaging.

Mediastinal Mass Schema

 

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CPSolvers: Anti-Racism in Medicine Series

Episode 22 – Live from SGIM 2023: Best of Antiracism Research at the Society of General Internal Medicine’s 2023 Annual Meeting

Show Notes by Alec J. Calac

June 22, 2023

 

Summary: This episode highlights a selection of antiracism research presentations at a live recording of the podcast at the 2023 SGIM Annual Meeting. This year’s episode, our third conducted at SGIM, is focused on the importance of language in medicine and the role it can play in perpetuating stigma and bias. During this episode, we hear from Dr. Som Saha, an internist whose research focuses broadly on the influence of race and racism in the doctor-patient relationship among other research subjects, Dr. Mary Catherine Beach, whose work has been targeted towards improving healthcare quality for patients who face systemic disadvantage especially  in the setting of HIV/AIDS and sickle cell disease, and Dr. Pooja Lagisetty, whose work is focused on  understanding how stigma impacts access to care for people living with chronic pain and opioid use disorder. This episode is hosted by Sudarshan (Sud) Krishnamurthy and Ashley Cooper. The show notes for this episode were written by Alec Calac.

 

Episode Learning Objectives

After listening to this episode, learners will be able to…

1. Differentiate between stigma and bias in health care and the electronic health record using provided examples.
2. Describe difficulties and examples of how to measure unconscious race bias in medical practice.
3. Identify strategies to mitigate bias and stigma in the electronic health record as a trainee and medical practitioner.

    

Credits

• Written and produced by: Sudarshan Krishnamurthy, Ashley Cooper, Team
• Hosts: Sudarshan Krishnamurthy, Ashley Cooper
• Infographic: Creative Edge Design
• Audio Edits: Madellena Conte 
• Show Notes: Alec J. Calac
• Guests: Dr. Som Saha, Dr. Mary Catherine Beach, Dr. Pooja Lagisetty

 

Time Stamps

0:00 Opening

00:23 Introductions

01:50 Guest Introduction 1

02:43 Guest Introduction 2

04:05 Guest Introduction 3

05:25 Guest Career Paths and SGIM Research

07:20 Anti-Racist Praxis and Sickle Cell Clinical Research/Scale Development

10:00 Unconscious Race Bias

16:30 Positive, Negative, Neutral Language in the Electronic Health Record

19:54 Use Language to Personalize and Humanize Notes

21:22 Considerations for Alternative Language

25:20 “Disbelief of Pain” and Scare-Quotes

26:45 Interrupt Transmission of Stigma in the Electronic Health Record

29:20 Beginning of Audience Questions and “Euphemism Treadmill”

35:00 Reorienting Language

38:00 “Value” in the Electronic Health Record

40:00 Question about “Positive Language” as a Tool

42:00 Language and Intended Audiences, Context

45:50 Question on Multi-Level and/or System-Level Interventions

48:00 Becoming Conscious about the Unconscious

49:35 “Thinking Fast and Slow”

50:30 Question on Person-First Language and Artificial Intelligence

53:50 Pearls and “Ending with Hope”

 

Speaker Biographies (Abbreviated)

• Dr. Som Saha received his medical degree and post-graduate training in internal medicine from the University of California, San Francisco, and completed post-doctoral training in the Robert Wood Johnson Clinical Scholars Program (RWJ) at the University of Washington, where he obtained a master’s degree in public health. He subsequently worked at OHSU and the Portland VA for 2 decades before moving to Johns Hopkins University. Dr. Saha’s research focuses broadly on the influence of race and racism in the doctor-patient relationship, its relation to disparities in the quality of health care, and its implications for diversity in the healthcare workforce. He has also served as a Council member and Secretary of SGIM. He has been a research advisor or mentor for over 50 students, fellows, and junior faculty, over a third of whom have been from racial/ethnic groups underrepresented in medicine.

