The Clinical Problem Solvers

CPSolvers: Anti-Racism in Medicine Series

Episode 15: Housing is Health: Racism and Homelessness – Clinician + Community Perspectives 

Show Notes by: Victor Anthony Lopez-Carmen, MPH

April 5, 2022

Summary: This episode highlights homelessness’ impact on health, the structural and racialized nature of homelessness, and practical interventions to address housing inequities. This is the last of three episodes interrogating the relationships between race, place, housing, and health. During this episode, we gained insight from special guests Dr. Margot Kushel and Mr. Bobby Watts about what brought them into their fields, how their work reaches the most marginalized, and what can be done at the community and structural level to address homelessness. Dr. Margot Kushel is a Professor of Medicine and Division Chief at the Division of Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center and Director of the UCSF Center for Vulnerable Populations and UCSF Benioff Homelessness and Housing Initiative. Mr. Bobby Watts is the chief executive officer of the National Health Care for the Homeless Council. This episode was hosted by Sudarshan Krishnamurthy, Jazzmin Williams, and Alec Calac.

Episode Learning Objectives:

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

1. Learn about non-stigmatizing language for healthcare providers when talking about individuals experiencing homelessness
2. Understand how systemic racism, including injust housing policies and over-policing, are at the root of homelessness and its disproportionate impact on Black and Brown communities
3. Understand the systemic factors that have increasingly led to the aging population experiencing homelessness today
4. Learn how homelessness contributes to adverse health outcomes, especially in the context of the COVID-19 pandemic
5. Describe  the utility of medical respite care when working with patients experiencing homelessness

Credits

• Written and produced by: Sudarshan Krishnamurthy, Jazzmin Williams, Alec J. Calac, Victor A. Lopez-Carmen, MPH, Naomi F. Fields, LaShyra Nolen, Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins
• Hosts: Sudarshan Krishnamurthy, Jazzmin Williams, Alec J. Calac
• Infographic: Creative Edge Design
• Audio edits: David Hu
• Show notes: Victor Anthony Lopez-Carmen, MPH
• Guests: Dr. Margot Kushel and Mr. Bobby Watts

Time Stamps

00:00 Introduction

04:31 Guest career paths

11:58 Non-stigmatizing language around homelessness

19: 30 Structural racism and homelessness

33:09 Increasingly older population experiencing homelessness

42:01 Medical respite care

48:30 Criminalizing and over-policing homelessness

53:19 Key takeaways

Episode Takeaways

1. We must know the housing status of our patients, and how to ask about it.

Our guests remind us to ask our patients about their housing status using non-judgmental and non-stigmatizing language. If we do not know the housing status of our patients, then we do not know one of the most fundamental things that is going to affect their health and wellbeing. 

2. Know your community resources.

Our guests emphasize that physicians must be familiar with community resources. Do you have a medical respite center? Do you have a coordinated entry system (CES) in your community? Can you refer your patient there? 

3. If we are not part of the solution, we are complicit in structural injustice. 

Dr. Kushel and Mr. Watts remind healthcare providers to speak out about the structural causes of homelessness. Push back against individual narratives that blame individuals for systemic injustice. Push back against dehumanizing language. Push back against discussions that homelessness is caused by substance use or mental health problems. 

4. Disaggregated data on homelessness is vital. 

Missing racial and ethnic data on homelessness is an example of structural racism. We must know who we are serving to truly be able to tackle the systemic injustices that cause disproportionate rates of homelessness in America.

Pearls

Formative Career Moments:  

• Dr. Kushel explained how discharging patients experiencing homelessness only for them to come back a few days later in worse shape was unacceptable. This pattern led Dr. Kushel towards work on solving the systemic failures causing “catastrophic” health outcomes in populations experiencing homelessness. 
• Mr. Watts added a tangible example where people experiencing homelessness would be dropped off by ambulances in front of the center for homelessness where he worked, which was not equipped to deal with their medical circumstances. They would eventually end up back at where the hospitals they came from. Experiences like this made him want to contribute to solutions in the community.

Speaking about Homelessness: 

• Dr. Kushel encouraged people to go past the textbooks and learn from people on the frontlines of homelessness. This humanizes the crisis and also centers the lived experiences of persons experiencing homelessness as the experts who can teach us more than any textbook. 
• Dr. Kushel emphasized that we should use person-first language because homelessness is an experience and there is no such thing as an inherently homeless person. Some people also prefer  to use unhoused instead of homeless.
• Mr. Watts encouraged use of the term neighbor, such as “neighbors without homes, unhoused neighbors, or neighbors experiencing homelessness. Another term he uses is “people with the lived expertise of homelessness,” which centers them as experts in solution-making. 
• Dr. Kushel detailed how the use of dehumanizing language equates to complicity in a narrative that systemically harms our neighbors with lived expertise in homelessness.
• Dr. Kushel emphasized that we must speak to the structural racism at the root of disproportionate rates of homelessness in communities of color, instead of just focusing on mental health and substance use. 

Restrictive Housing Policy and Homelessness Today: 

• Mr. Watts described how property tax laws give more public funding to school districts in higher socioeconomic neighborhoods than poorer neighborhoods, leading to worse educational outcomes and thus higher rates homelessness in low-income neighborhoods. 
• Dr. Kushel and Mr. Watts remarked that housing, especially expensive house ownership, is massively subsidized in comparison to apartment renting, meaning populations who are less likely to own houses receive less financial support from state and federal housing programs.
• Dr. Kushel described how the wealth gap created by discriminatory housing policies also means that more racial minorities are renting properties, making them more vulnerable to gentrification and eviction, contributing further to the housing crisis.
• Mr. Watts explained that predatory home or apartment lending targets Black and Brown people, leading to higher rates of poverty and homelessness in those communities. He also described how other policies like redlining and racist policing practices contribute to the mass incarceration of Black and Brown people, increasing homelessness in those communities. 

Aging Compositions of the Population Experiencing homelessness across the US: 

• Dr. Kushel explained that in the early ’90s in San Francisco, 11% of those experiencing homelessness were 50 and older. By 2003, 37% were 50 and older. Now, among single adults experiencing homelessness, the median age is much closer to 50, meaning about half are under 50 and half are over 50. 44% had never once been homeless before the age of 50. So, the population experiencing homelessness is increasingly older. 
• Mr. Watts noted that the aging population experiencing homelessness came of age during mass incarceration, over policing, and thus many of them had histories with the prison system. Most were due to drug-related non-violent crimes that haunted them and limited employment opportunities throughout their lives. 
• Dr. Kushel also noted that housing became less and less affordable, adding on to the vulnerability of those in this generation who could not obtain well-paying jobs due to non-violent criminal histories. 
• Mr. Watts described how life expectancy among those experiencing homelessness is 20-30 years shorter than those with stable housing. This means they don’t benefit from social security because they are dying before they can receive it.

Health and Homelessness: 

• Dr. Kushel emphasized that people experiencing homelessness have elevated hospitalization rates and longer stays due to more comorbidities, and are more likely to be re-hospitalized.
• Mr. Watts described how care for people experiencing homelessness needs to take into account the realities of being without a house, such as having medications stolen or going bad because of lack of refrigeration (e.g. insulin), greater decompensation after discharge because of a lack of a place to rest, and other factors that lead to poorer health outcomes. 
• Our guests explained that inpatient and outpatient treatment plans need to prioritize knowing the patients’ housing status, shared decision-making, and creating plans that take homelessness into account so treatment regimens are effective. 
• Dr. Kushel commented that in order to create systemic changes that will decrease rates of homelessness and improve the health outcomes of those experiencing homelessness we need disaggregated data to fully understand which groups in society are most impacted and why.

Medical Respite Care: 

• Mr. Watts advocated for medical respite, a safe place to heal and “short circuit” the street-emergency room-street-emergency room cycle as a way to treat people experiencing homelessness who are not sick enough for inpatient service, but too sick to send back out to the streets, only for their sickness to worsen. Because of less hospitalization return rates, Dr. Kushel emphasized that medical respite programs also save taxpayer money. 
• Dr. Kushel and Mr. Watts emphasized that respite medical care needs to be integrated into the continuum of care and homeless response systems.  
• Dr. Kushel explained that medical respite care via the National Institute for Medical Respite Care was very successful during the COVID-19 pandemic and is inspiring more and more communities to integrate respite care into their practices. 

Policing: 

• Mr. Watts noted how the crack cocaine epidemic shifted the race demographics of homelessness in NYC from largely older, white drinkers to “50/50 young African American and Latinx”, with many cycling in and out of the carceral system due to over-policing and mass incarceration, which only made the crisis worse.
• Mr. Watts emphasized that to this day, you are still more likely to be arrested for drug charges if you are Black or Brown, even though rates of drug use are equal across races. This is due to over policing of Black and Brown communities, which leads to higher rates of homelessness in those populations.
• Mr. Watts and Dr. Kushel described how criminalizing homelessness is counter-productive and increases stigma, especially when the media focuses on one’s homelessness in the context of a crime. He states that people who are experiencing homelessness are actually more vulnerable to crimes happening to them, so they deserve more protection and service from the criminal justice system. Mr. Watts highlighted a program called CAHOOTS (Crisis Assistance Helping Out On The Streets) as a great, evidence-based mobile response model for addressing urgent needs among those experiencing homelessness.

References

1. Margot Kushel, M.D. UCSF Profiles. https://profiles.ucsf.edu/margot.kushel
2. G. Robert (Bobby) Watts, M.P.H., M.S., National Healthcare for the Homeless Council, Who We Are. https://nhchc.org/who-we-are/staff/ceo/
3. Hahn JA, Kushel MB, Bangsberg DR, Riley E, Moss AR. BRIEF REPORT: the aging of the homeless population: fourteen-year trends in San Francisco. J Gen Intern Med. 2006;21(7):775-778. doi:10.1111/j.1525-1497.2006.00493.x
4. Semere W, Kaplan L, Valle K, Guzman D, Ramsey C, Garcia C, Kushel M. Caregiving Needs Are Unmet for Many Older Homeless Adults: Findings from the HOPE HOME Study. J Gen Intern Med. 2022 Feb 15:1–9. doi:10.1007/s11606-022-07438-z
5. Studying Homelessness: Using Research to Impact Social Determinants of Health by Margot Kushel, MD. https://www.youtube.com/watch?v=O4LMVx1WiKs
6. Caring for Homeless People During COVID-19 Pandemic. An Interview with Bobby Watts. AMA Journal of Ethics. https://www.youtube.com/watch?v=E7Z80jADnrg&t=495s
7. Homeless community in San Diego resists police terror and demands safe housing – Liberation News
8. Lopez, M., Rothstein, R. Segregated by Design. Silkworm Studio. Published April 5, 2019. Accessed April 3, 2022. https://vimeo.com/328684375
9. Swift, C. Crisis Assistance Helping Out On the Streets. Community Access. January 18, 2019. Accessed April 3, 2022. https://www.communityaccess.org/storage/images/Miscellaneous/Community_Feedback_Forum_2019/3_Crisis_Assistance_Helping_Out_on_the_Streets_CAHOOTS_presentation.pdf
10. Kushel M. Older homeless adults: can we do more?. J Gen Intern Med. 2012;27(1):5-6. doi:10.1007/s11606-011-1925-0

Disclosures 

The hosts and guests report no relevant financial disclosures.

Citation

Watts B, Kushel M, Krishnamurthy S, Williams J, Calac AJ, Lopez-Carmen VA, Fields NF, Nolen L, Tsai J, Ogunwole SM, Onuoha C, Watkins A, Essien UR, Khazanchi R. “Episode 15: Housing is Health: Racism and Homelessness – Clinician and Community Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. April 5, 2022.

Show Transcript

Ann Marie, Jack, and Dan talk through the hemoptysis and pulmonary-renal syndromes schemas based on a case presented by Sharmin

Schemas:

Hemoptysis

Pulmonary Renal Syndrome

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Dr. Rehman presents an unsolved Dx mystery from Pakistan!

Patreon

We’ve spiced up Patreon!

Check out these two examples tier 3 videos

The Tale of the Toe – https://vimeo.com/689507245

Spontaneous versus Secondary Peritonitis – https://vimeo.com/687572741

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We are incredibly grateful to Dr. Rabia Qaiser for sharing a superb case with RR.

You might need Dr. Google for this one.

Thank you for your support. Without you, the RLR series would not exist.

RR

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Why? 

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We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Vijay presents a case of left upper extremity weakness to Vale and John.  

Neurology DDx Schema

Valeria Roldan

@ValeRoldan23

Valeria is a medical student at Universidad Peruana Cayetano Heredia. She was born and lives in Lima, Perú. She hopes to pursue a Neurology residency. Her interests include neuro-infectious diseases, transgender health, and medical education. Her work with CPSolvers involves being a part of the Virtual Morning Report team and serving on the Spanish schemas team. Outside of Medicine, she loves running, hiking, cooking pasta, and spending time with her dogs.

John Acquaviva

@DrJAStrange

John Acquaviva is a third-year medical student attending Lake Erie College of Osteopathic Medicine in Erie, Pennsylvania. He has a passion for both clinical and academic neurological concepts and plans to practice neurology after medical school. He has a special interest in autoimmune neurology and neuroimmunology, but is excited about all neurological clinical presentations. In his free time, he enjoys hanging out with friends, long-boarding, and running while listening to neurology podcasts.

Vijay Balaji

@VijayBramhan

Vijay is currently a third-year internal medicine resident at Ramaiah Medical College & Hospital, Bangalore, India, and has interests in medical education and clinical reasoning. Outside academics, his interests include playing basketball, cooking, and philosophy.

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Travis and Simone present a clinical unknown to Anand.

Schema:

Dyspnea

Splenomegaly

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Dear Patrons,

This was an EPIC recording with one of our dearest friends and colleagues, Dr. Aisha Rehman!

You can follow her on Twitter @ https://twitter.com/ai_rehman

Dr. Aisha Rehman, thank you for taking the time to present your patient’s case. 

We are still awaiting a final diagnosis. Dr. Rehman and RR would appreciate any thoughts you might have regarding her patient. Please comment below or send us a private message. There will definitely be a part 2 as more data returns.

ARR thanks you in advance.

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Dr. Croglio presents a riveting diagnostic journey to RLR.

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Happy Sunday to our dear patrons.

We hope you enjoy this one as much as we enjoyed recording it.

You will want to follow https://twitter.com/mendesthiagob after listening to the episode!

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RR discuss a fascinating cause of confusion and a tremor

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It is hard to believe we are already at 80 episodes with 719 patrons. We cannot thank each of you enough for allowing RR to chase their dream of teaching/learning diagnostic reasoning. We all are on an epic journey together.

This episode is very special because we feature a mentor, advisor, and supporter of CPSolvers’ effort from day 1 and episode 2 (hyponatremia). We feel lucky to know Uncle Bob. He is a great human being, physician, and teacher.  

Make sure to listen after our outro theme song for case updates by UB.

Enjoy!

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Cardionerds, Tommy and Dinu, present a case to Dr. Vaidya, Lindsey, and Dan.

Dr. Anjali Vaidya

Dr. Vaidya is a heart failure and transplant cardiologist at the Lewis Katz School ofMedicine at Temple University, where she serves as the co-director of the Pulmonary Hypertension, right heart failure, and CTEPH program, as well as APD for the cardiology fellowship program and residency advisor for the internal medicine residency.

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Dear Patrons!

Sometimes things are not what they seem. We hope you enjoy this episode.

Many thanks for your continued support.

Your two goofy clinical problem solvers,

RR

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In this episode, Anna & Smitha review the schemas of Inflammation and Glomerulonephritis as they work through a case presented by Emma.

Glomerulonephritis

Inflammation – Overview

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Dear friends,

This episode is longer than usual but trust us that you will enjoy the magic created by Mike. He is a storyteller and a superb teacher.

Mike – we are grateful you joined us for the hour. Hands down one of the top 3 cases RR have ever discussed.

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CPSolvers: Anti-Racism in Medicine Series

Episode 14: Race, Place, and Health: Clinician and Community Perspectives

Show Notes by Alec Calac

February 15th, 2022

Summary: This episode highlights how racism manifests in the built environment, and how community and individual-level efforts can mitigate these inequities. This discussion is the second of three planned conversations around the connections between race, place, and health. Our latest episode welcomes first-time guests Dr. Eugenia South, a physician-scientist and Vice Chair for Inclusion, Diversity, and Equity in the Department of Emergency Medicine at the Perelman School of Medicine, and Noelle Warford, Executive Director of the grassroots organization Urban Tree Connection. Hosted by team members Naomi Fields and LaShyra Nolen,our guests present their community-based work in Pennsylvania and lay bare the connections between race, place, and health.