   

• Dr. Mary Catherine Beach is a professor in the School of Medicine, with appointments in the Center for Health Equity and the Berman Institute of Bioethics, at Johns Hopkins University. Dr. Beach’s research focuses on humanizing healthcare by promoting respect for patients as well as improved patient-clinician communication. Much of her work has been targeted toward improving healthcare quality for patients who face systemic disadvantage and in the setting of HIV/AIDS and sickle cell disease (SCD). Her research has been funded by the National Institutes of Health, the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, and the Greenwall Foundation. Dr. Beach has won numerous awards for her scholarship and mentorship, including the David Levine Mentoring Award from the Johns Hopkins School of Medicine in 2015. She also is the 2017 recipient of the George L. Engel Award for outstanding research contributions to the theory, practice, and teaching of effective healthcare communication and related skills. In 2022, Dr. Beach was elected as a Hastings Center Fellow; and in 2023 was awarded the Excellence in Ethics Award from the Society of General Internal Medicine.

   

• Dr. Pooja Lagisetty received her medical degree from the Johns Hopkins School of Medicine and completed her internal medicine residency at Massachusetts General Hospital.  Following residency, she was a Robert Wood Johnson Clinical Scholar and received health services research methodology training.  She is currently an Assistant Professor of Medicine in the Division of General Internal Medicine at the University of Michigan and also a research investigator at the Center for Clinical Management and Research at the Ann Arbor VA. Clinically, she is boarded in both Internal Medicine and Addiction Medicine and practices as a primary care physician and teaching hospitalist.  Her research focuses on understanding how stigma impacts access to care for people living with chronic pain and opioid use disorder.  She is also interested in designing multidisciplinary care models for people with comorbid pain and substance use disorders in the general medical setting.  

Episode Takeaways

• • Stigma in Healthcare: Sud begins by asking our guests what led them to their current career paths and what work they are presenting at SGIM. Many of them share intersecting interests in stigma and other factors, such as chronic pain management, language (“drug-seeking” in the electronic health record), and the patient-provider relationship. Clinician-researchers are increasingly interested in developing novel scales and measures that can quantify stigma in healthcare. As noted by our guests, it is difficult to measure invisible factors such as unconscious race bias, because it is impossible to directly measure these factors. Instead, proxy factors, and other types of experimental inquiry (e.g., qualitative methods) have to be used to describe the impact that factors like bias have in health care. Importantly, there is a lot of nuance around language. It may be difficult to discern the impact that stereotypical language can have in health care because language is very contextual and means different things to different groups.

     

• Stigma (Adverse Impact) vs. Bias (Personal Characteristic): Important to make a distinction between these two concepts. Society stigmatizes certain behaviors, such as drug injection and alcohol use. When a health care provider uses such language (e.g., a person who injects drugs), they may not have any bias against the patient, but they are using language that ascribes stigma to the patient based on societal norms. Another example of phrasing, such as “delightful” and “pleasant” may convey positive bias for one group of patients over another, depending on their racial and/or social identities, but may not be examples of stigma. It is not always clear what is an example of stigma and/or bias in the electronic health record. Learn more here: Negative Patient Descriptors: Documenting Racial Bias In The Electronic Health Record | Health Affairs

   

• Use Language for Good: Think about what people will remember when they access a patient’s electronic health record. Language can be a powerful tool for good, especially in the backdrop of the opioid epidemic.

   

• Opioid Epidemic and Stigma: Providers generally have a fear or discomfort using opioid agents as treatment for individuals with substance use disorders. Coupled with stigma, bias, and language used to describe these patients in the electronic health record, this perfect storm of factors can work against efforts to help patients in need of safe, comprehensive healthcare services.

   

• Active Use of the Electronic Health Record: Be mindful of the use of “scare-quoting” and other phrasing that could be misinterpreted. Consider taking on an active role in interrupting the continued communication of language that is outdated and no longer relevant to the care of the patient. As mentioned earlier, humanizing the electronic health record can have a significant impact down the line.