Episode Learning Objectives:

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

1. Understand the historical and present-day role of land dispossession and property rights in determining health along lines of race and place.
2. Learn how advancing individual agency and distributive justice can empower community organizers and initiatives.
3. Understand the factors that promote and inhibit long-term resiliency and sustainability of place-based initiatives.
4. Learn how we can reimagine health by decolonizing wealth and philanthropy in modern society.
    

Credits

• Written and produced by: Naomi F. Fields, LaShyra Nolen, Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Alec Calac, Victor Lopez Carmen, MPH, Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Sudarshan Krishnamurthy, Chioma Onuoha, Dereck Paul, MD, MS, Ayana Watkins, Jazzmin Williams
• Hosts: Naomi F. Fields, LaShyra Nolen
• Infographic: Creative Edge Design
• Audio edits: David Hu
• Show notes: Alec Calac
• Guests: Dr. Eugenia South, MD, MSPH, and Noelle Warford, MSW

Time Stamps

00:00 Introduction

05:40 Built environments and structural racism

11:18 Agricultural perspective, land rights, and settler colonialism

15:00 Responsible community engagement and catalyzing individual agency

21:58 Engaging communities outside of the ivory tower

27:00 Scaling up interventions to the community level

32:29 Intervention sustainability

37:18 Decolonizing philanthropy and place-based investments

42:40 Navigating trade-offs and mitigating ethical tensions

49:20 Key takeaways

Episode Takeaways

1. Your “why” has to be clear before you engage in community-based work.

Ms. Warford reminds us that we need strong, sound ideological positions and guiding principles before engaging with the communities around us. She asks to think about what we are doing today to make it easier for people to live in the future. Our ancestors considered our present to be impossible, so how can we use our ideas and experiences to effect positive change in our communities? These movements require action, not passivity.

2. Take time to learn from your patients. Be curious.

Clinicians are incredibly privileged individuals. Dr. South reminds us that it is our great honor to talk to people in an exam room. Our patients are not just a list of problems. They are individuals who interact with environments that affect their health. She encourages us to see beyond these problems, and ask patients about their lives, challenges, and successes. Everything is important. Unfortunately, medical practice does not always allow us to slow down and take this time to listen. But, finding ways to do so can prove illuminating as well as rewarding.

Pearls

Built Environment, Physical Health, and Mental Health

• Dr. South detailed that there are clear physical health benefits associated with place-based interventions, but unfortunately many lots and buildings sit vacant and destitute across the US. There’s also more. When interviewing community members in Philadelphia, she shared that longstanding disinvestments in their communities made them feel “unimportant” and “neglected” by society, which had effects on their mental health.
• The 2021 Build Back Better Act recognized the impact that the built environment has on health, calling for environmental improvements such as planting trees.
• Ms. Warford is the Executive Director of Urban Tree Connection, a grassroots organization in West Philadelphia that uses land-based strategies and urban agriculture as tools for fostering community leadership and power.  She presented a powerful argument that connected settler colonialism, Indigenous genocide, and chattel slavery with modern-day property rights and tax codes. By preventing Black and Brown people from developing relationships with the land and using it as a way of forming social connection, as well as communal sustenance, structural racism manifests along lines of race and place. 
• Lash echoed this and also reaffirmed points made by Dr. South that the built environment changes how individuals see themselves, limiting their ability to push back on the status quo.

Individual Agency and Redistribution of Resources

• Ms. Warford centered the conversation and reminded the audience that it is not just healthcare systems that are being pushed to the brink. Non-profit organizations are experiencing the same organizational stress.  Working with Dr. South and others, Urban Tree Connection is helping community members realize their inherent agency and leadership capacity.
• In the process of redesigning the Memorial Garden in West Philadelphia, Ms. Warford and Dr. South foregrounded the reality that spaces have to be rooted in people’s experiences. There is often a sentiment that “If you build it, they will come”; however, one should not make assumptions about what community members want. It is important to get their perspectives and figure out what the “little things” are. The vision for any community-informed project has to meet community members where they are. What are their priorities? What are their needs?
• Continuing this conversation, Dr. South shared that “solutions have to be solutions, not fantasies.” Approaching community problems with an academic approach will not necessarily have community interests in mind (or prioritize them). By moving outside of this academic mindset, organizers and facilitators can work to effect meaningful, long-lasting change in the community.

Sustainability

• Dr. South has studied a variety of place-based interventions including vacant lot greening, abandoned house remediation, tree planting, and structural repairs to homes. She was recently awarded a $10 million grant from the National Institutes of Health that will allow her and her team to conduct a randomized-controlled trial that combines many interventions instead of just one. A serious concern that she and many others have is the sustainability of interventions after grant funding ends. Funding structures, especially from government agencies, are not exactly permissive of this.
• To promote sustainability, Dr. South and Ms. Warford encouraged the audience to confront the ethical tension between place-based interventions and long-term sustainability after funding streams dry up. It is important to educate and engage key stakeholders such as policymakers who can work to address these limitations.
• Ms. Warford shared that funding priorities are not necessarily community priorities. In limited funding environments, non-profit organizations often apply for any and all available funding streams, which may gradually shift the organization’s priorities, a phenomenon often referred to as mission creep.

   

Decolonizing Wealth and Philanthropy

• Our panelists detailed how much wealth is generated from the labor of Black and Brown people. Unfortunately, it is difficult for that wealth to be reinvested in those very same communities. Ms. Warford encouraged our listeners to think about how we can decolonize wealth and philanthropy, noting that place-based investments have to be gradual and intentional. She shared that funding entities must recognize the labor of community members and provide funds for their work. “People power” is a resource that must be cultivated, respected, and valued.

Recognizing Your Role

• Naomi recapped much of the discussion and shared that it was clear that “there is no quick fix.” Much of the work involves education, finances, time, and people power. Dr. South shared that there are many ways to be a part of dismantling structural racism. Some people are more front-facing, while others work behind-the-scenes. All perspectives and skillsets are welcome in this process. Ms. Warford shared that it will take time to navigate away from capitalist structures and extractive economies. It is important to celebrate the small wins and strive for the greater vision. LaShyra shared some personal reflections to this effect. The goal for this work will always be liberation and agency. When you’re just trying to make it every day, you don’t always have the privilege to do anything else.

References

1. Urban Health Lab. Urban Health Lab. Accessed January 3, 2022. https://www.urbanhealthlab.org
2. Urban Tree Connection. Accessed January 3, 2022. http://www.urbantreeconnection.org/index.php
3. Meet the Board: Noelle Warford. NESAWG. Published August 19, 2020. Accessed January 3, 2022. https://nesawg.org/news/meet-board-noelle-warford
4. Noelle Warford, Everyday Genius. Da Vinci Art Alliance. Accessed January 3, 2022. https://davinciartalliance.org/everyday-genius-blog/noelle-warford
5. Eugenia C. South, MD, MSPH. Opinion | If Black lives really matter, we must invest in Black neighborhoods. Washington Post. Accessed January 3, 2022. https://www.washingtonpost.com/opinions/2021/03/16/black-neighborhoods-parks-safety/
6. De Maio F, Rothstein R, Khazanchi R, Tsai J, Krishnamurthy S, Ogunwole M, Fields NF, Nolen L, Onuoha C, Watkins A, Williams J, Paul D, Essien UR. “Episode 200: Antiracism in Medicine Series – Episode 11 – Racism, Redlining, and the Path Towards Reconciliation.” The Clinical Problem Solvers Podcast. Published October 11, 2021. Accessed January 3, 2022. https://clinicalproblemsolving.com/2021/10/11/episode-200-antiracism-in-medicine-series-episode-11-racism-redlining-and-the-path-towards-reconciliation/
7. Eugenia C. South, MD, MSPH. Opinion | To Combat Gun Violence, Clean Up the Neighborhood – The New York Times. Accessed January 3, 2022. https://www.nytimes.com/2021/10/08/opinion/gun-violence-biden-philadelphia.html
8. “A Randomized Controlled Trial of Concentrated Investment in Black Neighborhoods to Address Structural Racism as a Fundamental Cause of Poor Health.” National Institutes of Health RePORTER. Accessed January 2, 2022. https://reporter.nih.gov/project-details/10413510#description
9. “Penn Researchers to Study the Impact of Environmental and Economic Interventions on Reducing Health Disparities in Black Philadelphia Neighborhoods with Nearly $10M Grant.” Penn Medicine. Accessed January 2, 2022. https://www.pennmedicine.org/news/news-releases/2021/october/penn-researchers-to-study-the-impact-of-environmental-and-economic-interventions
10. “How a scientist in Philadelphia is addressing health inequity.” Matter of Fact with Soledad O’Brien. Published December 17, 2021. Accessed January 2, 2022. https://www.matteroffact.tv/how-a-scientist-in-philadelphia-is-addressing-health-inequity/
11. Urban Tree Connection 2021 Annual Report. Accessed January 2, 2022. http://www.urbantreeconnection.org/admin/resources/2021-utc-annual-reportcompressed.pdf
12. Gardner JR. “A Willfully Misunderstood Earmark Can Help Reduce Climate-Change Heat Deaths.” The New Yorker. Published November 29, 2021. Accessed February 8, 2022. https://www.newyorker.com/news/daily-comment/more-tree-canopy-can-stop-climate-change-from-killing-vulnerable-americans 
13. H.R.5376 – 117th Congress (2021-2022): Build Back Better Act. (2021, November 19). https://www.congress.gov/bill/117th-congress/house-bill/5376/text
14. VolunteerHub. “Nonprofit Mission Creep: What is It? How to Prevent It.” Accessed February 8, 2022. https://www.volunteerhub.com/blog/what-is-mission-creep/ 

Disclosures 

The hosts and guests report no relevant financial disclosures.

Citation

South E, Warford N, Fields NF, Nolen L, Calac A, Lopez-Carmen V, Tsai J, Krishnamurthy S, Ogunwole M, Onuoha C, Watkins A, Williams J, Paul D, Essien UR, Khazanchi R. “Episode 14: Race, Place, and Health: Clinician and Community Perspectives.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. February 15, 2022.

Show Transcript

RR discuss an important patient phone call
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Dear Patrons,

We enjoyed this tremendously. It was an honor to discuss a case at the University of Pittsburgh Medical Center.

We hope you enjoy it. 

Ryan, we cannot thank you enough for being such an amazing friend and colleague. You put the case together expertly. You presented it flawlessly. You made it an experience we will cherish forever.

Thank you,

RR

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Lindsey presents a case of fever in a returning traveler to Sharmin, Jack, and Dan. 

Fever in a Returning Traveler Schema

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We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Maria presents a case of increased drowsiness to Dr. Mathieu Brunet and Dr. Mattia Rosso. 

Neurology DDx Schema

Maria Jimena Aleman

Maria Jimena Aleman María Jimena Alemán was born and raised in Guatemala where she currently works in community and rural health care. After suffering from long standing neurophobia, she has embraced her love for neurology and will pursue a career in this field. She looks forward to dedicating her life to breaking barriers for Latin women in medical fields and improving medical care in her country. Maria is one of the creators of a medical education podcast in Spanish called Intratecal. Her life probably has a soundtrack of a mix between Shakira and Ella Fitzgerald. Outside of medicine she enjoys modern art, 21st century literature, and having hour long conversations over a nice hot cup of coffee or tequila.

Mathieu Brunet

Mathieu Brunet is an emergency physician and trauma team leader at the Hôpital du Sacré-Coeur-de-Montréal and an assistant professor of emergency medicine at Université de Montréal in Canada. After his emergency medicine training, he completed a Fellowship in Resuscitation & Reanimation at Queen’s University in Canada and a Master of Traumatology with the University of Newcastle in Australia. Mathieu has been a regular listener of the podcast and the daily Virtual Morning Reports. He finds The Clinical Problem Solvers to be an invaluable resource to progress and maintain motivation on the lifelong journey toward clinical reasoning expertise.

Mattia Rosso 

Mattia Rosso is a neurology resident at the Medical University of South Carolina (MUSC) in Charleston. He is interested in movement disorders, behavioral neurology, and autoimmune neurology. He is also passionate about the intersection between the humanities and medicine, with a focus on the fields of medical history and bioethics. Outside work, he enjoys photography, cinema, and discovering new music. Since starting residency, Clinical Problem Solvers have been an irreplaceable source of learning and inspiration. 

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In this episode, Dr. Elliot Tapper discusses a clinical unknown case presented by Dr. Jennifer Mundell

Jennifer Mundell 

Jennifer Mundell, MD FACP is the associate program director for Ascension St Vincent Internal Medicine Residency Program. She graduated from University of Louisville School of Medicine and completed IM residency at Ascension St. Vincent in 2016. The residents best know her for building differentials, baking cakes, and owning more cars than garage spaces. During her free time, she enjoys writing up interesting cases with residents, taking her family to a beach, and planning next year’s Halloween decorations.

Elliot Tapper

Elliot Tapper, MD is an Assistant Professor in the Division of Gastroenterology at the University of Michigan in 2016. His clinical activity and research efforts focus on the outcomes of patients with cirrhosis, particularly those with hepatic encephalopathy. He did his residency and was resident, chief resident, and a fellow in gastroenterology and transplant hepatology, at Beth Israel Deaconess Medical Center where he served as Director of Quality Improvement for the Liver Center. He is very active on twitter and tweets at @ebtapper

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Emma presents a case to Dr. Yao Heng, followed by a discussion about her experience as a woman in Internal Medicine procedural subspecialty. 

Dr. Yao Heng

Dr. Yao Heng was born in Bangkok, Thailand. She immigrated to the US in her 20’s. After graduating from the University of California, Berkeley with a Bachelor of Arts in Biochemistry, she received her medical degree at the University of California, San Francisco. She completed her residency in Internal Medicine at the University of California, San Francisco and specialty fellowship in Gastroenterology at the University of Washington. She went to University of Brugmann in Brussel, Belgium for special training in biliary tract disorders. She has been practicing gastroenterology and hepatology at Kaiser Permanente since 1992. She is currently in charge of the capsule endoscopy and balloon enteroscopy programs at San Francisco Kaiser. She has a strong interest in small bowel disorders, the microbiome and gut directed hypnotherapy. 

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Our dearest friend  Samy, from the Medical University of Graz in Austria, presented RR a doozy of a case.

We always get nervous when Samy presents, and we know it is ON once we hear “the labs may be helpful.”

Happy Sunday. Thank you as always for your support. And thank you Samy for the epic case and teaching.

RR

This episode is available on Patreon only.

Why? 

More about the RLR series here. 

We are thrilled to share an episode where R does not rudely interrupt the other R! 

We hope you enjoy this one as much as we enjoyed recording it.

Thank you as always.

RR

This episode is available on Patreon only.

Why? 

More about the RLR series here. 

RLR are back on the podcast with 4 fascinating cases.

Over the winter, they’ve been releasing a lot of cool content on Patreon.

Check it out for much more RLR content.

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We wish each of you a happy new year!

Thank you for all your support.

We hope you enjoy the final RLR episode of 2021.

Rabih and Reza

This episode is available on Patreon only.

Why? 

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Doug presents an unknown case of vision loss to Dr. Cherayil, Lindsey and Dan. 

Dr. Neena Cherayil. Dr. Cherayil is an Assistant Professor of Neurology in the Departments of Neurology and Ophthalmology at Northwestern University Feinberg School of Medicine in Chicago, Illinois. She completed her neurology residency followed by a neuro-ophthalmology fellowship at the University of Pennsylvania. She is currently associate clerkship director of the neurology clerkship at Feinberg as well as co-module leader for the MS2 Neurosciences course.  She enjoys leading morning report every week with the neurology residents and students and seeing the fascinating spectrum of afferent and efferent neuro-ophthalmic complaints in clinic. Her particular academic interests include diagnostic reasoning and curricular development with a focus on neuro-anatomic localization.  Her favorite cranial nerve is, of course, CN III – the oculomotor nerve.

CPSolvers team members Rafael Medina and Simone Vais take a moment to reflect on what is going on in the world of medicine focusing on vaccine uptake with two incredible experts on the matter about what their experiences have been.

Dr. Matifadza Hlatshwayo Davis.

Dr. Davis is the Director of Health for the City of St. Louis. Dr. Hlatshwayo Davis received her medical degree from Cleveland Clinic Lerner College of Medicine and a Master’s in Public Health Degree from Case Western Reserve University. She completed her internal medicine residency at University Hospitals Case Medical Center. She went on to complete her Infectious Diseases fellowship at the Washington University School of Medicine (WUSM), also completing a one year HIV fellowship and a Sexually Transmitted Infections (STI) fellowship. She has held many, many positions throughout her illustrious career in medicine. Dr. Hlatshwayo Davis is now a national and international medical contributor on COVID-19 with a particular focus on marginalized populations, as well as the Director of Health for the city of St. Louis (among much else). Her career passions include community engagement, the care of people living with HIV and the impact of COVID-19 infection in marginalized populations. 