   

• “Euphemism Treadmill”: This describes the process of replacing words that have taken on a stigmatizing, pejorative, or derogatory connotation with new words that are more humanizing, and how this is an iterative (unlearning-learning) process. An interesting conversation followed that included discussions about the DSM in psychiatry and psychology (personal failing vs. medical disorder) and how this language-shifting process is likely multi-generational in scale.

Pearls

• “Do no harm” through language. Be conscious about the words and phrases used in the clinical encounter and electronic health record. Preserve the dignity of the patient. Small changes can have a large impact.

   

• Include personalizing and humanistic details in the electronic health record. The work begins with educating our learners, while incorporating these lessons into our clinical practice simultaneously.

 

References

 

Beach MC, Park J, Han D, Evans C, Moore RD, Saha S. Clinician Response to Patient Emotion: Impact on Subsequent Communication and Visit Length. Ann Fam Med. 2021 Nov-Dec;19(6):515-520. doi: 10.1370/afm.2740. PMID: 34750126; PMCID: PMC8575526.

 

Park J, Saha S, Chee B, Taylor J, Beach MC. Physician Use of Stigmatizing Language in Patient Medical Records. JAMA Netw Open. 2021 Jul 1;4(7):e2117052. doi: 10.1001/jamanetworkopen.2021.17052. PMID: 34259849; PMCID: PMC8281008.

 

Beach MC, Saha S. Quoting Patients in Clinical Notes: First, Do No Harm. Ann Intern Med. 2021 Oct;174(10):1454-1455. doi: 10.7326/M21-2449. Epub 2021 Aug 17. PMID: 34399061.

 

Beach MC, Saha S, Park J, Taylor J, Drew P, Plank E, Cooper LA, Chee B. Testimonial Injustice: Linguistic Bias in the Medical Records of Black Patients and Women. J Gen Intern Med. 2021 Jun;36(6):1708-1714. doi: 10.1007/s11606-021-06682-z. Epub 2021 Mar 22. PMID: 33754318; PMCID: PMC8175470.

 

Kosakowski S, Benintendi A, Lagisetty P, Larochelle MR, Bohnert ASB, Bazzi AR. Patient Perspectives on Improving Patient-Provider Relationships and Provider Communication During Opioid Tapering. J Gen Intern Med. 2022 May;37(7):1722-1728. doi: 10.1007/s11606-021-07210-9. Epub 2022 Jan 6. PMID: 34993861; PMCID: PMC9130417.

 

Benintendi A, Kosakowski S, Lagisetty P, Larochelle M, Bohnert ASB, Bazzi AR. “I felt like I had a scarlet letter”: Recurring experiences of structural stigma surrounding opioid tapers among patients with chronic, non-cancer pain. Drug Alcohol Depend. 2021 May 1;222:108664. doi: 10.1016/j.drugalcdep.2021.108664. Epub 2021 Mar 18. PMID: 33757709; PMCID: PMC8058315.

 

Disclosures 

The hosts and guests report no relevant financial disclosures.

 

Citation

Saha, S, Beach, M, Lagisetty, P, Cooper A, Krishnamurthy S, Calac A, Pierce G, Essien UR, Fields NF, Lopez-Carmen V, Nolen L, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 22: Live from SGIM 2023: Best of Antiracism Research at the Society of General Internal Medicine’s 2023 Annual Meeting” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. June 25, 2023.

 

Show Transcript 

 

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Episode description

RR discuss a grounding case of chest pain

 

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Dr. Kimberly Manning and her father, Mr. William Draper, commemorate Juneteenth, the holiday that celebrates the day when all remaining enslaved Black Americas were freed in Galveston Texas, on June 19th, 1865, with this hour-long storytelling event. 

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We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Dr. Gabriela Pucci presents a case of right arm weakness to Promise and Ravi. 