Dr. Teresa Villela

Dr. Villela is a graduate of Tucson High School, Yale University, and the University of Connecticut School of Medicine. She currently serves as Chief of Family and Community Medicine at San Francisco General Hospital and is Professor and Vice Chair in the UCSF Department of Family and Community Medicine.

Her interests include chronic illness care, family medicine education, reproductive health, health of Latinxs in the U.S., and health care disparities.  Her clinical practice includes inpatient adult medicine, short-term nursing home care, and ambulatory family medicine. She lives with her partner in the Mission district of San Francisco; they have a daughter who is a junior in college. All three are vaccinated against COVID and 2 of 3 have had boosters.    

This episode is available on Patreon only.

Why? 

More about the RLR series here. 

Sharmin presents a case of angioedema to Jack, Dan and Lindsey.

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CPSolvers: Anti-Racism in Medicine Series

Episode 13: Centering Asian Americans: Racism, Violence, and Health

Show Notes by Naomi F. Fields

December 21, 2021

Summary: This episode is about racism faced by Asian-Americans, why it often goes unrecognized, and how we can work to rectify these wrongs. This discussion is hosted by Jazzmin Williams, Rohan Khazanchi, MPH, and Jennifer Tsai MD, MEd, as they interview Thu Quach, PhD, an epidemiologist and galvanizing leader who has led the Asian Health Services (Oakland, CA) in addressing racial disparities in COVID-19, and Tung Nguyen, MD, a Professor of Medicine at the University of California, San Francisco, and a nationally-renowned health disparities researcher. Our inspiring guests help us to contextualize struggles faced by Asian-Americans even as they outline and energize within us a path forward – together.

Content Warning: This episode contains themes of violence, trauma-induced mental health concerns, and brief mentions of suicide. If you or someone you know is struggling with suicidal thoughts, please call the National Suicide Prevention Hotline at 800-273-8255, that’s 800-273-TALK.

Episode Learning Objectives:

After listening to this episode learners will be able to…

1. Define the myth of the “Model Minority” and explain how it impacts the racism experienced by Asian-Americans.
2. Describe how divisiveness amongst minoritized groups was and remains politically orchestrated, and how minority groups can work together in solidarity against White oppression.
3. Appreciate how intergenerational trauma may surface amongst Asian-Americans, and how these intergenerational relationships may also offer fertile ground for generating understanding. 
4. Highlight how structural racism against Asian-Americans surfaces in clinical settings, and describe means of counteracting such structures.
5. Understand how engaged community-based work, centered on trust and accountability, has supported the health of communities served by Oakland, CA’s Asian Health Service.
6. Reckon with the health disparities that exist amongst Asian-Americans, how such disparities are related (in part) to insufficient data-gathering, inequitable clinical settings, and violence, and how they were further exacerbated by the COVID-19 pandemic. 

Credits

• Written and produced by: Jazzmin Williams, Rohan Khazanchi, MPH, Jennifer Tsai MD, MEd, Alec Calac, Victor Lopez-Carmen, MPH, Utibe R. Essien, MD, MPH, Sudarshan Krishnamurthy, Naomi F. Fields, LaShyra Nolen, Chioma Onuoha, Ayana Watkins, and Michelle Ogunwole, MD
• Hosts: Jazzmin Williams, Rohan Khazanchi, MPH, and Jennifer Tsai MD, MEd 
• Infographic: Creative Edge Design
• Audio edits: David Hu
• Show notes: Naomi F. Fields
• Guests: Thu Quach, PhD, and Tung Nguyen, MD

Time Stamps

00:00 Introduction

04:00 How Dr. Thu Quach’s and Dr. Tung Nguyen’s journeys shape their work

11:40 Policy work as a way of mitigating burnout

12:55 Balancing individual and communal focus (include?)

14:12 Origin of Asian Health Services

16:35 Impact of the COVID-19 pandemic on Asian communities in Oakland 

17:40-17:50 Content Warning: Mention of suicide

22:25 Forms of Anti-Asian racism 

25:17 The danger of gaslighting Asian-Americans and of comparing oppressions

27:51 Explanation of the model minority myth and a deeper dive into comparative oppressions

30:03 Engaging with community members via validation, and operationalizing means of working against anti-Asian racism

33:58 Dr. Jennifer Tsai reflecting on her father’s experience 

37:10 Dr. Nguyen on pathways to intergenerational connection and combatting erasure

39:45 Dr. Quach on intergenerational trauma and reconciliation 

43:56 Rohan Khazanchi reflecting on Asian-American disparities in Nebraska and community strength

46:30 Data collection and disaggregation: strengths, challenges, and insufficiencies 

56:14 Structural anti-Asian racism in clinical settings

59:22 Clinical tools and takeaways

Episode Takeaways:

• Recognize that structural barriers can embed anti-Asian racism into clinical settings. 

Insufficient language services (i.e., provision in only English +/- Spanish), limitations of medical technology (i.e., difficulty of sending patient messages through the electronic medical record in languages other than English), limited healthcare literacy, and English-only signage on healthcare campuses are just a few of the structurally racist barriers faced by many Asian folks seeking healthcare. Dr. Nguyen encourages us to recognize how such barriers represent assumptions about people’s capabilities, how they can worsen people’s healthcare, and how they communicate exclusion to our Asian patients. 

• See the world through others’ eyes, and act.

Dr. Nguyen calls us to ask ourselves: “If [my] mother and father were like this person, how would they negotiate the system that I’m in? What can I do to either ameliorate those problems, or to fix those problems behind the scenes, so they don’t have to deal with them on a day to day basis?” This can help us reach the goal of taking care of patients in the ways that they want to be taken care of, by operationalizing the vision Dr. Quach shared for “letting lived experiences guide us.” 

• Create spaces to have conversations about the broader contexts affecting patients. 

Dr. Quach reminds us that environmental factors and the political landscape affect patients’ wellbeing everyday. Creating spaces where these experiences can be shared by patients as well as by practitioners can highlight the structural nature of seemingly individualized problems. By appreciating the impact of factors affecting entire communities, we can be better positioned to act upon them. 

• Remember that more deeply understanding your patients can provide meaning!

Seeking to more deeply understand your patients is not an additional burden: ultimately, it is an additional benefit. Dr. Nguyen describes that in his experience, striving for understanding deepens the patient-provider relationship over time and offers fulfillment to him as well as to his patients. 

Pearls

• Case study: Oakland, CA’s Asian Health Services’ origin, ethos, and lessons
  • Dr. Quach describes the community- and advocacy-based origins of Asian Health Services, a Federally Qualified Health Center in Oakland, CA. She also describes their role in detecting and relaying the double-bind of challenges (COVID-19 and racism) being faced by community members throughout the pandemic, and how her team generated solutions that signaled their ongoing responsibility to the communities they served.
• Asian-Americans face both apparent and enshrouded forms of racism, both of which have directly related health effects.
  • Dr. Nguyen goes on to expand on these forms. One form includes the eye-catching racist acts that explicitly manifest anti-Asian sentiments, such as violence toward elders, verbal abuse, and gun violence. In addition to the physical wrongs done to the victims, these acts function as community stressors that harm the mental, emotional, and physical wellbeing of so many others. 
  • Another more insidious form of racism is erasure. This often manifests in a glaring lack of recognition of many of the problems faced by many Asian Americans. In the healthcare space, it can also result in a lack of data collection to demonstrate and understand issues faced by these groups. As a result, there are often failures to address their unique needs. 
• The “Model Minority” myth engenders both the racist erasure of Asian-Americans and division amongst minority groups. 
  • Created in the 1960s by conservatives seeking to divide minority groups during the Civil Rights Movement, the model minority myth projects the relative success of some Asian-Americans onto all Asian-Americans; and subsequently casts  them as an “ideal” group unaffected by the problems and negative stereotypes that plague other minority groups. In so doing, the model minority myth obscures how White supremacy actually affects Asian-Americans, and perpetuates a zero-sum game which pits minority groups against each other rather than alongside each other in solidarity. 
• Data on the problems faced by Asian Americans is lacking. This perpetuates further erasure of Asian-American health disparities, and there are multiple needed interventions to redress this injustice disparity. 
  • Erasure often conceals the need for the collection of information that would spotlight challenges/inequities faced by Asian-Americans. For instance, Dr. Nguyen describes how the National Academy of Medicine and the Centers for Disease Control, amongst other major health organizations, issued valid and needed statements about the impact of COVID-19 on other minority groups, but did not mention the problems faced by Asian- Americans – nor the fact that the data was insufficient. The resulting message implied to the public was that no problems existed. 
  • Additionally, data collection practices often do not capture all experiences due to usage of inaccessible language, or neglecting to spotlight voices from the most marginalized community members. 
  • Data disaggregation, which seeks to spotlight specific ethnic groups within the Asian diaspora, can be a helpful step in better understanding the experiences unique to Asian-American communities we serve. It requires recognizing the diversity of experiences and gaining buy-in from community members. 
• “You don’t fight fire with fire, you fight fire with water.” – Fred Hampton
  • Dr. Nguyen mentioned this quote, and expounded upon it to say, “You don’t fight racism, with more racism you fight racism with solidarity and partnership and coalition building.” Although the Model Minority myth has generated divisiveness amongst minority groups, true power can come from folks turning away from gaslighting and the wrly named “Oppression Olympics” to recognize that we all need to work together against the real enemy: Oppression writ large by White supremacy. 
• Within Asian-American communities, intergenerational relationships can be a critical strength. 
  • Multiple members of this episode describe challenging experiences with bridging understanding of their elder family members that may mirror dynamics within Asian-American communities more broadly. 
  • On the one hand, these relationships convey the intergenerational traumas (of migration, of racism, and the like) that impact elders’ experiences, yet may differ from those of younger individuals. 
  • Simultaneously, these relationships present opportunities to connect interpersonally as “genuine human beings,” and to find solution-generating commonalities. 
  • Relatedly, our guests both describe experiences acting as “cultural brokers” to assist with healthcare needs of their elders that impacted their own journeys into medicine. These insights primed them to understand what challenges community members might be facing now. 

References

1. Asian Health Services. https://asianhealthservices.org 
2. Catch Me Up to Speed Podcast. “Episode #9: Asian-American history.” https://www.audible.com/pd/Episode-9-Asian-American-history-Podcast/B094JN9KMY?ref=a_pd_Catch-_c0_lAsin_0_1&pf_rd_p=1da7ab30-c785-4a0e-a160-4a7e7077b353&pf_rd_r=3QRHMQRNRTAS8S8BFX2Q 
3. Public Broadcasting Service. “Asian Americans: The history of identity, contributions, and challenges experienced by Asian Americans.” https://www.pbs.org/show/asian-americans/ 
4. Asian American Voices. “My language, my right.” https://www.asianamvoices.org/     
5. Chu JN, Stewart SL, Gildengorin G, et al. Effect of a media intervention on hepatitis B screening among Vietnamese Americans. Ethn Health. 2019;1-14. doi:10.1080/13557858.2019.1672862
6. Quach T, Von Behren J, Tsoh J, et al. Improving the knowledge and behavior of workplace chemical exposures in Vietnamese-American nail salon workers: a randomized controlled trial. Int Arch Occup Environ Health. 2018;91(8):1041-1050. doi:10.1007/s00420-018-1343-2
7. Yan BW, Hwang AL, Ng F, Chu JN, Tsoh JY, Nguyen TT. Death Toll of COVID-19 on Asian Americans: Disparities Revealed. J Gen Intern Med. 2021 Nov;36(11):3545-3549. doi: 10.1007/s11606-021-07003-0.
8. Jones CP, Maybank A, Nolen L, Fields N, Ogunwole M, Onuoha C, Williams J, Tsai J, Paul D,  Essien UR, Khazanchi, R. “Antiracism in Medicine – Episode 5: Racism, Power, and Policy: Building the Antiracist Health Systems of the Future.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/antiracism-in-medicine/. January 19, 2021.
9. Los Angeles Times (2021). “Hate crimes against Asians jumped 107% in California in ‘an epidemic of hate’.” https://www.latimes.com/california/story/2021-06-30/california-attorney-general-hate-crimes 
10. California Department of Justice (2021). Anti-Asian hate crime events during the COVID-19 pandemic. https://oag.ca.gov/system/files/media/anti-asian-hc-report.pdf 
11.  The Practice (2019). “The Model Minority Myth.” Harvard Law School.  https://thepractice.law.harvard.edu/article/the-model-minority-myth/
12. Kawai, Yuko. (2005). Stereotyping Asian Americans: The Dialectic of the Model Minority and the Yellow Peril, Howard Journal of Communications, 16:2, 109-130, DOI: 10.1080/10646170590948974
13. Smith, Andrea. “Chapter Six: Heteropatriarchy and the Three Pillars of White Supremacy: Rethinking Women of Color Organizing”. Color of Violence: The INCITE! Anthology, edited by INCITE! Women of Color Against Violence, New York, USA: Duke University Press, 2016, pp. 66-73. https://doi.org/10.1515/9780822373445-008
14. Hampton, F. (1969). “Power anywhere where there’s people.” https://www.historyisaweapon.com/defcon1/fhamptonspeech.html 

Disclosures 

The hosts and guests report no relevant financial disclosures.

Citation

Quach T, Nguyen T, Williams J, Tsai J, Fields NF, Calac A, Lopez-Carmen V, Krishnamurthy S, Nolen L, Onuoha C, Watkins A, Williams J, Essien UR, Ogunwole M, Khazanchi R. “Antiracism in Medicine – Episode 13: Centering Asian Americans: Racism, Violence, and Health.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/antiracism-in-medicine/. December 21, 2021.

Show Transcript

This episode is available on Patreon only.

Why? 

More about the RLR series here. 

Rabih discusses the case with one key question: Do we use an AND or an Or or, Both?

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Wow. What a session. Thank you so much for your support. And thank you to our live audience.

It was wonderful seeing each of you.

RR

This episode is available on Patreon only.

Why? 

More about the RLR series here. 

We continue our campaign to #EndNeurophobia, with the help of Dr. Aaron Berkowitz. This time, Maria presents a case of episodic transient loss of consciousness to Gabriel and Ravi.

Schema 1

Schema 2

Neurology DDx Schema

Maria Jimena Aleman

Maria Jimena Aleman was born and raised in Guatemala where she currently is a medical student in Universidad Francisco Marroquin. After suffering from long standing neurophobia, she has embraced her love for neurology and will pursue a career in this field. She also looks forward to dedicating her life to breaking barriers for Latin women in medical fields and improving medical care in her country. Maria is one of the creators of a medical education podcast in Spanish called Intratecal. Her life probably has a soundtrack of a mix between Shakira and Louis Armstrong. Outside of medicine she enjoys modern art, 21st century literature and having hour long conversations over a nice hot cup of coffee or tequila.

Gabriel Talledo

Gabriel is a MS2 student from Cayetano Heredia University. When it comes to medicine, he enjoys dermatology, infectiology, and LGBTQ+ health. He fell in love with his career when he understood medicine not just as a concept of knowledge but a combination of knowledge and social justice pursuit. He loves cooking Peruvian cuisine (one of the best in the world), eating, jogging and watching TV series. Recently he is doing a transgender education program at his university and a volunteering of sexual education in Lima schools.

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We truly hope you enjoy this one. It is a superb case. 

Thank you as always for your support. 

Fasten your seatbelts … and … let’s go!

Thanks,

RR

This episode is available on Patreon only.

Why? 

More about the RLR series here. 

Dr. Kushal, Dr. Saman, and Dr. Brandon discuss a case of worsening dyspnea and fever.

Schema

Dr. Kushal Vaishnani

Dr. Kushal Vaishnani is a Hospitalist at Atrium Health. He finished his medical school at B.J. Medical College, Ahmedabad, India. He completed his transitional year at Brandon Regional Hospital and Internal Medicine residency at LSUHSC – University Hospital and Clinics in Lafayette. His academic interests include clinical reasoning, medical education, high value care, and infectious diseases.

Dr. Saman  Nematollahi

Saman is from Tucson, AZ. He graduated from the University of Arizona College of Medicine, finished internal medicine residency at Columbia, and his infectious diseases fellowship at Johns Hopkins. He is now working as a transplant ID physician at the University of Arizona. He is also completing his Master’s of Education in the Health Professions. He enjoys cooking with Reza and washing the dishes. In his spare time, he loves to watch PJ Masks with his wife and son, who was featured in Episode 42 as AstroBoy.