Promise Lee @promiseflee

Promise Lee is currently a 3rd year medical student at Loyola University Chicago Stritch School of Medicine. She is an aspiring internal medicine physician with interests in GI, obesity medicine, public health, and clinical reasoning. Outside of medicine, Promise is a food and fitness enthusiast who loves enjoying the outdoors, spending time with family and friends, and experimenting with new recipes.

 

Gabriela Figueiredo Pucci @gabifpucci

Gabriela Figueiredo Pucci, MD, is a Neurology PGY 1 at University of Pittsburgh Medical Center. Originally from Brazil, she graduated from Unicamp and completed her first Neurology residency at UNESP. She is enthusiastic about breaking down complex Neurology topics into infographics on her website (www.Neudrawlogy.com). She is passionate about Clinical Reasoning and loves to be part of the CPSolvers. On her free time, she likes to travel, cook, bake, and watch competitive cooking and baking reality shows.

Ravi Singh @rav7ks

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

 

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https://clinicalproblemsolving.com/wp-content/uploads/2023/06/6.8.23-SLS-RTP.mp3Episode description: The spaced learning series team discusses a case of intermittent episodes of presyncope in a patient found to have hypoglycemia and polycythemia.   Featuring: Anna FretzKirtan PatoliaPriyanka Athavale Schemas:SyncopeHypoglycemiaPolycythemia 

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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.

 

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RR dedicate this episode to our beloved Rafa Medina. 

Rafa’s GoFundMe page.

 

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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. 

 

 

 

 

 

 

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CPSolvers: Antiracism in Medicine Series

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…

1. Explain how the current state at the border is informed by historical immigration injustices.
2. 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. 
3. 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

1. 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.
2. Saadi, A. Undark. Opinion: Covid-19 Shows Us Why We Should Keep ICE Out of Hospitals. https://undark.org/2020/03/25/covid-19-immigration-hospitals/ 
3. Saadi. A. Boston Globe. The invasion of Ukraine reminds me of growing up in Iran. The trauma is lasting. https://www.bostonglobe.com/2022/03/16/magazine/invasion-ukraine-reminds-me-growing-up-iran-trauma-is-lasting/?outputType=amp
4. 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.
5. 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
6. 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
7. 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.
8. 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

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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.

Neurology DDx Schema

 

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.

 

Sridhara Yaddanapudi

@syaddana_neuro

 

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 Singh

@rav7ks

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

 

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CPSolvers: Anti-Racism in Medicine Series

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…

1. Explain how the dark legacy of discrimination and deliberate oppression of Indigenous Peoples has led to present-day disparities across the world
2. Describe how medicine has held some white men to high esteem, even when they harbored significant racist and sexist notions
3. 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

1. 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
2. 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
3. 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
4. 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
5. 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
6. 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
7. Lafontaine AT, Lafontaine CJ. A retrospective on reconciliation by design. Healthc Manage Forum. 2019;32(1):15-19. doi:10.1177/0840470418794702
8. Lafontaine A. Indigenous health disparities: a challenge and an opportunity. Can J Surg. 2018;61(5):300-301. doi:10.1503/cjs.013917
9. 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
10. 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
11. 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
12. Calac AJ. Opinion: William Osler desecrated Indigenous remains. His name should be removed from UCSD. The San Diego Union Tribune. https://www.sandiegouniontribune.com/opinion/commentary/story/2021-08-24/sir-william-osler-uc-san-diego-indigenous-skulls-racist
13. Canadian Press. Alberta surgeon handed 4-month suspension for hanging noose on operating-room door. Haida Gwaii Observer. https://www.haidagwaiiobserver.com/news/alberta-surgeon-handed-4-month-suspension-for-hanging-noose-on-operating-room-door/

Disclosures 

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

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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 

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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.

 

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Ann Marie presents a case to Dan, Jack, and Sharmin of a young patient with tachycardia, lower extremity edema, who later develops pharyngitis. 

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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.

Neurology DDx Schema

 

Maria Jimena Aleman

 

@MariaMjaleman

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

@kiaracamacho96

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

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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.