Dr. Brandon Pearce

Brandon Pearce is a third-year Internal Medicine resident at Ascension St. Vincent in Indianapolis.  His medical interests include pulmonary critical care and clinical education.  In his spare time, he enjoys basketball, hiking with his fat Labradors, and traveling.

CPSolvers: Anti-Racism in Medicine Series

Episode 12: Our Land is Our Health: Addressing Anti-Indigenous Racism in Medicine

Show Notes by LaShyra Nolen

November 23rd, 2021

Summary: This episode is about the ways we can combat anti-Indigenous sentiments and actions in our efforts to promote anti-racism in medicine and public health. This discussion is hosted by our new team members Alec Calac and Victor Lopez-Carmen, as they interview Dr. Tom Sequist, member of the Taos Pueblo Tribe and Chief Patient Experience and Equity Officer at Mass General Brigham, and Dr. Sophie Neuner, proud member of the Karuk Tribe, and a Research Associate at the Johns Hopkins Center for American Indian Health. Together, these two phenomenal guests help us understand the structural and individual challenges of Indigenous peoples in academic medicine, public health, and beyond.

Episode Learning Objectives:

After listening to this episode learners will be able to…

1. Understand the historical and present-day role of settler colonialism behind health disparities in Indigenous populations.
2. Learn ways to address the lack of representation of Indigenous peoples in academia and how to create safe learning environments for Indigenous peoples in these academic spaces.
3. Understand the importance of disaggregated health data and how the burden of proof for “blood quantum” requirements can be detrimental to Indigenous peoples.
4. Learn the ways COVID-19 and climate change have exacerbated health inequities within Indigenous populations.
5. Learn tangible ways to center the Indigenous communities in advocacy efforts at the interpersonal and institutional level.

Credits

• Written and produced by: Rohan Khazanchi, MPH, Michelle Ogunwole, MD, Alec Calac, Victor Lopez Carmen, MPH, Utibe R. Essien, MD, MPH, Jennifer Tsai MD, MEd, Sudarshan Krishnamurthy, Naomi F. Fields, LaShyra Nolen, Chioma Onuoha, Dereck Paul, MD, MS, Ayana Watkins, Jazzmin Williams
• Hosts: Alec Calac and Victor Lopez Carmen, MPH
• Infographic: Creative Edge Design
• Audio edits: David Hu
• Show notes: LaShyra Nolen
• Guests: Dr. Tom Sequist, MD, MPH and Dr. Sophie Neuner, MD, MPH

Time Stamps

00:00           Introduction

05:25           What do I call you?

10:37           “Blood quantum” and the burden of proof

18:05           Challenges of Indigenous Peoples in medical spaces

24:50           COVID-19 and climate change’s impact on Indigenous Peoples

30:27           Racism in academia and creating safe spaces

41:22           “Data genocide”  

50:11           What can listeners do going forward?

62:10           Key takeaways

Episode Takeaways:

1. Take the time to learn about how Indigenous Peoples influence the world around you.

From the street names of the cities in which we live to the nature that surrounds us, Dr. Sequist reminds us of the importance of taking the time to learn about how Indigenous Peoples have influenced and continue to influence every aspect of our lives. He encourages us to learn about the original inhabitants of lands on which we reside and to do the work to learn about the ongoing contributions from tribes around us. This is especially important when we consider the lasting role colonialism, genocide, and racism has played in attempted erasure of these communities and their culture.

1. Learn about the good and the ugly when it comes to the history of Indigenous Peoples.

Victor reminds us that we can hold two truths at the same time. Dr. Sequist also encourages us to, in addition to learning about the rich cultural traditions and invaluable contributions of Indigenous Peoples, to also acknowledge the historical and ongoing oppression these communities face. Indigenous Peoples continue to suffer disproportionately from health inequities, mental illness, poverty, climate change and police brutality, all of which have been exacerbated by the COVID-19 pandemic. We must recognize these struggles were born out of settler colonialism and learn this history while actively working to undo present harms.

1. Do not exclude Indigenous peoples in your research narratives. If you’re going to, acknowledge your limitations. 

Dr. Neuner reminds us of the importance of centering Indigenous Peoples in our research and data because this information helps drive policy and health initiatives that can address barriers to health in the community.

Pearls

 Common Terms Used to Refer to Indigenous Peoples

• Our guests and hosts remind us of the importance of not making assumptions about someone’s identity. It is often preferable to use tribal affiliation when referring to Indigenous Peoples rather than terms like Indigenous or Native American. By not doing so, we obscure critical knowledge about relationality, Indigenous clans, and communal origins.
• The term “American Indian or Alaska Native” is a legal racial and ethnic identifier which is why we might see it used in legal documents and research manuscripts. Many manuscripts have moved towards using Black, Indigenous, People of Color (BIPOC), but this term may be doing more harm than good for Indigenous Peoples. Read III.A.I-2 of Why BIPOC Fails (Deo, M., 2021) to understand why.
• The term “Native American” is frequently used but does not cover Indigenous Peoples from across the world

The Burden of Proof

• Dr. Sequist discusses “blood quantum”, which is an attempt by the federal government to reduce one’s identity as an Indigenous person to a percentage of blood affiliated with specific Tribes in the US. This flawed measure can be harmful for many reasons. It notably creates a burden of proof for Indigenous trainees to prove their identity, which can provide additional stress during application and interview cycles.

COVID-19 and Indigenous Peoples

• Alec reminds us that Indigenous Peoples represent 6% of the global population across more than 70 countries, but around 15% of the global population experiencing poverty.
• Many of the health inequities we have seen for Indian Country during COVID-19 are directly linked to settler colonialism. This is further exacerbated by poverty, lack of cell phone coverage, food insecurity, broadband internet, and a shortage of trusted messengers with appropriate training in Tribal communities.
• Dr. Neuner reminds us that many Native communities live in multigenerational housing (over 65% of communities have elders living with them) which made it challenging to socially distance during the pandemic.

Data Genocide

Dr. Neuner reminds us about the importance of data for advocacy for Indigenous communities, especially during COVID-19. More background here from the Urban Indian Health Institute.

“Without data you can’t change anything.” 

Some of the challenges with data collection discussed were:

• Limited availability disaggregated data and how being listed as “other” on surveys leads to compounded distrust in medical systems  
• Limited accessibility to that data for Tribal communities being surveyed
• Logistical challenges of collecting necessary data, including the training and funding of community members

Ways to Help Uplift Indigenous Peoples in Academia  

Our guests share some ways we can help support and uplift Indigenous peoples:

• Community-based participatory research that benefits Tribal communities in meaningful ways
• Working towards making education free for Native students
• Promoting Tribal sovereignty 
• Advocating for climate justice
• Aligning institutional missions to support Indigenous peoples locally, nationally, and globally  

Creating Supportive Spaces

Our guests remind us of the importance of thinking beyond addressing the “pipeline” to increase representation of Indigenous Peoples in medicine, but also emphasize the importance of creating safe spaces for these students to thrive.

• This includes being mindful of language and the etiology of the words we use in academic and medical spaces (e.g., “low on the totem pole”, “let’s have a powwow”)
• This also includes understanding the unique challenges Indigenous students face when away from their communities in predominantly white institutions, which can often affect their mental health and wellbeing.  

References

1. Dr. Neuner’s podcast, Indiginae: https://caih.jhu.edu/programs/indigenae-podcast
2. United Nations Declaration on the Rights of Indigenous Peoples https://www.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html
3. Native Land is an app to help map Indigenous territories, treaties, and languages. https://native-land.ca/
4. NPR Code Switch Podcast Episode: “So What ‘Exactly’ is Blood Quantum?” https://www.npr.org/sections/codeswitch/2018/02/09/583987261/so-what-exactly-is-blood-quantum
5. Indigenous Peoples and global poverty rates https://www.worldbank.org/en/topic/indigenouspeoples#1
6. Teem Vogue: “Native Communities Face Higher Risks During Coronavirus Pandemic Thanks to Legacy of Colonization” https://www.teenvogue.com/story/coronavirus-native-reservations
7. Perspective by Dr. Tom Sequist “Paving the Way — Providing Opportunities for Native American Students” N Engl J Med 2005; 353:1884-1886. doi:10.1056/NEJMp058218
8. The Impact of Internet Access in Indigenous Communities in Canada and the United States: An Overview of Findings and Guidelines for Research https://www.internetsociety.org/wp-content/uploads/2020/07/Impact-Indigenous_Communities-EN.pdf
9. Boston Globe article: “Where are all the Native American medical students?” by Victor Lopez-Carmen https://www.bostonglobe.com/2021/01/24/opinion/where-are-all-native-american-medical-students/

Disclosures 

The hosts and guests report no relevant financial disclosures.

Citation

Sequist T, Neuner S, Calac A, Lopez-Carmen V, Tsai J, Krishnamurthy S, Ogunwole M, Fields NF, Nolen L, Onuoha C, Watkins A, Williams J, Paul D, Essien UR, Khazanchi R. “Episode 12: Our Land is Our Health: Addressing Anti-Indigenous Racism in Medicine.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. November 23, 2021.

Reza discusses the case of a young man who suddenly became to feel unsteady.

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Dr. Michael Thomashow presents an unknown case to Dr. Anisha Dua, Dan Minter, Doug Pet and Lindsey Shipley. 

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Anisha B. Dua MD, MPH 

Anisha B. Dua MD, MPH is an Associate Professor of Medicine in the Division of Rheumatology, Rheumatology Fellowship Program Director and Director of the Northwestern Vasculitis Center at Northwestern University Feinberg School of Medicine. Dr. Dua interests are in rheumatology, education, and vasculitis. She completed her Rheumatology fellowship at Rush University as well as fellowships in medical education at The University of Chicago and Integrative Medicine at Northwestern. She is a former member of the Committee on Training and Workforce for the American College of Rheumatology, worked with the ACGME to develop the new subspecialty milestones for Rheumatology, and is currently the Chair of the ACR In-Training-Exam committee. Dr. Dua currently leads a multidisciplinary team in the clinical management of vasculitis patients. She recently assisted in the development of the American College of Rheumatology (ACR) Guideline for the Treatment and Management of Vasculitis, is on the Board of Directors for the Vasculitis Foundation and a member of the Scientific Advisory Council for the Rheumatology Research Foundation. She has served in leadership capacities both locally and nationally through the American College of Rheumatology, the Vasculitis Foundation, and the ACGME in the areas of education as well as vasculitis. You can follow her on twitter @anisha_dua

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In the diagnostic journey, nothing is more important than the frame. The wrong frame leads to the wrong diagnosis. However, sometimes you need multiple frames with the flexibility to pivot from one frame to another like Lionel Messi and his left foot. Rabih shows us the power of the frame in this episode.

Happy Sunday!

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RR

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Sharmin and Dr. Kaylin Nguyen delve deeper into the imposter phenomenon. They discuss the origin of the term, the problems with the mainstream definition, and how it should be reframed. 

Imposter Syndrome Treat the Cause, Not the Symptom

Contextualizing the Impostor “Syndrome”

Stop Telling Women They Have Imposter Syndrome

End Imposter Syndrome in Your Workplace

Dr. Kaylin Nguyen

Dr. Kaylin Nguyen was born in Vietnam and grew up in Southern California. After graduating from UCLA, she completed both medical school and Internal Medicine residency at UCSF. She is currently a second year Cardiology fellow at Stanford and has interests in cardiovascular imaging, health disparities, and digital health. She enjoys hiking, drinking copious amounts of herbal tea, and well-timed puns.

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Medicine is quite humbling. We are fallible. 

We would love for each of you to try and solve this case as it unfolds and then share your thoughts with us.

Thank you for your continued support.

RR

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Dr. Ravi Singh interviews CPSolvers team members Rafael Medina, Sukriti Banthiya, and Rabih Geha who illustrate the Do’s (Rafael and Sukriti) and Don’ts (Rabih) of a residency application interview.
This is for anyone interviewing, but especially for IMGs.

Enjoy part 2 with Rabih Geha. 

Dr Ravi Singh

Doctor Ravi Singh graduated from the University Medical School of Debrecen in Hungary.
He did residency at the MedStar Health Internal Medicine Residency program in Baltimore, Maryland. He then moved to Sinai hospital/Johns Hopkins internal medicine residency program as an academic hospitalist.
Dr Singh is currently an associate Program Director Internal Medicine Residency Program at Sinai Hospital, in Baltimore and also a clerkship site director at Sinai for Johns Hopkins School.

Dr. Ravi Singh interviews CPSolvers team members Rafael Medina, Sukriti Banthiya, and Rabih Geha who illustrate the Do’s (Rafael and Sukriti) and Don’ts (Rabih) of a residency application interview.
This is for anyone interviewing, but especially for IMGs.

Enjoy part one with Rafael and Sukriti. 

Dr Ravi Singh

Doctor Ravi Singh graduated from the University Medical School of Debrecen in Hungary.
He did residency at the MedStar Health Internal Medicine Residency program in Baltimore, Maryland. He then moved to Sinai hospital/Johns Hopkins internal medicine residency program as an academic hospitalist.
Dr Singh is currently an associate Program Director Internal Medicine Residency Program at Sinai Hospital, in Baltimore and also a clerkship site director at Sinai for Johns Hopkins School.s

We hope you enjoy! And as always, thank you for your support. The RLR series is only possible because of you.

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In this episode, Simone & Emma review the schemas of Altered Mental Status and Microangiopathic Hemolytic Anemia as they work through a case presented by Moses.

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Lisa Sanders, MD, founder and writer of the popular Diagnosis column for  New York Times Magazine, and Laura Glick, MD, STUMP RR through a very exciting case. 

We hope you enjoy it as much as we enjoyed being stumped.

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CPSolvers team members–Rafael Medina (lead organizer),Valeria Roldán, Gabriel Talledo,  and Andrea Guzman facilitate a conversation with Drs. Gallo and Singh who shared authentic, practical, and inspirational insight into the IMG journey to apply to residency in the USA.  

 Dr Alice Gallo

Doctor Alice Gallo graduated from the Medical School of the Pontifícia Universidade Católica do Rio Grande do Sul in Brazil. She did residency at the Hospital Nossa Senhora da Conceição, repeated it at the University of Miami Miller School/Jackson Memorial Hospital/VA Hospital. She did a Pulmonary and Critical Care Fellowship at Mayo Clinic in Rochester, and joined the Critical Care staff at Mayo in 2017. Dr. Gallo is an Associate Professor of Medicine and Associate Program Director for the Internal Medicine Residency Program Mayo Clinic in Rochester.

Dr Ravi Singh

Doctor Ravi Singh graduated from the University Medical School of Debrecen in Hungary. He did residency at the MedStar Health Internal Medicine Residency program in Baltimore, Maryland. He then moved to Sinai hospital/Johns Hopkins internal medicine residency  program  as an academic hospitalist. Dr Singh is currently an associate Program Director Internal Medicine Residency Program at Sinai Hospital, in Baltimore and also a clerkship site director at Sinai for Johns Hopkins School.

Join VMR

Download CPSolvers App here

Patreon website

CPSolvers team members–Rafael Medina (lead organizer),Valeria Roldán, Gabriel Talledo,  and Andrea Guzman facilitate a conversation with Drs. Gallo and Singh who shared authentic, practical, and inspirational insight into the IMG journey to apply to residency in the USA. 

 Dr Alice Gallo

Doctor Alice Gallo graduated from the Medical School of the Pontifícia Universidade Católica do Rio Grande do Sul in Brazil. She did residency at the Hospital Nossa Senhora da Conceição, repeated it at the University of Miami Miller School/Jackson Memorial Hospital/VA Hospital. She did a Pulmonary and Critical Care Fellowship at Mayo Clinic in Rochester, and joined the Critical Care staff at Mayo in 2017. Dr. Gallo is an Associate Professor of Medicine and Associate Program Director for the Internal Medicine Residency Program Mayo Clinic in Rochester.

Dr Ravi Singh

Doctor Ravi Singh graduated from the University Medical School of Debrecen in Hungary. He did residency at the MedStar Health Internal Medicine Residency program in Baltimore, Maryland. He then moved to Sinai hospital/Johns Hopkins internal medicine residency  program  as an academic hospitalist. Dr Singh is currently an associate Program Director Internal Medicine Residency Program at Sinai Hospital, in Baltimore and also a clerkship site director at Sinai for Johns Hopkins School.

Join VMR

Download CPSolvers App here

Patreon website