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CPSolvers: Anti-Racism in Medicine Series 

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…

1. Explain how the criminalization and racialization of substance use builds to the present-day opioid epidemic and shapes inequities in care.
2. Describe how the media shapes public sentiment toward substance use and addiction treatment.
3. 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

1. 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.
2. American Medical Association; Manatt Health. National roadmap on state-level efforts to end the opioid epidemic: leading-edge practices and next steps. https://www.end-opioid-epidemic.org/wp-content/uploads/2019/09/AMA-Manatt-National-Roadmap-September-2019-FINAL.pdf. Published September 2019. Accessed October 17, 2022.
3. 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
4. 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
5. 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
6. 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
7. 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.
8. 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
9. 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.
10. 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.
11. 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
12. 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
13. 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.
14. 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
15. 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.
16. Kuehn, B. M. (2022). Black Individuals Are Hardest Hit by Drug Overdose Death Increases. JAMA, 328(8), 702. https://doi.org/10.1001/jama.2022.13702
17. 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
18. Naseem S. Miller. (2021, May 17). Racial disparities in opioid addiction treatment: Primer & research roundup. The Journalist’s Resource. https://journalistsresource.org/home/systemic-racism-opioid-addiction-treatment/
19. 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
20. 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
21. Race and the Criminalization of Drugs. (2021, April 22). National Press Foundation. https://nationalpress.org/topic/race-and-the-criminalization-of-drugs/
22. 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
23. 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
24. 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.

 

Show Transcript

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Sharmin, Dan, Ann Marie, and Jack discuss an interesting case of non-resolving pneumonia with some radiologic surprises!

Schemas:

CAP

Pulmonary Disease and Eosinophilia

Lung Nodules

Lung Cavities

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Reza and Rabih discuss a fascinating case of unilateral lower extremity edema. 

 

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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.

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 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. 

 

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Reza and Rabih discuss a tricky case of acute severe dyspnea

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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.

Neurology DDx Schema

 

 

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.

 

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.

 

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Maani and Emily are joined by Dr. Rachael Lee for a clinical unknown.

 

Dr. Rachael Lee

@DoctorRachael

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.

 

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Reza and Rabih discuss a fascinating case of AMS, infection and polyuria. 

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Moses presents a case of hypoglycemia to Vale and Simone. 

 Hypoglycemia Schema

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Ann Marie, Jack and Dan discuss and delve deeper into hypokalemia and hypophosphatemia schemas based on a case presented by Sharmin.

 

Schemas

• Hypokalemia
• Hypokalemia a practical approach
• Hypophosphatemia

 

 

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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.

Neurology DDx Schema

 

John Acquaviva

@DrJAStrange

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.

 

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CPSolvers: Anti-Racism in Medicine Series 

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…

1. Understand the history of mass incarceration and its effect on health

2. Recognize how cultures of punishment and control within carceral spaces and within clinical settings impact health

3. Learn how to best care for and support those experiencing violence at the hands of the carceral system

4. 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:

1. 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. 

2. 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.

3. 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

1. Black Feminist Bioethics: Centering Community to Ask Better Questions. Hastings Cent Rep. 2022 03; 52 Suppl 1:S21-S23. James JE. PMID: 35470879.

2. Race, Racism, and Bioethics: Are We Stuck? Am J Bioeth. 2022 03; 22(3):22-24. James JE. PMID: 35258424.

3. 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.

4. 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.

5. 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

6. 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.

7. Kaba, Mariame, et al. No More Police: A Case for Abolition. The New Press, 2022.

8. Roberts, Dorothy. Torn Apart: How the Child Welfare System Destroys Black Families–and How Abolition Can Build a Safer World. Basic Books, 2022.

9. 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.

Show Transcript 

https://clinicalproblemsolving.com/wp-content/uploads/2022/10/RLR-for-podcast_Syncope.mp3

Reza discussed a mind-blowing case presented by Rabih

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